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Project Lazarus/CCNCA statewide initiative to prevent drug overdoseDr. Robin Gary CummingsDeputy Secretary for Health ServicesState Health DirectorCCNC has taken on a strong commitment to combat the prescription drug epidemic. I am going provide a little back ground on CCNC, data, and an overview and update of CCNCs Project Lazarus initiative. Resources: Community Care of North Carolina1.4+ million Medicaid lives in CCNCMedical Homes in CCNC 14 Networks- local control1600+ Practices4,500+ PCP providersBehavioral Health19 Psychiatrists in the 14 Networks 14 Full-time Behavioral Health Coordinators in the Networks44 Network pharmacists, now with Behavioral Health pharmacy training14 Identified Chronic Pain Coordinators14 Clinical Directors- MD, non-psychiatristsData Management ToolsCPI FlagsPain Agreements UploadedBH Care AlertsLME/MCO Priority Patients2CCNC is a large program in NC, touching 1.4million people and their families with a broad range of services. 2 Each CCNC Network Has:A Clinical DirectorA physician who is well known in the community Works with network physicians to build compliance with CCNC care improvement objectivesProvides oversight for quality improvement in practices Serves on the State Clinical Directors CommitteeA Network Director who manages daily operationsCare Managers to help coordinate services for enrollees/practicesA PharmD to assist with Medication Management of high cost patientsPsychiatrist to assist in mental health integrationPalliative Care and Pregnancy Home CoordinatorsCCNC regional network structure and org to provide comprehensive services.3Unintentional 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. As you heard from Dr. Marshall, prescription drugs are now the leading cause of drug deaths in NC, easily surpassing illicit drugs. 4Number of Unintentional Drug-Related Overdose Deaths By Year, Robeson County, N.C., 2003-2012 (N=100)The number of unintentional drug-related overdose deaths in Robeson peaked in 2011.
5Rates 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
6Another powerful indicator of the impact of the epidemic is the growth in newborns with drug withdrawal syndrome. CCNC recognizes that there are populations other than patients with chronic pain that are at risk from the misuse and abuse of narcotic pain relievers. This slide shows that since 2010, the rate of babies born with drug withdrawal syndrome (often called neonatal abstinence syndrome) has increased close to 300 percent among NC residents since 2004.One of the areas that the Chronic Pain Initiative will focus on is making sure that young, pregnant women are referred for substance abuse treatment prior to the birth of their babies.
Where Pain Relievers Were Obtained
1 The Other category includes the sources: Wrote Fake Prescription, Stole from Doctors Office/Clinic/Hospital/Pharmacy, and Some Other Way.Bought/Took from Friend/Relative14.8%Drug Dealer/Stranger3.9%Bought on Internet0.1%Other 14.9%Free from Friend/Relative7.3%Bought/Took fromFriend/Relative4.9%OneDoctor80.7%Drug Dealer/Stranger1.6%Other 12.2%Source Where Respondent ObtainedSource Where Friend/Relative ObtainedOne Doctor19.1%More than One Doctor1.6%Free from Friend/Relative55.7%More than One Doctor3.3%Non-medical Use among Past Year Users Aged 12 or Older 20067Project Lazarus: A State Wide Response to Managing PainBased on pilot project from Wilkes County
Funding mechanism:Kate B. Reynolds grant- $1.3 millionMatching funds from Office of Rural Health- $1.3 millionMAHEC grant for western counties
Total Funds available $2.6 million
CCNCs is based of a program many of you are aware of, Project Lazarus, and their promising success in Wilkes County where opioid deaths were reduced by 60%.
CCNC reached out to Kate B Reynolds and the office of Rural Health and secured $2.6 million to expand Project Lazarus to a state-wide initiative, an effort to provide recourses to replicated the early successes in Wilkes County.
