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2010 Report Helping Prevent OD Deaths Project Lazarus empowers communities to address the epidemic

WHO WE ARE Fred Wells Brason II, Director Catherine (Kay) Sanford, VP for Research Dr. Su Albert, Medical Director Dana Zacharias, Community Awareness Coordinator Donna Shumate, Finance and Grant Administrator Karen R. Brason, Operations Assistant Nabarun Dasgupta, UNC Dissertation Evaluation

Overdose Deaths have Stopped Increasing in Wilkes County In the past twelve months, the staff of Project Lazarus has maintained a vigorous schedule of local action in Wilkes County, coalition building support throughout western North Carolina, giving presentations at scientific conferences, and conducted state-of-the-art research on overdose prevention. Throughout our presentations we have emphasized the need for balance between pain management and prevention of the harms resulting from substance misuse and abuse. We have endeavored to inspire and empower local communities, and show that a community-based approach is possible. Preliminary unadjusted data from Wilkes County suggests that the overdose death rate has dropped from 43 per 100,000 in 2008 to 29 per 100,000 in 2010. While it is too early to draw a conclusion from these numbers, we are highly encouraged that Wilkes County did not see the increases in overdose deaths that nearly every other county in NC experienced. A thorough evaluation of the program is underway.

PROJECT LAZARUS Project Lazarus is a comprehensive community-based prescription overdose prevention program in western North Carolina.

PO Box 261 Moravian Falls, NC 28654 USA (336) 667-8100

We have continued our collaboration with the US Army and the Eastern Band of Cherokee Indians to bring an evidence supported community-based approach to the prevention of misuse, abuse and overdose involving prescription opioids. Naloxone distribution began in 2010, and will continue to expand next year. Our efforts have been made possible through sustained and generous support from our sponsors: the Drug Policy Alliance, an unrestricted educational grant from Purdue Pharma L.P., and the Northwest Community Care Network (NCCN). Local business partners have included Brame Huie Pharmacy, Wilkes Motor Speedway, Biscuitville, WalMart and Kohl’s. We would also like to thank the Wilkes County Health Department, Wilkes Regional Medical Center, the Sheriff’s Office, Wilkesboro and North Wilkesboro Police Departments, Crime Stoppers, Wilkes County Schools, Wilkes Community College, and many more civic and community organizations and churches. Our academic partners are Wake Forest University and the Unversity of North Carolina at Chapel Hill. THANK YOU!

Project Lazarus is more than naloxone prescriptions

Project Lazarus offers education and tools that individuals can use to tighten supply, reduce demand for drugs and provide harm reduction to save lives Project Lazarus was busy in 2010. •• There were face-to-face meetings between our medical director and 35 physicians from local practices on safer opioid prescribing. This represents about half of the DEA-registered physicians and 70% of the practices in the county. The faceto-face sessions are similar to “academic detailing,” but were developed for a local audience. •• We have continued to encourage all prescribers in Wilkes County to use the state’s Controlled Substances Reporting System (CSRS, or prescription monitoring program). With 70% of prescribers registered, Wilkes County has by far the highest rate of utilization of the CSRS in the state (average 20%). •• Pill take-back days in Wilkes County in March and September returned thousands of units of unused meds. We have secured funding from CrimeStoppers for a permanent site for disposal. •• The first patients received their free take-home naloxone kits in Wilkes County in 2010. •• We hired a Community Awareness Coordinator to create and implement an interactive prescription drug abuse prevention program, while also providing school education (left). •• The case manager in the emergency department of Wilkes Regional Medical Center continues to coordinate care for patients with chronic pain, dental and substance abuse. This position is jointly funded by the NCCN and the hospital. •• We were invited to present the Project Lazarus model to diverse audiences, from Michael Moore’s Film Festival in Michigan to the Womack Army Medical Center in Fayetteville to the Qualla Boundary of the Eastern Band of Cherokee Indian Reservation. In Washington, we have been part of Congressional Briefings, met with the White House Office of National Drug Control Policy (ONDCP), presented to the Food and Drug Adminisitration (FDA), and participated in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) semimonthly overdose outbreak surveillance teleconference. •• Project Lazarus also collaborates with PainSAFE Opioid911, the American Pain Foundation, and the Harm Reduction Coalition.

Local Action

Coalition Building



Project Lazarus is the central community group that coordinates overdose prevention efforts in Wilkes County. The Chronic Pain Initiative (CPI, above), focuses on improving quality of care for Medicaid beneficiaries, but influences medical practice throughout the county.

