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Project Lazarus Wilkes County, North Carolina

Project Lazarus Wilkes County, North Carolina. Preventing opioid poisonings Promoting responsible pain management. Project Lazarus. Wilkes County. Population 67,000 70 miles across Layoffs by major employers Not much heroin How much injection?.

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Project Lazarus Wilkes County, North Carolina

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  1. Project Lazarus Wilkes County, North Carolina Preventing opioid poisonings Promoting responsible pain management

  2. Project Lazarus

  3. Wilkes County • Population 67,000 • 70 miles across • Layoffs by major employers • Not much heroin • How much injection? This slide and next, images from the Wilkesboro Historical Society

  4. Domestic Experience http://www.npr.org/templates/story/story.php?storyId=17578955

  5. Naloxone hydrochloride (Narcan®) • Mu-opioid receptor antagonist • Can’t get high from it • Clear liquid • Used in anesthesiology • Used in emergency • Quick acting • Lasts 30-90 minutes • Generic (cheap?) • Delivered via injection (IM, SC, IV) or nasal

  6. Naloxone ( ) in the Brain N opioid receptors activated by heroin and prescription opioids opioids broken down and excreted O H M H O M N N N Pain Relief Pleasure Reward Respiratory Depression Reversal of Respiratory Depression Opioid Withdrawal

  7. Harm Reduction Coalition - NY carrying case face shield 1 mL vial of 0.4 mg/mL naloxone (2) rubber gloves (2) safety IM syringes (2) alcohol pads

  8. Harm Reduction Coalition - NY instructions (Spanish & English) prescription

  9. Chicago Recovery Alliance IM syringe prescription on box 10 mL vial of 0.4 mg/mL naloxone

  10. Summary of Evaluations • No overall increase in drug use or frequency of use • No unexpected major medical side effects • Possible increase in desire to seek drug treatment • Excellent identification of appropriate use scenarios • What is the alternative? Source: Maxwell, S., et al., J Addict Dis, 2006. 25(3): p. 89‐96; Sporer, K.A. and A.H. Kral, Ann Emerg Med, 2007. 49(2): p. 172‐7; Green TC, et al. ICRDH, Warsaw, Poland, May 2007.

  11. Methadone primarily prescribed for pain Source: Sanford, K. (2004). Findings and Recommendations of the Task Force to Prevent Deaths from Unintentional Drug Overdoses in North Carolina, 2003. N.C. Injury and Violence Prevention Branch - North Carolina Department of Health and Human Services, www.ncpublichealth.com.

  12. Overlapping Populations • Blue color jobs and physical pain • 32% of pain patients in a NC university hospital pain clinic had misuse behaviors • Higher pain among drug abusers • Historic substance use pattern Source: Ives, T.J., et al., BMC Health Serv Res, 2006. 6: p. 46.

  13. Patient Education DVD • Patient responsibilities in pain management • Recognizing signs and symptoms of opioid overdose • Importance of calling 911 • Rescue breathing • Administering naloxone • Options for substance abusetreatment To be taken home www.anypositivechange.org

  14. Potential Indications/Populations 1. Patient release after emergency medical care involving opioid poisoning/intoxication 2. Suspected history of illicit or nonmedical opioid use 3. High-dose opioid prescription (> 50 mg of morphine equivalence/day) 4. Any methadone prescription to opioid naïve patient Any opioid prescription and … 5. smoking/COPD/emphysema/asthma or other respiratory illness or obstruction 6. renal dysfunction, hepatic disease 7. known or suspected concurrent alcohol use 8. concurrent benzodiazepine prescription 9. concurrent SSRI or TCA anti-depressant prescription 10. Prisoner released from custody 11. Release from opioid detoxification or mandatory abstinence program 12. Voluntary request from patient 13. Patients in methadone or buprenorphine detox/maintenance (for addiction or pain) 14. Patient may have difficulty accessing emergency medical services (distance, remoteness) 15. Other (specify): _______________________________________