The Initiative was started awarded in early summer 2013. Areas of FocusClinical 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 interventionsThe CCNC Project Lazarus has 3 focus areas: Clinical Education, Community Involvement, and Outcome studyPartnersPartners in roll-out coordinated through CCNC:Project Lazarus- Community Coalitions (funding for 100 counties)
Governors Institute/CCNC- 40 Clinical Trainings for all prescribers and dispensersLocal Mentor program through CCNCLocal TA and Consultation through CCNC
UNC Injury Prevention Research Center- report outcomes of projectThe partners that are helping coordinate this initiative with CCNC include:
Dr. Mike Lancaster, Medical Director Behavioral Medicine, CCNC heads the Project Lazarus Initiative
Fred Brason with Project Lazarus provides support for community coalitions
Dr. Sara McEwen with the Governors Institute provides training of providers and dispensers, and
Dr. Steve Marshall and Dr. Ringwalt at the UNC Injury Prevention Research Center conduct program evaluation of the initiative.Areas of Focus for Project LazarusSafer Opioid Prescribing- decrease in unintentional poisonings Increased enrollment and use of CSRSEducation on and dispensing of Naloxone as rescue medicationSpecial projects:Dental PainOpioids in pregnant womenSickle Cell disease and painThe Clinical Education component include:Safer Opioid Prescribing,Increased CSRS enrollment and use, Increased Awareness and use of Naloxone, and Projects targeted at special populations or prescribers.
CCNC Infrastructure to Support Project LazarusProject ManagerChronic Pain Initiative Coordinators in each of 14 NetworksCare Managers to support patients in connecting to and remaining in careNetwork Psychiatrists to provide education and support to Primary Care PhysiciansInformatics Center to make available pain contracts and special treatment plans for patients Each CCNC network has positions you can collaborate with support the success of the Project Lazarus Initiative. Community CoalitionsCoalitions to be developed in each CountyInvolve local leaders from health departments, law enforcement, Public Health, school systems, advocate groups, local CCNC, and clinical leadersLeadership of coalition to be determined by each countyFunding through Project Lazarus available to help support each county coalitionLocal health departments can, and in many locations are, playing an active role in community coalitions supported by the initiative. Updates on Early Results since March 2013Eight trainings for prescribers and dispensers- average attendance 55-60Enrollment in CSRS:Prescribers (MD, DO, PA, FNP)8/201230%9/201333% (increase over 2400 prescribers)National average 28%Pharmacists8/2012 17%9/201342%Some preliminary results of the initiative:
8 prescriber and dispenser trainings have been The trainings have had a role in increases seen in CSRS enrollment.
Legislative Support in 2013Supports for CSRS to enhance enrollment and use:Delegate authorityReporting time of 72 hours from 7 daysReporting of aberrant patterns in patients and physicians for follow-up by physicians and licensing BoardsPassage of Good Samaritan LawSupports distribution and use of Naloxone as rescue drug in overdose situationsSupports physician prescribingThe legislative updates described by Elizabeth Hudgins compliment the CCNC initiative.
This initiative directly benefits from the bills.
CCNC played an active role in supporting the legislation and is actively involved in implementing changes enabled by S 222 and S 20.North Carolinas Response:Coordinating with Many Partners
North Carolina Injury and Violence Prevention BranchEpidemiology, Policy, Partners, CommunityPoisoning Death Study
Comprehensive Community Approach Chronic Pain InitiativeOpioid Death Task Force
Policy & Practice Research
North CarolinaPolicyMonitoring SystemDrug Take BackPrescription Drug
Div. of Public Health,
SAC Poisoning WorkgroupEnforcementSBI & Medical Board
Div. Medical Assistance,Div. Mental Health/ DD/Substance Abuse
17NC has worked for with many partners over the past decade to confront this epidemic.
One of the points of coordination is the Injury Prevention Branches' Poisoning work group.
This is slide represents the many organizations and strategies employed by this workgroup.17Call to Action:What can the Division of Public Health do?
18Time for NC to renew its commitment to attack this epidemicASTHOs Presidential Challenge
19Today I am announcing we are joining 18 other states to take on ASHTHOs Presidential ChallengeASTHOs Presidential ChallengeIdentify an area of concentrationImprove Monitoring & SurveillanceExpand Prevention StrategiesExpand and Strengthen EnforcementImprove Access to Treatment & Recovery
18 states to date have signed on
15x15: Reduce prescription drug use by 15% by 201520The challenge is to reduce Prescription drug use 15% by 2015. Eac