We draw on the success and experience of the Substance Abuse Task Force of the Wilkes Healthy Carolinians Council to build coalitions. We also work with the award winning Community Care Networks (Medicaid) & the Governor’s Institute to bring the Project Lazarus model with CPI statewide.

In 2010, we presented at more than 30 scientific conferences and meetings, from Raleigh to England. Closer to home, we presented the Project Lazarus model to 19 counties in NC. The Drug Policy Alliance funded us to expand our model in western North Carolina.

Project Lazarus benefits from the latest research findings. Combining mortality, hospital emergency department admissions and prescribing data, we have a clear picture of phenomena like overdose and doctor shopping.

“The goals of Project Lazarus are consistent with the Board’s statutory mission to protect the people of North Carolina.

The Project Lazarus Model

Project Lazarus makes judicious use of availabile data sources for surveillance. Data sources include emergency department visits, vital statistics, medical examiner files, law enforcement records, and data from the Controlled Substances Reporting System (CSRS).

The Board therefore encourages its licensees to abide by the protocols employed by Project Lazarus and to cooperate with the program’s efforts to make naloxone available to persons at risk of suffering drug overdose.” - North Carolina Medical Board, August 2008

Thanks to Dr. Janelle Rhyne and the NC Medical Board for continued support of Project Lazarus.

2. Monitoring

Drug overdose deaths have risen steadily in NC over the last decade, due primarily to unintentional poisonings from exposure to prescription opioids. Western NC has a higher burden of overdoses than the rest of the state, but also has higher prescribing of opioid for pain.

5. Evaluation In order to assess the impact that Project Lazarus is having on the community, evaluation studies include process and outcome evaluations. Process measurements include acceptability, policy changes, and data quality. Outcomes monitored include overdose statistics, reports of overdose reversals, and the use of substance abuse treatment resources. Whenever possible, independent evaluations are initiated. One such study found that after the CPI, providers in Wilkes County saw substantial improvements in key clinical indicators. Evaluation can also identify things that need improvement.

1. Community Activation and Coalition Building At the center of the Project Lazarus model is a strong community coalition. These are the basic principles. - Community organizers must know their communities. - Communities must be made aware they have a problem. - Communities must be engaged in designing the intervention. - Communities must be kept up-to-date about the results.

4. Rescue Medication Prevention efforts are not always sufficient to avoid all overdose deaths, or may take a long time to be effective in diseases as complex as substance abuse/addiction and chronic pain.

Dana Zacharias

The rescue component of Project Lazarus is a proactive response to the failures of prevention mechanisms. Rescue focuses on: 1) changing the practice of medicine (prescribing of an antidote for opioid-induced respiratory depression); 2) educating people to be better patients; and 3) changing community attitudes towards the misuse and abuse of opioids.

Contributing to the Evidence Base We were invited by the Centers for Disease Control and Prevention (CDC) to submit a paper describing the Project Lazarus model for peer-review in a special issue of a new scientific journal. Contact us for a copy of the article. More publications are on the way in 2011! Dasgupta N, Sanford C, Albert S, Brason FW II. Opioid Drug Overdoses: A prescription for harm and potential for prevention. American Journal of Lifestyle Medicine. January/February, 4(1), p. 32-7.

Dr. Albert & Dr. Gamble in Winston-Salem

SAMHSA Army National Guard Immersion

3. Prevention The prevention of overdoses must occur at multiple levels throughout the community. 1. Education of physicians in pain management. 2. Distribution of pain management tool kit. 3. Modification of ED opioid use. 4. Case management of ED and Medicaid patients. 5. Use of Controlled Substances Reporting System. 6. Hire specialized drug diversion law enforcement officials. 7. Pilot study of Project Lazarus in Wilkes County 8. School-based campaigns. 9. Unused prescription medication take-back days. 10. Public service announcements and billboards. 11. Increase options for substance abuse treatment. 12. Educational DVD on safe storage and disposal. 13. Support group for pain patients.

