Project Lazarus description FINAL - Reviewed literature/Project Lazarus, North... · Project...

download Project Lazarus description FINAL - Reviewed literature/Project Lazarus, North... · Project Lazarus

of 21

  • date post

    10-Nov-2018
  • Category

    Documents

  • view

    218
  • download

    0

Embed Size (px)

Transcript of Project Lazarus description FINAL - Reviewed literature/Project Lazarus, North... · Project...

  • ProjectLazarus WilkesCounty,NorthCarolina Page|0

    PROJECTLAZARUSWilkesCounty,NorthCarolina

    PolicyBriefingDocument

    Preparedfor:NorthCarolinaMedicalBoard

    Inadvanceof:

    PublicHearingRegardingPrescriptionNaloxone

    Wednesday,November14,2007

    Raleigh

    Ifyouevergetinameetingwithsomeprofessionaltypepeople,tellemthat,youknow,peoplelikeusno,werenotprofessionals,butifwehaveitathandwecansavesomebodyslifewiththisstuff[naloxone]

    ...itsalifesaver,theresnoquestion.

    FromaprogramparticipantinChicagoMaxwellS,etal.JAddictDis.2006;25(3):8996.

  • ProjectLazarus WilkesCounty,NorthCarolina Page|1

    EXECUTIVESUMMARY

    WhatisthetargetpopulationforProjectLazarus?WhatwilltheNCprogramlooklike?[Page3]InWilkesCounty,25ormoreresidentshavediedannuallyinthepastseveralyearsfromunintentionaldrugoverdoses.Themajorityofdeathswereduetorespiratorydepressionfromunintentionalopioidoverdoses(technicallycalledunintentionalpoisoning).ProjectLazarusisapilotprograminWilkesCounty,NCfortheprescriptionanddistributionofintranasalnaloxone(adrugthatreversesrespiratorydepressionthatoccursfromopioidoverdoses)forthepurposeofpreventingdeath.Whileparallelmeasuresarebeingundertakentoimprovetheprescriptionofopioidsforpainmanagementandtoreducetheillicitabuseoftheseessentialmedications,ProjectLazarusisaimedatreducingfatalitiesamong13subpopulationsthatareatincreasedriskofabusingormisusingnarcoticsanddyingfromafataldrugoverdose.ProjectLazarusincludesa20minutestructurededucationalinterventionthatteacheshowto:1)recognizethesignsofanopioidoverdose,2)understandtheimportanceofcalling911,3)performrescuebreathing,4)administerintranasalnaloxone,and5)obtaintreatmentofsubstanceabuseandmisuse.TheProjectalsoincludesaprotocolfordocumentingthemedicalencounter(followingtheparadigmforinfluenzavaccination)andprovidesakitcontainingprefilledsyringesofnaloxonewithadaptersfornasaladministration.

    Aretheregroupswhoareopposedtotheprogramandwhy?[Page10]

    NoorganizedgroupshavevoicedoppositiontoprescriptionnaloxoneinNorthCarolina.Despiteinitialconcernsinothercitiesandcountriesthatthedistributionofmedicationstoreverserespiratorydepressionafteranunintentionaldrugoverdose,noevidenceofincreasedabuseofstreetdrugshasbeendocumentedwheretheseprogramsareinplace.

    Byourapproval/allowingthisprogramtogoforwardareweabettingillicitdruguse?[Page10]

    ProjectLazarusisnotabettingillicitdruguse.Experiencinganoverdoseisatraumaticeventthatelicitscomplexemotionalreactions.Thereisevidencetosuggestthatoverdosesurvivorsarereceptivetobehaviorchangeandthatsurvivinganoverdosemayserveasanopportunitytodiscussdrugtreatmentoptionswiththevictim,familyandpeers.OtherprescriptionnaloxoneprogramsintheUShaveobserveddecreasesininjectiondruguseandincreasedentryintosubstanceusetreatmentinthemonthfollowingnaloxoneadministration.

