Project Lazarus/CCNC
A statewide initiative to prevent drug overdose
Dr. Robin Gary Cummings
Deputy Secretary for Health Services
State Health Director
Resources: Community Care of North Carolina
1.4+ million Medicaid lives in CCNC Medical Homes in CCNC
o 14 Networks- local controlo 1600+ Practiceso 4,500+ PCP providers
Behavioral Healtho 19 Psychiatrists in the 14 Networks o 14 Full-time Behavioral Health Coordinators in the Networkso 44 Network pharmacists, now with Behavioral Health
pharmacy trainingo 14 Identified Chronic Pain Coordinatorso 14 Clinical Directors- MD, non-psychiatrists
Data Management Toolso CPI Flagso Pain Agreements Uploadedo BH Care Alertso LME/MCO Priority Patients
2
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
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.
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
50
100
150
200
250
300
350
400
450
500
550
Cocaine & Heroine
Methadone
Other Opioids & Synthetic Narcotics
Men
tions
of S
ubst
ance
s Co
ntrib
uting
to D
eath
2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
5
10
15
20
25
53
7
10
7
10 10
7
22
19
Year
Nu
mb
er o
f Dea
ths
Number of Unintentional Drug-Related Overdose Deaths By Year, Robeson County, N.C., 2003-2012 (N=100)
Rates of Hospitalizations Associated with Drug Withdrawal Syndrome in Newborns per 100,000 Live BirthsNorth Carolina, 2004-2011
Source: N.C. State Center for Health Statistics, 2006-2011Analysis by Injury Epidemiology and Surveillance Unit
355% Increase
104.4154.4 157.5
221.8
314.7
394.9
475.1
197.1
0
100
200
300
400
500
2004 2005 2006 2007 2008 2009 2010 2011
Year
Rate
per
100
,000
live
bir
ths
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 fromFriend/Relative
4.9%
OneDoctor80.7%
Drug Dealer/Stranger
1.6%Other 1
2.2%
Source Where Respondent Obtained
Source Where Friend/Relative Obtained
One Doctor19.1%
More than One Doctor
1.6%
Free from Friend/Relative
55.7%
More than One Doctor3.3%
Non-medical Use among Past Year Users Aged 12 or Older 2006
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
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
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
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
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
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
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)
8/2012 30%
9/2013 33% (increase over 2400 prescribers)
National average 28%
Pharmacists
8/2012 17%
9/2013 42%
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
North Carolina’s Response:Coordinating with Many Partners
North Carolina Injury and Violence Prevention BranchEpidemiology, Policy, Partners, Community
Poisoning Death StudyComprehensive 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
Call to Action:What can the Division of Public Health do?
ASTHO’s Presidential Challenge
ASTHO’s Presidential Challenge
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
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
Call to Action:What can Local Health Departments do?
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