Military Workshop-1, National Rx Drug Abuse Summit, April 2-4, 2013. Becoming A Leader in Your Community presentation by Brigadier General Rebecca Halstead (ret.), Fred Wells Brason II and Lt. Col. Dr. Anthony Dragovich

1. The
First
Person
You
Must
Lead
is
You
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

2. Learning
Objec8ves
• 1.
Outline
clinically-­‐effecAve,
paAent-­‐centered
treatments
for
pain
therapy
without
the
use
of
addicAve
medicaAons.
• Discuss
how
to
bring
about
a
greater
awareness
and
access
to
these
paAent-­‐
centered
treatments.
• InvesAgate
the
integraAon
of
partnerships
across
the
DoD
and
civilian
medicine.

3. Disclosure
Statement
• Consultant
for
Standard
Process
and
will
have
off-­‐label
discussion.

4. My Background

5. My
Diagnosis
and
Treatment

6. Deployment
to
Iraq
ACHA

8. Networking
to
Make
a
Difference
AmeriCorps
US
Dept.
of
Veteran
Affairs
Drug
Enforcement
Standard
Process
Veterans
Health
AdministraAon
AdministraAon
Office
of
PaAent
Centered
Care
and
Cultural
TransformaAon
Senate
Veterans
Affairs
WestCare
Intergovernmental
RelaAons
CommiXee
Center
for
Women
Veterans
NOVA/Pharmacist
Veteran/Consultant
Council
for
Women
and
Girls
NaAonal
Guard
Bureau
 Nutri8on
Pain
Management
 Chiroprac8c
NaAonal
InsAtutes
of
Health
Task
Force
 Training
The
NaAonal
Council
for
US
Dept.
of
Health
 Coaching
Behavioral
Health
and
Human
Services
NaAonal
FoundaAon
for
Women
Legislators
US
Substance
Abuse
and
Pa8ent-­‐Centered
Mental
Health
Services
Care
DAV

9. Outcomes
• Encouraged
• Educated
• Integrated
SoluAon
Requires
Integrated
Approach
• CreaAng
HOPE
• Inspiring
Change—Increase
Focus
on
NutriAon:
– We
all
eat…
– Everyday,
mulAple
Ames
a
day…
– Significant
potenAal
to
either
get
it
a
lot
wrong
or
a
lot
right…

10. Preventing
opioid
poisonings
Promoting
responsible
pain
management

11. Our
Partners
and
Sponsors

12. COLLABORATION
Project
Lazarus
believes
that
communiAes
are
ulAmately
responsible
for
their
own
health
and
that
every
drug
overdose
is
preventable.
We
are
a
non-­‐profit
organizaAon
that
provides
training
and
technical
assistance
to
community
groups
and
clinicians
throughout
North
Carolina
and
beyond.
Using
experience,
data,
and
compassion
we
empower
communiAes
and
individuals
to
prevent
drug
overdoses
and
meet
the
needs
of
those
living
with
chronic
pain.
“A
PUBLIC
HEALTH
APPROACH
TO
OVERDOSE
PREVENTION”
STATEMENT
OF
R.
GIL
KERLIKOWSKE,
DIRECTOR
OFFICE
OF
NATIONAL
DRUG
CONTROL
POLICY
EXECUTIVE
OFFICE
OF
THE
PRESIDENT
AUGUST
23,
2012
“Project
Lazarus
is
an
excep3onal
organiza3on—not
only
because
it
saves
lives
in
Wilkes
County,
but
also
because
it
sets
a
pioneering
example
in
community-­‐
based
public
health
for
the
rest
of
the
country.”

13. UnintenAonal
Poisoning
Deaths
by
County:
N.C.,
1999-­‐2009
Prepared by Project Lazarus fwith an StaAsAcs,
Source:
N.C.
State
Center
or
Health
unrestricted educational grant1from Purdue by
Vital
StaAsAcs-­‐Deaths,
999-­‐2009
Analysis
Pharmapidemiology
and
Surveillance
Unit
Injury
E LP, NED101356
4/9/13 13

