1. Project Lazarus/CCNC A statewide initiative to prevent drug overdose Dr. Robin Gary Cummings Deputy Secretary for Health Services State Health Director

2. Resources: Community Care of North Carolina  1.4+ million Medicaid lives in CCNC  Medical Homes in CCNC o 14 Networks- local control o 1600+ Practices o 4,500+ PCP providers  Behavioral Health o 19 Psychiatrists in the 14 Networks o 14 Full-time Behavioral Health Coordinators in the Networks o 44 Network pharmacists, now with Behavioral Health pharmacy training o 14 Identified Chronic Pain Coordinators o 14 Clinical Directors- MD, non-psychiatrists  Data Management Tools o CPI Flags o Pain Agreements Uploaded o BH Care Alerts o LME/MCO Priority Patients 2

3. Each CCNC Network Has:  A Clinical Director  A physician who is well known in the community  Works with network physicians to build compliance with CCNC care improvement objectives  Provides oversight for quality improvement in practices  Serves on the State Clinical Directors Committee  A Network Director who manages daily operations  Care Managers to help coordinate services for enrollees/practices  A PharmD to assist with Medication Management of high cost patients  Psychiatrist to assist in mental health integration  Palliative Care and Pregnancy Home Coordinators

4. Unintentional poisoning mortality rates by type of narcotic: North Carolina residents, 2000-2010* 4 *Source: NC SCHS, annual poisoning report prepared for Project Lazarus, based on ICD-10 T codes that identify the five narcotic categories associated with unintentional/undetermined intent poisonings on death certificates.

5. Number of Unintentional Drug-Related Overdose Deaths By Year, Robeson County, N.C., 2003-2012 (N=100)

6. Rates of Hospitalizations Associated with Drug Withdrawal Syndrome in Newborns per 100,000 Live Births North Carolina, 2004-2011 Source: N.C. State Center for Health Statistics, 2006-2011 Analysis by Injury Epidemiology and Surveillance Unit 355% Increase

7. Where Pain Relievers Were Obtained 1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.” Bought/Took from Friend/Relative 14.8% Drug Dealer/ Stranger 3.9% Bought on Internet 0.1% Other 1 4.9% Free from Friend/Relative 7.3% Bought/Took from Friend/Relative 4.9% One Doctor 80.7% Drug Dealer/ Stranger 1.6% Other 1 2.2% Source Where Respondent Obtained Source Where Friend/Relative Obtained One Doctor 19.1% More than One Doctor 1.6% Free from Friend/Relative 55.7% More than One Doctor 3.3% Non-medical Use among Past Year Users Aged 12 or Older 2006

8. Project Lazarus: A State Wide Response to Managing Pain  Based on pilot project from Wilkes County  Funding mechanism:  Kate B. Reynolds grant- $1.3 million  Matching funds from Office of Rural Health- $1.3 million  MAHEC grant for western counties  Total Funds available $2.6 million

9. Areas of Focus  Clinical Education- tool kits and trainings focus on opioid prescribing for primary care docs, ED docs, and CCNC care managers  Community Involvement- Involvement of all levels of community to demonstrate the drug problem is a community problem  Outcome Study- evaluate the outcomes to assure the effectiveness of the interventions

10. Partners  Partners in roll-out coordinated through CCNC:  Project Lazarus- Community Coalitions (funding for 100 counties)  Governor’s Institute/CCNC- 40 Clinical Trainings for all prescribers and dispensers  Local Mentor program through CCNC  Local TA and Consultation through CCNC  UNC Injury Prevention Research Center- report outcomes of project

11. Areas of Focus for Project Lazarus  Safer Opioid Prescribing- decrease in unintentional poisonings  Increased enrollment and use of CSRS  Education on and dispensing of Naloxone as rescue medication  Special projects:  Dental Pain  Opioids in pregnant women  Sickle Cell disease and pain

12. CCNC Infrastructure to Support Project Lazarus  Project Manager  Chronic Pain Initiative Coordinators in each of 14 Networks  Care Managers to support patients in connecting to and remaining in care  Network Psychiatrists to provide education and support to Primary Care Physicians  Informatics Center to make available pain contracts and special treatment plans for patients

13. Community Coalitions  Coalitions to be developed in each County  Involve local leaders from health departments, law enforcement, Public Health, school systems, advocate groups, local CCNC, and clinical leaders  Leadership of coalition to be determined by each county  Funding through Project Lazarus available to help support each county coalition

14. Updates on Early Results since March 2013  Eight trainings for prescribers and dispensers- average attendance 55-60  Enrollment in CSRS:  Prescribers (MD, DO, PA, FNP)  8/201230%  9/201333% (increase over 2400 prescribers)  National average 28%  Pharmacists  8/2012 17%  9/201342%

15. Legislative Support in 2013  Supports for CSRS to enhance enrollment and use:  Delegate authority  Reporting time of 72 hours from 7 days  Reporting of aberrant patterns in patients and physicians for follow-up by physicians and licensing Boards  Passage of Good Samaritan Law  Supports distribution and use of Naloxone as rescue drug in overdose situations  Supports physician prescribing

16. North Carolina’s Response: Coordinating with Many Partners

17. North Carolina Injury and Violence Prevention Branch Epidemiology, Policy, Partners, Community Poisoning Death Study Comprehensive Community Approach Chronic Pain Initiative Opioid Death Task Force Policy & Practice Research North Carolina Policy Monitoring System Drug Take Back Prescription Drug Substance Abuse Div. of Public Health, SAC Poisoning Workgroup Enforcement SBI & Medical Board Div. Medical Assistance, Div. Mental Health/ DD/Substance Abuse

18. Call to Action: What can the Division of Public Health do?

19. ASTHO’s Presidential Challenge

20.  Identify an area of concentration  Improve Monitoring & Surveillance  Expand Prevention Strategies  Expand and Strengthen Enforcement  Improve Access to Treatment & Recovery  18 states to date have signed on 15x15: Reduce prescription drug use by 15% by 2015

21. ASTHO’s Presidential Challenge North Carolina’s Areas of Concentration Improve Monitoring & Surveillance  Increase available data  Continue & expand linkage projects  Increase public health surveillance using CSRS Expand Prevention Strategies  CCNC/ Project Lazarus  Expand access to Naloxone Expand and Strengthen Enforcement  Coordinate efforts with law enforcement

22. Call to Action: What can Local Health Departments do?

23. Local Health Department Actions  Coordinate with your CCNC Regional Director  Form or Join a Substance Abuse Coalition  Request your Poisoning Data tables from CCNC or DPH  Use NC DETECT to monitor your prescription drug ED visits  Enhance your data from local sources  Have a signed standing order for Naloxone by your Medical Director  Take an active role to facilitate and coordinate with local groups  Make presentations at local medical societies on your prescription drug prevention activities  Advocate with local providers to register and use CSRS