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 control
o 1600+ Practices
o 4,500+ PCP providers
 Behavioral Health
o 19 Psychiatrists in the 14 Networks
o 14 Full-time Behavioral Health Coordinators in the Networks
o 44 Network pharmacists, now with Behavioral Health
pharmacy training
o 14 Identified Chronic Pain Coordinators
o 14 Clinical Directors- MD, non-psychiatrists
 Data Management Tools
o
o
o
o
CPI Flags
Pain Agreements Uploaded
BH Care Alerts
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*
550
Cocaine & Heroine
500
Mentions of Substances Contributing to Death
Methadone
450
Other Opioids & Synthetic
Narcotics
400
350
300
250
200
150
100
50
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
*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.
4
Number of Unintentional Drug-Related Overdose Deaths By
Year, Robeson County, N.C., 2003-2012 (N=100)
25
22
19
Number of Deaths
20
15
10
10
7
5
10
10
7
7
5
3
0
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
2012
Rate per 100,000 live births
Rates of Hospitalizations Associated with
Drug Withdrawal Syndrome in Newborns
per 100,000 Live Births
North Carolina, 2004-2011
475.1
355% Increase
500
394.9
400
314.7
300
197.1
200
221.8
154.4 157.5
104.4
100
0
2004 2005 2006 2007 2008 2009 2010 2011
Source: N.C. State Center for Health Statistics, 2006-2011
Analysis by Injury Epidemiology and Surveillance Unit
Year
Where Pain Relievers Were Obtained
Bought on
Drug Dealer/ Internet
0.1%
Stranger
More than 3.9%
One Doctor
1.6%
Source Where Respondent Obtained
Other 1
4.9%
Source Where Friend/Relative Obtained
More than One Doctor
3.3%
Free from
Friend/Relative
7.3%
One Doctor
19.1%
Bought/Took
from Friend/Relative
14.8%
One
Doctor
80.7%
Free from
Friend/Relative
55.7%
Bought/Took from
Friend/Relative
4.9%
Drug Dealer/
Stranger
1.6%
Other 1
2.2%
Non-medical Use among Past Year Users Aged 12 or Older 2006
1
The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and
“Some Other Way.”
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 dispensersaverage 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 Branch
Epidemiology, Policy, Partners, Community
North Carolina
Comprehensive Community Approach
Chronic Pain Initiative
Opioid Death Task Force
Poisoning Death Study
Policy
Prescription
Drug
Monitoring
System
Substance
Abuse
SAC Poisoning
Workgroup
Policy & Practice
Research
Enforcement
SBI & Medical Board
Drug Take Back
Div. of Public Health,
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
15x15: Reduce prescription drug use by 15% by 2015
 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
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