The  First  Person  You  Must  Lead  is  You  

April  2  –  4,  2013  Omni  Orlando  Resort    

at  ChampionsGate  

Learning  Objec8ves  

•  1.  Outline  clinically-­‐effecAve,  paAent-­‐centered  treatments  for  pain  therapy  without  the  use  of  addicAve  medicaAons.  

•  Discuss  how  to  bring  about  a  greater  awareness  and  access  to  these  paAent-­‐centered  treatments.  

•  InvesAgate  the  integraAon  of  partnerships  across  the  DoD  and  civilian  medicine.  

Disclosure  Statement  

•  Consultant  for  Standard  Process  and  will  have    off-­‐label  discussion.  

My Background

My  Diagnosis  and  Treatment  

Deployment  to  Iraq  ACHA

Pa8ent-­‐Centered  Care  

Networking  to  Make  a  Difference  

US  Dept.  of  Veteran  Affairs                      Veterans  Health  AdministraAon          Office  of  PaAent  Centered  Care  and                              Cultural  TransformaAon          Intergovernmental  RelaAons          Center  for  Women  Veterans  

Council  for  Women  and  Girls  

NaAonal  InsAtutes  of  Health  

The  NaAonal  Council  for  Behavioral  Health  

NaAonal  FoundaAon  for  Women  Legislators  

DAV  

AmeriCorps  

Pain  Management    Task  Force  

NaAonal  Guard  Bureau  

Senate  Veterans  Affairs  CommiXee  

US  Substance  Abuse  and  Mental  Health  Services  

US  Dept.  of  Health    and  Human  Services  

Drug  Enforcement  AdministraAon  

Standard  Process  

WestCare  

NOVA/Pharmacist   Veteran/Consultant  

  Nutri8on    Chiroprac8c    Training    Coaching  

Outcomes  •  Encouraged  •  Educated  •  Integrated  SoluAon  Requires  Integrated  Approach  

•  CreaAng  HOPE  •  Inspiring  Change—Increase  Focus  on  NutriAon:  

– We  all  eat…  – Everyday,  mulAple  Ames  a  day…  – Significant  potenAal  to  either  get  it  a  lot  wrong  or  a  lot  right…  

Preventing  opioid  poisonings  Promoting  responsible  pain  management  

Our  Partners  and  Sponsors  

COLLABORATION  Project   Lazarus   believes   that   communiAes   are   ulAmately   responsible   for  their   own   health   and   that   every   drug   overdose   is   preventable.  We   are   a  non-­‐profit   organizaAon   that   provides   training   and   technical   assistance   to  community   groups   and   clinicians   throughout   North   Carolina   and   beyond.  Using   experience,   data,   and   compassion   we   empower   communiAes   and  individuals   to  prevent  drug  overdoses  and  meet   the  needs  of   those   living  with  chronic  pain.  

“A  PUBLIC  HEALTH  APPROACH  TO  OVERDOSE  PREVENTION”    STATEMENT  OF  R.  GIL  KERLIKOWSKE,  DIRECTOR  OFFICE  OF  NATIONAL  DRUG  CONTROL  POLICY  EXECUTIVE  OFFICE  OF  THE  PRESIDENT        AUGUST  23,  2012  

“Project  Lazarus  is  an  excep3onal  organiza3on—not  only  because  it  saves  lives  in  Wilkes  County,  but  also  because  it  sets  a  pioneering  example  in  community-­‐

based  public  health  for  the  rest  of  the  country.”  

UnintenAonal  Poisoning  Deaths  by  County:  N.C.,  1999-­‐2009  

4/9/13

Prepared by Project Lazarus with an unrestricted educational grant from Purdue

Pharma LP, NED101356 13

Source:  N.C.  State  Center  for  Health  StaAsAcs,  Vital  StaAsAcs-­‐Deaths,  1999-­‐2009  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

Source:  NC  CSRS  

Cost  of  HospitalizaAons  for  UnintenAonal  Poisonings:  NC,  2008  

•  Average  cost  of  inpaAent  hospitalizaAons      for  an  opioid  poisoning*:                $16,970.  

