Fred Wells Brason II fbrason@projectlazarus.org

Best Practices and Foundation Forum

Wilkes County, NC

Manual labor dominates employment options in this county of 69,000.

MoonshineMarijuana

Meth

Medicine

Wilkes 4 Marvelous M’s

Who is Project Lazarus?

• Non-profit organization

• Believes that communities are ultimatelyresponsible for their own health and that everydrug overdose is preventable.

• Preventing opioid/opiate poisonings

• Presenting responsible pain management

• Promoting Substance Use Treatment and Support services

Prevention – Intervention - Treatment

Prescription Medication UsePrevent – Intervene - Treat

Overdose –Who, What, When, Where, Why, How?

Patient misuse Family/Friends sharing to self medicate Accidental ingestion Recreational User Substance Use Disorder/Treatment/Recovery

I. Public Awareness – is particularly important because there are widespread misconceptions about the risks of prescription drug misuse and abuse. It is crucial to build public identification of prescription drug overdose as a community issue. That overdose is common in the community, and that this is a preventable problem must be spread widely.• Identify issue at local level• Broad-based outreach – all population groups

II. Coalition Action - A functioning coalition should exist with strong ties to and support from each of the key sectors in the community, along with a preliminary base of community awareness on the issue. Coalition leaders should also have a strong understanding of what the nature of the issue is in the community and what the priorities are for how to address it. • Community Sectors

• Why am I needed• What do I need to know• What needs to be done

THE HUB

THE HUB cont. Data and Evaluation

Epidemiologic Profile of Unintentional Poisonings NC

• All poisoning deaths• Opioid OD• Heroin OD• All Hospital and ED admission/visits; medicine and drugs• Opioid patients• Opioid prescribers• Benzodiazepine patients• Buprenorphine patients• Prescription/patient sleep aid• Prescription/patient stimulants• Self-inflicted Hospital/ED; medicine and drugs• Self-inflicted poisoning and opioid deaths

Community Education

- efforts are those offered to the general public and are aimed at changing the perception and

behaviors around sharing prescription medications, and improving safety behaviors around their use, storage, and disposal.

“Prescription medication: take correctly, store securely, dispose properly and never share.”

A prescriber can write appropriately, a pharmacist can dispense properly…but once in the community?

The SPOKES

14

COMMUNITY

• Why am I/We needed

• What do I/We need to know

• What needs to be done

Chronic Pain Initiative – CPI

PURPOSE

• Reduce risk of patient overdose

• Reduce risk of patient medication diversion

• Treatment of chronic pain - Exploring options

in addition to/instead of medications

• Use of the Prescribers Toolkit

• Bio/Psycho/Social Assessment

• Overdose/Respiratory Depression Risks

• Use of Prescription Drug Monitoring Program (CSRS)

• Treatment Agreement

• Urine screens/pill counts

• Co-Prescribing naloxone

• Prescribing Abuse Deterrent Formulations

Prescriber Education

Hospital Emergency Department (ED) Policies -

1) Embedded ED Case Manager2) “Frequent fliers” for chronic pain,

non-narcotic medication and referral3) No refills of controlled substances4) Mandatory use of PDMP (CSRS)5) Limited dosing (10 tablets)

THE SPOKES cont. Hospital ED Prescribing

Diversion Control – Law Enforcement, Pharmacist and Facility training on forgery, methods of diversion and drug seeking behavior.

THE SPOKES cont. Diversion ControlProject Lazarus - Project Pill Drop

MA DPH Study:"at least" two out of every three people who died of an opioid

overdose had been prescribed an opioid between 2011 and 2014.o But just 8.3 percent of those decedents had an active opioid

prescription in the same month as their death,

NC Medication Disposal Initiative

THE SPOKES cont. Pain Patient Support

Pain Patient Support - In the same way that prescribers benefit from additional education on managing chronic pain, the complexity of living with chronic pain makes supporting community members with pain important.

“Proper medication use and alternatives”Take correctly, store securely, dispose properly

and never share!

Additional modalities: health and wellness, music, breathing, physical therapies, acupuncture, yoga,

exercise, etc.

Substance Use Disorder treatment, Unfortunately, access to treatment is limited by two main factors:

• Acceptance, Availability and Accessibility of treatment options• Negative attitudes or stigma associated with addiction

in general and drug treatment.

• IntegrationLaw Enforcement – Behavioral Health –SA Treatment – ED – Health Department –Medical Providers – Labor and Delivery - OB/GYN

Drug treatment and Recovery

buprenorphine, naltrexone, methadone, 12 Step, abstinence programs,

residential, Peer Support

Survival

DOPAMINE

WATERFOOD

Understand the “Concept of Addiction”

Drug Problem

Crime

Death

Finances

Family

Health

Economics

Biological – TBI, PTSD

Cultural

Environmental

Depression

Trauma

Poverty

Drug Problem?

Lazarus Recovery

Services

Lazarus Peer Guides (LPGs) offer friendly companionship and successful experience navigating the pathway toward recovery.

We have:• A stable recovery. • A desire to enrich lives. • Specialized training and certification to handle a crisis, an overdose, and save lives.

Supportive Roles Lived ExperienceEmpathic Support Problem-Solving:Resource Support Crisis InterventionConstructive Support Community NavigationConnective Support Family Involvement

Support Groups

The Spokes - Naloxone - Increasing Access

• Respiratory depression/Overdose prevention training

• Distributing a script that gives patients specific language they can use with their family to talk about overdose and develop an action plan, similar to a fire evacuation plan

• Naloxone access to community, tribal groups and military

• Third Party Prescribing• Standing Orders• Pharmacy Dispensing• Program Distribution• New Devices• Federal/State Funding

• Wilkes Scripts related to overdose 2008 – 82%, 2011 – 0%

• Wilkes School SA incidences 7.3 per 1000 2011-2012 4.9 2012-20133.4 2013-20142.5 2014-2015

• SA ED visits down 15.3 %

• Involuntary commitments reduced/Less SA calls

• Diversion Tips increased• Crime 10% less

Wilkes County Results

“I would say 90 percent of people illegally selling pills aren’t getting it locally.

I think local doctors are doing a heck of a good job” with not prescribing excessively and to people with other than legitimate intentions.

The pills in Wilkes Sheriff’s Office cases “mostly come from pain clinics outside the county,” said Dancy.

LHD COALITION LEADERSHIP

OD ED VISITS PER 1k OPIOID SCRIPTSA priori selected metric for risk-benefit

COALITION FUNDING HELPSFunded coalitions had 18% lower rates than non-funded

PROFESSIONAL COALITIONS WORKINGCoalitions led by health departments had 26% lower rates

PRELIMINARY ANALYSISMuch more to be done! Does not take into account the interventions themselves

IS THERE A “HEALTHY COUNTY” BIAS?Propensity score modeling ahead

This decrease represents 4 fewer ED visits per 3,000 opioid scripts in counties with Health Department-led coalitions.

(20,000 NC ED visits - NC ED OD visit $12,000 – Medicaid $72 million 2014)

IMPACT in NC

• Most effective strategies to immediately reduce overdose rates were prescriber education related to pain management and addiction treatment

• Policies designed to limit the amount of opioidsdispensed in hospital emergency departments.

• Greater utilization of addiction treatment showed a delayedreduction in ED-related overdose visits.

• State and local strategies to prevent overdose should considerinterventions within the healthcare system, and use community-based coalitions to build and sustain supportfor these interventions

Project Lazarus.org

Fred Wells Brason IIfbrason@projectlazarus.orgRobert Wood Johnson Foundation

Community Health Leader Award 2012