  15. Intake Form Patient information Risk Factors/ Indications/ Populations (14) Document training Dispensing details

  16. New Mexico Dept. of Health • 2 mL pre-loaded syringes (1 mg/mL) • Three sets for rural residents in New Mexico • Nasal adaptor • No needles

  17. Massachusetts

  18. Intranasal Administration

  19. Project Lazarus Firsts • First naloxone program in the South • First time introduced into general medical practice – as a patient safety issue • First focus on prescription drugs • First to focus on pain patients • First time approved by a medical board • Community-based approach

  20. Pilot Evaluation • Hospital ED admissions • Medical examiner reports • Linkage to CSRS (prescription registry) • Quai-experimental design • Rutherford County as “control” • Patient experience surveys • Provider opinion surveys • Pilot testing of educational video • Monitoring for unintended consequences

  21. What do participants say? If you ever get in a meeting with some professional-type people,tell ‘em that, you know,people like us – no, we’re not professionals – but if we have it at hand we can save somebody’s life with this stuff [naloxone]…it’s a lifesaver, there’s no question.* * quote collected by Suzanne Carlberg-Racich, Chicago

  22. Thank you. • Drug Policy Alliance • Northwest Community Care Network • Michele Jonsson Funk, UNC • John Brownstein, Harvard • Fred Brason, Wilkesboro • Su Albert, Wilkes Co. Health Dept. • Kay Sanford, North Carolina • Doug Kramer • Mark Kinzly, Yale • Sharon Stancliff, HRC • Alex Kral, RTI • Thelma Wright, NCHRC • Alice Bell, Prevention Point Pittsburgh • Pam Lynch nab@unc.edu

  23. Backup slides

  24. Street Beliefs and Poisoning • Salt, milk, coffee injections will revive victim • False: Waste of time and may introduce bacteria • Ice on groin will revive victim • False: Waste of time • Cold shower will revive victim • False: Waste of time, risk of fall • Slapping or hitting will revive victim • False: Waste of time, risk of injury; but a good check for responsiveness (e.g., sternum rub)

  25. Heroin Poisonings in France Source: Carrieri PM, 2006, Clin Infect Dis, 43: S197-215, data from Emmanueli (slide 38)

  26. Heroin-related Crime in France Source: Emmanueli J, 2005, Addiction, 100: 1690-1700

  27. Number of Fatal Poisonings by Manner of Death: NC Residents, 1997-2006 Source: NC State Center for Health Statistics, August 2007

  28. Number of Fatal Overdoses from Narcotics by ICD-10 Drug Categories NC Residents, 2001-2006 Source: NC State Center for Health Statistics, T-codes 40.1, 40.5, 40.2 and 40.4 40.3, 8/ 2007

  29. Wilkes County & North Carolina • “Three times the state average” • Wilkes Co. = 24.5 per 100,000 per year (2005) • North Carolina = 10 per 100,000 per year (2005) • “Some of the highest in the US” • Rio Arriba Co., NM = 44 per 100,000 per year • New Mexico = 17.5 per 100,000 per year (2003) • United States = 7.5 per 100,000 per year (2003)

  30. Types and Causes of Pain Also: location, quality/character sprains, aches, toothache, burns, cramps arthritis, lower back pain, tendinitis natural fluctuations, physical activity, stress, falls, diet, sleep, exercise, weather, conmeds lower back pain, cancer, fibromyalgia, lupus, (osteo)arthritis, CRPS post-operative, slipped discs, pinched nerve, labor

  31. Pharmacotherapy of Pain Also: hepatic & renal f(x), gastric sprains, aches, toothache ? ?

  32. Unintentional Opioid Poisoning Deaths, USA, 1999-2003, 15-54 years-old

  33. Increasing Poisoning Mortality (USA) Unintentional Intentional Undetermined Intent Source: Paulozzi L, et al. Pharmacoepidemiol Drug Saf. 2006 Sep;15(9):618-27.

  34. Short-acting opioids Heroin Methadone Two-month moving averages of opioid overdose deaths, imputed, 15-54 year-olds, USA

  35. Unintentional Poisoning Death Rates, 1999-2003

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