•  Number  of  hospitalizaAons  for  unintenAonal      and  undetermined  intent  poisonings**:      5,833  

•  EsAmated  costs  in  2008:  $98,986,010  

Does  not  include  costs  for  hospitalized  substance  abuse  *Agency  for  Healthcare  Research  and  Quality  **  NC  State  Center  for  Health  StaAsAcs,  data  analyzed  and  prepared  by  K.  Harmon,  Injury  and  

Violence  PrevenAon  Branch,  DPH,  01_19_2011  

Survey  Profile  of  NC  CounAes  Local  Health  Departments  

89  Departments/100  CounAes  78%  Response  

TradiAonal  intervenAons  intended  to  prevent  drug  abuse  have  not  been  able  to  stop  overdose  deaths  in  North  Carolina.  

Survey: NC County Health Directors

Communi8es  lack  of  informa8on,  tools  and  leadership  to  prevent  ODs.  

Source:    2011  Project  Lazarus  Health  Director  Survey  

Differences  in  opioid  uAlizaAon  suggest  complex  phenomena  that  are  independent  of  pharmacology.  Large  ciAes  have  relaAvely  fewer  people  receiving  opioids  than  small  counAes.  Areas  with  the  highest  opioid  prescribing  also  have  the  highest  poverty.  

Source:  NC  CSRS  and  US  Census  

I.   Public  Awareness  –  is  parAcularly  important  because  there  are  widespread  misconcepAons  about  the  risks  of  prescripAon  drug  misuse  and  abuse.    It  is  crucial  to  build  public  idenAficaAon  of  prescripAon  drug  overdose  as  a  community  issue.  That  overdose  is  common  in  the  community,  and  that  this  is  a  preventable  problem  must  be  spread  widely.  

II.   Coali8on  Ac8on  -­‐  A  funcAoning  coaliAon  should  exist  with  strong  Aes  to  and  support  from  each  of  the  key  sectors  in  the  community,  along  with  a  preliminary  base  of  community  awareness  on  the  issue.    CoaliAon  leaders  should  also  have  a  strong  understanding  of  what  the  nature  of  the  issue  is  in  the  community  and  what  the  prioriAes  are  for  how  to  address  it.      

III.  Data  and  Evalua8on  -­‐  The  early  data  that  you  will  need  includes  certain    health  related  informaAon  like  number  of  emergency  department  visits  and    hospitalizaAons  due  to  overdose,  number  of  overdose  deaths,  number  of    providers  in  the  county  who  acAvely  use  the  PDMP,  number  of  prescripAons  and    recipients  for  opioid  analgesics  dispensed  and  other  controlled  substances.    

 THE  HUB  

Community  forums  must  be  repeated  to  

moAvate  the  necessary  stakeholders  to  take  acAon.  

Community  coaliAons  must  be  provided  tools  to  make  their  own  strategic  plans  

and  design  locally  appropriate  intervenAons.  

Coalition Development

Individual

Biological Psychological

Social Spiritual

Schools

Law Enforcement

Family Peers

Medical

Faith

Civic

Human Service

Youth

Treatment

Courts

Military

Local Gov’t/Health

ENVIRONMENTAL SITUATION

Tribal

Senior Services

Media

COMMUNITY  

Community  Educa8on  -­‐  efforts  are  those  offered  to  the  general  public  and  are  aimed  at  changing  the  percepAon  and    behaviors  around  sharing  prescripAon  medicaAons,  and  improving  safety    behaviors  around  their  use,  storage,  and  disposal.      

“Prescrip)on  medica)on:  take  correctly,  store  securely,      dispose  properly  and  never  share.”  

Prescriber  Educa8on  -­‐  Chronic  pain  is  recognized  as  a  complicated  medical    condiAon  requiring  a  substanAal  amount  of  knowledge  and  skill  for    appropriate  evaluaAon,  assessment,  and  management.  Reached  via  CME,    Lunch  and  Learn,  Grand  Rounds,  Webinars,  Medical  Case  Management        MeeAngs  –  Prescribers  Toolkit        1)    Pain  Agreements        2)    Use  of  PDMP        3)    Urine  Screens        4)    Assessment  modaliAes  -­‐  SBIRT            a.    Treatment  opAons  and  local  referral  network  

The  WHEEL    

Hospital  Emergency  Department  (ED)  Policies  -­‐  it  is  recommended  that  hospital  EDs    develop  a  system-­‐wide  standardizaAon  with  respect  to  prescribing  narcoAc      analgesics  as  described  in  the  Project  Lazarus/Community  Care  of  NC  Emergency    Department  Toolkit  for  managing  chronic  pain  paAents:      1)    Embedded  ED  Case  Manager      2)    “Frequent  fliers”  for  chronic  pain,  non-­‐narcoAc  medicaAon  and  referral      3)    No  refills  of  controlled  substances      4)    Mandatory  use  of  PDMP      5)    Limited  dosing  (10  tablets)  

Diversion  Control  -­‐  SupporAng  paAents  who  have  pain,  parAcularly  those  who  are  treated    with  opioid  analgesics,  is  an  important  form  of  diversion  control:  take  correctly,  store  securely,  dispose  properly  and  never  share.    