In order for everyone to hear your message, you must meet people where they are

All parts of society must have access to overdose prevention, whether they are doctors, pain patients, drug users, parents or children The Project Lazarus Model All overdose deaths are preventable •• The five-component strategy created by Project Lazarus is centered around community activation and a strong coalition of partners who have an active interest in preventing prescription overdose deaths. •• The Project Lazarus model capitalizes on existing data sources to provide perspectives on the overdose problem that can directly inform interventions. •• The multiple levels of prevention efforts and communitybased education are intended to reach pain patients and drug users without exacerbating stigma. •• The provision of take-home naloxone acknowledges that prevention efforts can fail or take years to have effect, and that overdose deaths can be prevented in the community. •• Finally, evaluations of specific interventions can provide input on how to improve the services.

Award-winning Video Did you know? The Project Lazarus video won the film festival prize at the Maine Maine International Symposium on Pharmaceuticals in 2009! Watch it again at or contact us for a DVD copy.


Wilkes Community College

Going Bilingual

Innovative Pharmacy Education

Many Project Lazarus materials are available in Spanish, too, including key instructions for reversing an overdose with naloxone. We anticipate translating more materials into Spanish in the coming year.

During Red Ribbon Week in October , ProjectLazarus provided community prescription drug awareness classes in Wilkes County Schools and has since provided to 705 Middle School, 513 Elementary and 54 High School students.

Thanks to the Harm Reduction Coalition and the Open Society Institute for letting us reprint their materials.

Support from Biscuitville provided for 5,000 flyers for prescription safety given to all prescription recipients the last week of October, coinciding with Red Ribbon week. Thanks to Peggy Sapp at for letting us use their artwork.

Making Air Waves The radio is still relevant! In 2010, we were interviewed on 14 sessions at local stations, including 3WC “Hometown Christian Radio” and WKBC “Hot Adult Contemporary”.

Getting Clean Wilkes County now has more drug treatment options for those suffering from substance use disorders, including the detox center. Working with Mountain Health Solutions, a new outpatient buprenorphine treatment facility opened in North Wilkesboro, accepting calls for appointments 24-hours/day. A treatment and prevention resource directory was completed and available online to all.

Sheriff Maston and Fred at Wilkes Motor Speedway West D Street, North Wilkesboro

Kay in Mitchell County The preliminary data and response to Project Lazarus has been overwhelmingly positive

“Mr. Brason is truly caring and will get you to the help you need. Everyone involved must be a willing participant to realize a life changing response.” Local Results with National Implications

Fred in Clay County

•• In 2007, Wilkes County had one of the highest rates of drug overdose deaths in the nation. Although there appears to have been a substantial decrease in overdose deaths in 2010 compared to recent years, a more thorough evaluation is required to properly account for external influences before we can draw conclusions. •• But there are some encouraging signs. For example, of the overdose deaths in Wilkes County in 2008, 82% had prescriptions from Wilkes County doctors. In 2010, only 10% of decedents’ prescriptions were written by Wilkes County doctors.

Reactions from Doctors and Nurses •• The Chronic Pain Initiative (CPI) in Wilkes County provides doctors and nurses with a toolkit and one-on-one refresher training on pain management. •• Dr. Doug Easterling at Wake Forest University conducted interviews with Wilkes clinicians to evaluate the CPI. The findings suggest that clinicians are using patient-provider agreements (“pain contracts”) and other tools more often because of the peer-to-peer pain management education sessions. Some other comments from the study: •• “Patients are more satisfied because they feel they’re validated having pain. If adhering to the contract, don’t have to feel guilty asking for pain meds.”

The Community Speaks

•• “Patients seem happier since they’re given the boundaries up front. More satisfied by knowing what to expect.”

The local online community message board regularly has discussions about Project Lazarus. The quote above comes from such a post. There is growing awareness in the community that Project Lazarus can help people get help at all stages of pain and addiction.

•• “Patients are made to be more honest about the issue once it’s documented.” •• “Improved perceptions among patients of how they need to contribute to their own plan/contract.”

Jim Graham and Fred at NC Public Health Association Conference, Wilmington

•• “Patients realize contract is binding and cannot veer from it.”

Beyond Wilkes

Online Presence

Project Lazarus has been working with pain management physicians in the US Army to develop an overdose prevention program called Operation OpioidSafe. We will also be working with the Eastern Band of Cherokee Indians to create a community based program for their nation.

We revamped our website to make it more user friendly. Our blog brings you the latest information on prescription opioid overdose research, practice and policy. Although only launched in August, we have had thousands of page views.

Project Lazarus annual report 2010  

Project Lazarus is a comprehensive community-based prescription overdoseprevention program in western North Carolina.

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