Chronic Pain InitiativeCCNC and Project Lazarus:

Chronic Pain and Community Initiative

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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)

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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:

Clinical Community FocusPrimary Care Physician Toolkit Take only your own medications

Emergency Department Toolkit Keep medications in a safe placeCare Management Toolkit Education on dangers of opioidsNetwork CPI Champion

What is the Chronic Pain Initiative?

Model is based on proper assessment, diagnosis, and treatment plan with Pain agreement as necessary

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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

Unintentional Poisoning Deaths by County: N.C., 1999-2009

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

1999 - 2001

Unintentional Poisoning Deaths by County: N.C., 1999-2009

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

2002 - 2005

Unintentional Poisoning Deaths by County: N.C., 1999-2009

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

2006 - 2009

Poisonings on the Rise

5.56.8

8.5 8.810.4 10.5 10.4

11.5 11.810.4

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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*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.

Mor

talit

y ra

te/1

00,0

00 p

opul

ation

NC mortality rates, unintentional and undetermined intent poisonings, 2001-2010

Problem Acute in Wilkes County

8.2 8.510.4 10.5

10.8 11.5

23.9

8.2

24.526.9 28.3

41.6

46

6.7 7.1 8 9.9

05

101520253035404550

2003 2004 2005 2006 2007 2008 2009

NC

Wilkes

USA

9

Mor

talit

y ra

te/1

00,0

00 p

opul

atio

n

Source: NC SCHS, August 2009

Unintentional and undetermined intent poisoning mortality ratesWilkes County, NC 2003-2009

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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): $98,986,010Does 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

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 narcotics 16,172

Medicaid Network Patient Case Management

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Controlled Substances/Overdoses

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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

138152

89

170140

179

220

176

231

339

277 272

365

287308

267

347

313

243

474

286

229

513

235

160

510

179

0

100

200

300

400

500

600

Cocaine & Heroin Other and SyntheticOpioids

Methadone

2001200220032004200520062007200820092010

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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)

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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

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Contents of the Toolkit

General information o Managing chronic pain

o Proper prescription writing

o Precautions

Tools for managing chronic pain patientso 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)

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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

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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

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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

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Project Lazarus Results1. Lower Risk in the Community 2. Similar Benefit to Patients

3. Improved Risk : Benefit

15%

69%

15%

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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 (X2=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)

22Source: CCNC 2011

LegendAccessCare Network Sites Community Care Plan of Eastern CarolinaAccessCare Network Counties Community Health PartnersCommunity Care of Western North Carolina Northern Piedmont Community CareCommunity Care of the Lower Cape Fear Northwest Community CareCarolina Collaborative Community Care Partnership for Health ManagementCommunity Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern PiedmontCarolina Community Health Partnership

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Contact

Dr. Mike Lancaster mlancaster@n3cn.org

Fred Wells Brason II fbrason@projectlazarus.org

www.communitycarenc.org www.projectlazarus.org