   -­‐  Law  Enforcement,  Pharmacist  and  Facility  training  on  forgery,  methods  of        diversion  and  drug  seeking  behavior  

Pain  Pa8ent  Support  -­‐  In  the  same  way  that  prescribers  benefit  from  addiAonal  educaAon  on  managing  chronic  pain,  the  complexity  of  living  with  chronic  pain  makes  supporAng  community  members  with  pain  important.      

“Proper  medica)on  use  and  alterna)ves”  

A  script  gives  paAents  specific  language  that  they  can  use  with  their  family  to  talk  about  overdose  and  develop  

an  acAon  plan,  similar  to  a  fire  evacuaAon  plan.  

Prescribetoprevent.org  

Harm  Reduc8on  –  Naloxone  rescue  medica8on              to  reverse  opioid  overdose  

The  North  Carolina  Medical  Board  has  issued  a  statement  supporAng  the  use  of  naloxone  to  prevent  overdoses:    “…The  preven)on  of  drug  overdoses  is  consistent  with  the  Board’s  statutory  mission  to  protect  the  people  of  North  Carolina.  The  Board  therefore  encourages  its  licensees  to  cooperate  with  programs  like  Project  Lazarus  in  their  efforts  to  make  naloxone  available  to  persons  at  risk  of  suffering  opioid  drug  overdose.”    

AMA,  June  19,  2012    “FataliAes  caused  by  opioid  overdose  can  devastate  families  and  communiAes,  and  we  must  do  more  to  prevent  these  deaths,”  said  Dr.  Harris.  “EducaAng  both  physicians  and  paAents  about  the  availability  of  naloxone  and  supporAng  the  accessibility  of  this  lifesaving  drug  will  help  to  prevent  unnecessary  deaths.”  

NADDI  supports  nasal  naloxone  The  NaAonal  AssociaAon  of  Drug  Diversion  InvesAgators  (NADDI)  has  taken  a  posiAon  to  encourage  law  enforcement  agencies  to  adopt  policies  that  would  allow  officers  to  carry  nasal  naloxone  with  them  to  administer  to  individuals  involved  in  a  an  opioid  overdose.  Proper  training  and  cerAficaAon  by  the  proper  authority  of  each  state  helps  to  ensure  proper  use  of  nasal  naloxone  on  those  in  distress  due  to  a  drug  overdose.  

Harm  Reduc8on  –  Naloxone  rescue  medica8on              to  reverse  opioid  overdose  

Addic8on  treatment,  especially  opioid  agonist  therapy  like  methadone  maintenance  treatment  or  office  based  buprenorphine  treatment,  has  been  shown  to  dramaAcally  reduce  overdose  risk.    Unfortunately,  access  to  treatment  is  limited  by  two  main  factors:    

•  Availability  and  accessibility  of  treatment  opAons,    •  NegaAve  aqtudes  or  s8gma  associated  with  addicAon    

 in  general  and  drug  treatment.      

Drug  treatment  and  Recovery  

Can  coali8ons  help  reduce  Rx  drug  abuse?  

•  CounAes  with  coaliAons  had  6.2%  lower  rate  of  ED  visits  for  substance  abuse  than  counAes  with  no  coaliAons  (but  this  could  be  due  to  random  chance)  

•  However,  counAes  with  a  coaliAon  where  the  health  department  was  the  lead  agency  had  a  staAsAcally  significant  23%  lower  rate  of  ED  visits  (X2=2.15,  p=0.03)  than  other  counAes.  

•  In  counAes  with  coaliAons  1.7%  more  residents  received  opioids  than  in  counAes  without  a  coaliAon.  

•  Coali8ons  may  be  useful  in  reducing  the  harms  of  Rx  drug  abuse  while  improving  access  to  pain  medica8ons  at  the  same  8me.  

