1. Chronic Pain Initiative CCNC and Project Lazarus: Chronic Pain and Community Initiative

2. Community Care of North Carolina (CCNC), in conjunction with non-profit organization Project Lazarus, is responding to some of the highest drug overdose death rates in the country through its Chronic Pain Initiative (CPI). Goals  Reduce opioid-related overdoses  Optimize treatment of chronic pain  Manage substance abuse issues (opioids) 2

3.  A set of interrelated programs designed to improve the medical care received by chronic pain patients, and in the process, to reduce the misuse, abuse, potential for diversion and overdose from opioid medication. Key program components: ClinicalCommunity Focus Primary Care Physician ToolkitTake only your own medications Emergency Department ToolkitKeep medications in a safe place Care Management ToolkitEducation on dangers of opioids Network CPI Champion What is the Chronic Pain Initiative? Model is based on proper assessment, diagnosis, and treatment plan with Pain agreement as necessary 3

4. Why are we looking at replication?  Evidence exists that the Wilkes County approach is changing conditions in ways that will reduce misuse, abuse, diversion and overdose from prescription opioids.  Changes in how medical professionals manage chronic pain patients and monitor their prescription use.  Change in opioid prescribing policy and practice within ED of Wilkes Regional Medical Center  Increased access to Naloxone and understanding of when and how to use  Pill take-back days  Community awareness, coalition building for community education  Reduction in unintentional poisoning deaths, especially those stemming from narcotics prescribed by providers based in Wilkes County 4

5. Unintentional Poisoning Deaths by County: N.C., 1999-2009 5 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit 1999 - 2001

6. Unintentional Poisoning Deaths by County: N.C., 1999-2009 6 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit 2002 - 2005

7. Unintentional Poisoning Deaths by County: N.C., 1999-2009 7 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit 2006 - 2009

8. Poisonings on the Rise 8 *Source: NC. State Center for Health Statistics; annually generated poisoning report for Project Lazarus. ** Mortality rates calculated from bridged population estimates (2001-2009) and 2010 US Census counts. Mortality rate/100,000 population NC mortality rates, unintentional and undetermined intent poisonings, 2001-2010

9. Problem Acute in Wilkes County 9 Mortality rate/100,000 population Source: NC SCHS, August 2009 Unintentional and undetermined intent poisoning mortality rates Wilkes County, NC 2003-2009

10. NC Cost of Hospitalizations for Unintentional Poisonings  Average cost of inpatient hospitalizations for an opioid poisoning*: $16,970  Number of hospitalizations for unintentional and undetermined intent poisonings**: 5,833  Estimated costs (2008): $98,986,010 Does not include costs for hospitalized substance abuse * Agency for Healthcare Research and Quality ** NC State Center for Health Statistics, data analyzed and prepared by K. Harmon, Injury and Violence Prevention Branch, DPH, 1/19/2011 10

11. 100 North Carolina counties # Cost Patients with >12 opioid scripts and >=10 ED visits in past 12 months 2,256 ED Visits (average per visit cost $2,610.00) $5,881,160 >12 narcotics16,172 Medicaid Network Patient Case Management

12. Controlled Substances/Overdoses 12

13. Opioids a Rising NC Problem t *Source: NC State Center for Health Statistics; annually generated poisoning report for Project Lazarus Narcotics causing or contributing to fatal unintentional and undetermined intent poisonings*: N.C. residents, 2001-2010 13

14. Key Ingredients in Chronic Pain Initiative  Establishment (or prior existence) of a community coalition that is able to develop and implement effective strategies to reduce substance use  A sense of urgency among local actors who have influence  Dedicated manager of the coalition with skills in process and content  Appropriate strategy for achieving a change in prevailing medical practice re: treatment of chronic pain patients (PCP and ED locations)  Tailored to local conditions  Includes education on the extent of the problem in the community and the role of providers in limiting supply and opportunities for diversion  Includes useful tools that providers can adopt (e.g., Medication Agreements, guidelines for proper script writing)  Explicit recommendations for hospital policies that limit dispensing of narcotics (especially to ED patients)  Take advantage of leverage points in larger environment (e.g., CSRS, Medicaid lock-in policy) 14

15.  Makes effective use of various partners in carrying out strategies including but not limited to:  Public health department – multiple strategies  County Medical Director – to reach physicians and ED  Medical providers – to change their own practice and educate other providers  Pharmacist – to other pharmacies in community  Law enforcement  Schools  Behavioral Health, Prevention and Treatment Programs and Organizations Key Ingredients in Chronic Pain Initiative 15

16. Contents of the Toolkit  General information o Managing chronic pain o Proper prescription writing o Precautions  Tools for managing chronic pain patients o Universal Precaution for Prescribing and Algorithm for assessing and managing pain o Pain Treatment Agreement o Format for progress notes o Medication flowsheet o Personal care plan o Prescriber and Patient education materials o Screening Forms and Brief Intervention o Naloxone Prescribing o Controlled Substance Reporting System (CSRS) 16

17. Primary Care Tool Kit Physician toolkit for treating chronic pain patients Encourage the use of Pain Treatment Agreements with chronic pain patients Encourage use of Provider Portal Encourage use of Controlled Substance Reporting System (CSRS) Encourage the assignment of pharmacy home for chronic pain patients lock-in program 17

18. Emergency Department Tool Kit Care management for pain patients visiting ED ED policy that restricts the dispensing of narcotics Encourage the Use of the CSRS by ED physicians Encourage the Use of Provider Portal in the ED Identify Chronic Pain Patients and Refer for Care Coordination based on ED assessment 18

19. Care Management Tool Kit  Provide support to ED identification of chronic pain patients- referrals to PCP or specialty services  Provide care management for patients identified by PCP practice as CPI patient; consider pharmacy lock-in program  Ongoing care management for Medicaid patients with narcotic prescriptions above threshold pain patients via TREO data  Educate PCPs and providers in utilization of Chronic Pain Tool Kit 19

20. Project Lazarus Results 1. Lower Risk in the Community 2. Similar Benefit to Patients 3. Improved Risk : Benefit 15%  69% 15%  20

21. Can coalitions help reduce Rx drug abuse?  Counties with coalitions had 6.2% lower rate of ED visits for substance abuse than counties with no coalitions (could be due to random chance)  However, counties with a coalition where the health department was the lead agency had a statistically significant 23% lower rate of ED visits (X 2 =2.15, p=0.03) than other counties  In counties with coalitions 1.7% more residents received opioids than in counties without a coalition.  Coalitions may be useful in reducing the harms of Rx drug abuse while improving access to pain medications.  More professional coalitions may have a greater impact on reducing Rx drug harms. Data Sources: NC Health Directors Survey, NC DETECT (2010), CSRS (2008-2010) 21

22. Source: CCNC 2011 Legend AccessCare Network SitesCommunity Care Plan of Eastern Carolina AccessCare Network CountiesCommunity Health Partners Community Care of Western North CarolinaNorthern Piedmont Community Care Community Care of the Lower Cape FearNorthwest Community Care Carolina Collaborative Community CarePartnership for Health Management Community Care of Wake and Johnston CountiesCommunity Care of the Sandhills Community Care Partners of Greater MecklenburgCommunity Care of Southern Piedmont Carolina Community Health Partnership 22

23. Contact  Dr. Mike Lancaster  mlancaster@n3cn.org mlancaster@n3cn.org  Fred Wells Brason II  fbrason@projectlazarus.org fbrason@projectlazarus.org  www.communitycarenc.org www.communitycarenc.org  www.projectlazarus.org www.projectlazarus.org 23