    Arethereunintendeddeleteriouseffectsofapproval?[Page11]

    Therearerelativelyfewdeleteriouseffectsfromtheadministrationofnaloxoneafteradrugoverdose.Adverseeventsassociatedwithnaloxoneadministrationareconsistentwithacuteopioidwithdrawal,which,albeitunpleasant,arebetterthandeath.Returnofrespiratorydepressionmayoccurwithlongactingopioidandcontrolledreleaseformulations.Educationandsupplementalnaloxonevialsareprovidedtomitigatethisrisk.

  • ProjectLazarus WilkesCounty,NorthCarolina Page|2

    WhatisthenarcoticoverdoserateforNCand/ortheproposedservicearea?Howmanylives/hospitalizationswouldbesavedbythisprogram?[Page13]WilkesCountyhasarateofaccidentalopioidpoisoningdeathsnearlyfivetimesgreaterthanthenationalaverage,andthreetimeshigherthanthestateaverage.In2005,18deathsresultedinarateof27.4per100,000peryear;20deathsreportedin2006gavearateof30.5per100,000peryear,predominatelyduetomethadone.In2007,themortalityrateshavebeensimilar,with13accidentalopioidpoisoningdeathsinWilkesCounty,with2pendinginvestigations.ThecostofinpatienthospitalizationsaloneforopioidpoisoninginNorthCarolinaismorethan$20millionperyear,halffromuninsuredandMedicaidpatients.ForeachoverdosepreventedthroughProjectLazarus,therewillbea$20,000to$30,000savingsinmedicalexpensesandlostproductivity,suggestinghighpotentialforafavorablecosteffectivenessbenefit.

    WhatisthelegalstatusofprescriptionnaloxoneprogramsinNorthCarolina?[Page15]PrescribingnaloxonetoopioiddrugusersinNorthCarolinaisfullyconsistentwithstateandfederallawsregulatingdrugprescribing.Anylegalrisksindistributingnaloxoneinthisstatearenotsubstantialandcanbemitigatedbyinformedprogramdesign;therisksofmalpracticeliabilityareconsistentwiththosegenerallyassociatedwithprovidinghealthcare.

  • ProjectLazarus WilkesCounty,NorthCarolina Page|3

    WhatisthetargetpopulationforProjectLazarus?WhatwilltheNCprogramlooklike?

    Context

    InWilkesCounty,theprescriptionnaloxoneprogram,ProjectLazarus,isonecomponentofamultifacetedresponse(theChronicPainInitiative,seebelow)toanepidemicofthemisuseandabuseofprescriptionopioidsthathasresultedinanunprecedentedincreaseinfatalunintentionalpoisonings.Fataldrugoverdosesoccurfromlegallyprescribednarcotics,suchasfentanyl,hydrocodone,methadoneandoxycodone,aswellasfromstreetdrugssuchascocaineandheroin.Inthisdocument,themisuseofanarcoticreferstheinappropriatemedicaluseofaprescribednarcoticbyapatient(suchasnonadherencewhenapatientdoesnotfollowaprescribersrecommendedusage/dosage).Abusealwaysreferstothenonmedical(i.e.,recreational)useofanarcotic.Bothlegalprescriptionandillegalstreetdrugscanbeabused.

    Project Lazarus, Wilkes County, North Carolina

    Context

    o IncreasingnumberofdeathsfromunintentionaloverdosesofprescriptionopioidsinWilkesCounty.

    o ChronicPainInitiativebalancesadequatepainmanagementwithpreventionofharmfromprescriptionopioiduse.

    Educationalintervention

    20minuteeducationaltrainingthatincludes:

    1)recognizingsignsandsymptomsofopioidoverdose2)understandingtheimportanceofcalling9113)learningrescuebreathing4)theappropriateuseofnaloxone5)optionsforsubstanceusetreatment

    Kitwith2dosesof1mg/mLnaloxonehydrochlorideinprefilledneedlelesssyringes,nasaladaptors,instructions,referralstolocalsubstanceabuse/dependencetreatment

    Followinginfluenzavaccineparadigm,recordkeepingformedicalencounter

    Targetpopulations:medicalandnonmedicalusersofprescriptionopioids,withknownriskfactorsforopioidpoisoning.