•  More  professional  coali8ons  may  have  a  greater  impact  on  reducing  Rx  drug  harms.  

32  

www.projectlazarus.org  Fred  Wells  Brason  II  

!

Wilkes  County  NC  RESULTS  

The  overdose  death  rate  dropped  69%  in  two  years  auer  the  start  of  Project  Lazarus  and  the  Chronic  Pain  IniAaAve.  

Wilkes County Opioid Prescribing Wilkes  County  had  higher  than  state  average  opioid  dispensing  during  the  implementaAon  of  Project  Lazarus  and  the  Chronic  Pain  IniAaAve.  Access  to  

prescripAon  opioids  was  not  dramaAcally  decreased.  

Source:  NC  CSRS  

In  2011,  not  a  single  OD  decedent  had  an  opioid  prescripAon  from  a  Wilkes  County  prescriber.  The  fundamental  risk:benefit  raAo  for  opioids  can  be  altered  for  the  beXer  

through  a  community-­‐wide  approach.  

Wilkes  County  Overdose  Script  History  

NC  Medical  Board/NC  Medical  Society/NC  Hospital  AssociaAon  NC  College  of  Emergency  Physicians/Family  PracAce/Physicians  Assistants  NC  Div.  MHDDSAS/OTP’s/PDMP  SBI/NC  Sheriffs  AssociaAon  Carolinas  Poison  Center  Dental  Society  FQHC  PrevenAon  OrganizaAons  CoaliAons  

Kate  B.  Reynolds  Charitable  Trust  -­‐  Office  of  Rural  Health  

NC  Alliance  for  Health  

Community  Care  NC  

Project  Lazarus*  –  Governors  InsAtute  for  SA  –  UNC  Injury  and  PrevenAon  Research  Center  

*(includes  NC  Div.  of  Public  Health  CDC  Transforma)on  Grant  and  MAHEC  CMS  Innova)ons  Grant)  

NC  Statewide  CollaboraAve  

Information projectlazarus.org              communitycarenc.org                      

Fred  Wells  Brason  II  FWBrason2@projectlazarus.org      Robert  Wood  Johnson  Community  Health  Leader  Award  2012    

AddiAonal  efforts  underway  in  NM,  VA,  TN,  OH,  MD,  ME,  OK,  etc.    

Dr.  Mike  Lancaster  mlancaster@N3CN.org  

Opera8on  OpioidSAFE  A  Collabora8ve  Effort  

April  2  –  4,  2013  Omni  Orlando  Resort    at  ChampionsGate  

Learning  Objec8ves  

•  Demonstrate  a  collaboraAve  military/civilian  program  

•  Describe  a  method  to  address  opioid  dependence  for  paAents  with  severe  pain  

Disclosure  Statement  

•  No  disclosures  to  report  

Disclaimer  

The  content  of  this  presentaAon  is  solely  the  opinion  and  creaAon  of  the  presenter  and  is  not  necessarily  US  Government  policy  or  opinion.  

OperaAon  OpioidSAFE    A  Case  IllustraAon  

The  Problem  

•  Soldiers  •  Pain  •  Pain  Treatments  

OperaAon  OpioidSAFE  

•  Project  Lazarus  Program  •  Comprehensive  Pain  Treatment  

•  Risk  StraAficaAon  •  Opioid  Weaning/DetoxificaAon  Pathways  

Program  ExecuAon  

•  Physician  and  Provider  EducaAon  •  PaAent  and  Family  EducaAon  •  Cultural  Molding  •  Expert  Specialty  Pain  Medicine  ConsultaAon  

Selected  OperaAon  OpioidSAFE  Results  

•  47  paAent  enrolled  in  our  suboxone  program  • Mean  Treatment  154  days  •  Success  rate  67.3%  

•  DOD/VA  OpioidSAFE  conference  •  89  aXendees  •  100%  rated  as  Good  or  Excellent  •  87%  =    fit  their  pracAce  •  88%  =    would  change  their  pracAce    

Of  every  one-­‐hundred  men,  ten  shouldn't  even  be  there,  eighty  are  nothing  but  targets,  nine  are  real  fighters...We  are  lucky  to  have  them,  they  make  the  baHle...AH  but  ONE,  one  of  them  is  a  Warrior...he  will  bring  the  others  back  

Heraclitus  c.  500  B.C.