    Evaluationofpilotprogram

  • ProjectLazarus WilkesCounty,NorthCarolina Page|4

    TheChronicPainInitiativeissponsoredbytheNorthwestCommunityCareNetwork.Theothercomponentsoftheresponseinclude:casemanagementofanddatacollectiononpatientsinitiatingopioidtherapy,establishmentofapharmacyhomesystem,collaborationwithmentalhealthplanning,bettermanagementofpatientsintheemergencydepartment,utilizationofthecontrolledsubstancesreportingsystem,andphysicianeducation,includingdevelopmentanddisseminationofatoolkitonopioidprescribingandpainmanagementforprescribers.

    ThegoalsoftheChronicPainInitiativeareto:decreaseED(emergencydepartment)utilizationbydrugseekers,decreaseuseofmultipleprescribersandmultiplepharmacies,improveHCP(healtcareprovider)efficacyinchronicpainmanagement,encourageappropriatepainclinicreferrals,encouragecomanagementmodelforpartnershipwithpainclinic,reducenumberofunintentionalpoisoningsfromdrugoverdoses,anddecreasecostsassociatedwithimproperuseofprescriptionopioids.Itisourintentiontodevelopareproducible,comprehensiveapproachtochronicpainmanagementthatmaybeduplicatedbyothersinNorthCarolina.

    TargetPopulations

    Justasthephysiologicalandanatomicalbasesforpainandaddictionsharecommonpathwaysinthecentralnervoussystem,thecommunitylevelresponsetoprescriptionopioiduseproblemsmustaddresspainandabuse/addictionsimultaneously.Thedistinctionbetweenmedicalandnonmedicaluseofprescriptionopioidscanchangeovertimeforagivenindividual.Apatientwithalegitimateacutepainconditioncouldkeepleftoveropioidmedicationforatalaterpainfulcondition;atthatpointalegitimatepainpatientisconsideredtobeabusingthemedication.Patientswithhistoryofalcoholusedisordermayrespondwelltoopioidtherapyandcompletemedicationusewithoutuntowardincident.Whileillicitdrugs(heroin,cocaine,methamphetamine)maybeinvolvedinapoisoningevent,itisjustaslikelythatlegalprescriptionmedications(benzodiazepines,TCAandSSRIantidepressants)willalsobeimplicated.

    Thetreatmentofseverechronicpainisnowclearlyrecognizedbythemedicalcommunityasacompellingneedinthepracticeofmedicine.Thepatientpopulationisbroad,astherecipientsofpainmanagementshouldnotberestrictedtothosewithterminalcancerorwhoareunderthecareofahospiceprogram.OpioidsarethemainstayofpharmacologicmanagementofmoderatetoseverechronicpainintheUnitedStates.Inrecognitionoftheirvitallyimportantplaceinmedicalpractice,opioidsforuseinpainmanagementandthepharmacotherapyofopioiddependencehavebeenplacedontheWorldHealthOrganizationsListofEssentialMedicines(Herget2005).Nevertheless,itisalsorecognizedthatchronicpainisoftendifficulttotreatintheoutpatientsetting.AlthoughprescribersshouldfollowthepainmanagementrecommendationspostedbytheNCMedicalBoardontheirwebsite(also,Trado2004),itdoesnotguaranteethattheirpatientswillfollowinstructionsorthattheirpatientsdonotalsohaveacomorbiddependencedisorderthatgreatlyenhancesthecomplexitiesencounteredbythemedicalcommunity.Thesetwoverydifferentissuescanleadtobothmisuseandabuseoftheprescribeddrug,sometimesatthesametimeoratdifferenttimes.Examplesofmisuseandabusearewhenapatientexperiencesinadequatepaincontrolandtakesmoretabletsthanprescribed(misuse)ortakespartoftheprescriptionasprescribedandthenusestheremainingpillsfornonmedicalreasons(abuse).Tocomplicatethesituationfurther,peoplewithabuse/dependencedisordersfrequentlysufferfromseverechronicpainthuscomplicatingthestrategiesfortreatingbothconditions.Effectivestrategiesforopioid

  • ProjectLazarus WilkesCounty,NorthCarolina Page|5

    therapyinpatientswithahistoryofsubstanceusehavebeenelaborated(SchnollandWeaver2003),andhealthcareprovidershaveadutytoreducepainfulconditionsinsuchpatients.