14. Cost
of
HospitalizaAons
for
UnintenAonal
Poisonings:
NC,
2008
• Average
cost
of
inpaAent
hospitalizaAons
for
an
opioid
poisoning*:
$16,970.
• Number
of
hospitalizaAons
for
unintenAonal
and
undetermined
intent
poisonings**:
5,833
• EsAmated
costs
in
2008:
$98,986,010
Does
not
include
costs
for
hospitalized
substance
abuse
*Agency
for
Healthcare
Research
and
Quality
**
NC
State
Center
for
Health
StaAsAcs,
data
analyzed
and
prepared
by
K.
Harmon,
Injury
and
Violence
PrevenAon
Branch,
DPH,
01_19_2011
Source:
NC
CSRS

17. Survey
Profile
of
NC
CounAes
Local
Health
Departments
89
Departments/100
CounAes
78%
Response

18. TradiAonal
intervenAons
intended
to
prevent
drug
abuse
have
not
been
able
to
stop
overdose
deaths
in
North
Carolina.

19. Survey: NC County Health Directors
Communi8es
lack
of
informa8on,
tools
and
leadership
to
prevent
ODs.
Source:
2011
Project
Lazarus
Health
Director
Survey

20. Differences
in
opioid
uAlizaAon
suggest
complex
phenomena
that
are
independent
of
pharmacology.
Large
ciAes
have
relaAvely
fewer
people
receiving
opioids
than
small
counAes.
Areas
with
the
highest
opioid
prescribing
also
have
the
highest
poverty.
Source:
NC
CSRS
and
US
Census

22. THE
HUB
I. Public
Awareness
–
is
parAcularly
important
because
there
are
widespread
misconcepAons
about
the
risks
of
prescripAon
drug
misuse
and
abuse.
It
is
crucial
to
build
public
idenAficaAon
of
prescripAon
drug
overdose
as
a
community
issue.
That
overdose
is
common
in
the
community,
and
that
this
is
a
preventable
problem
must
be
spread
widely.
II. Coali8on
Ac8on
-­‐
A
funcAoning
coaliAon
should
exist
with
strong
Aes
to
and
support
from
each
of
the
key
sectors
in
the
community,
along
with
a
preliminary
base
of
community
awareness
on
the
issue.
CoaliAon
leaders
should
also
have
a
strong
understanding
of
what
the
nature
of
the
issue
is
in
the
community
and
what
the
prioriAes
are
for
how
to
address
it.
III.
Data
and
Evalua8on
-­‐
The
early
data
that
you
will
need
includes
certain
health
related
informaAon
like
number
of
emergency
department
visits
and
hospitalizaAons
due
to
overdose,
number
of
overdose
deaths,
number
of
providers
in
the
county
who
acAvely
use
the
PDMP,
number
of
prescripAons
and
recipients
for
opioid
analgesics
dispensed
and
other
controlled
substances.

23. Coalition Development
Community
forums
must
be
repeated
to
moAvate
the
necessary
stakeholders
to
take
acAon.
Community
coaliAons
must
be
provided
tools
to
make
their
own
strategic
plans
and
design
locally
appropriate
intervenAons.

24. COMMUNITY
ENVIRONMENTAL
Family
SITUATION
Peers
Schools
Military
Medical
Individual
Human
Tribal
Biological
Service
Psychological
Faith
Social
Media
Spiritual
Civic
Courts
Youth
Senior Law Treatment
Services Enforcement
Local Gov’t/Health

26. The
WHEEL
Community
Educa8on
-­‐
efforts
are
those
offered
to
the
general
public
and
are
aimed
at
changing
the
percepAon
and
behaviors
around
sharing
prescripAon
medicaAons,
and
improving
safety
behaviors
around
their
use,
storage,
and
disposal.
“Prescrip)on
medica)on:
take
correctly,
store
securely,
dispose
properly
and
never
share.”
Prescriber
Educa8on
-­‐
Chronic
pain
is
recognized
as
a
complicated
medical
condiAon
requiring
a
substanAal
amount
of
knowledge
and
skill
for
appropriate
evaluaAon,
assessment,
and
management.
Reached
via
CME,
Lunch
and
Learn,
Grand
Rounds,
Webinars,
Medical
Case
Management
MeeAngs
–
Prescribers
Toolkit
1)
Pain
Agreements
2)
Use
of
PDMP
3)
Urine
Screens
4)
Assessment
modaliAes
-­‐
SBIRT
a.
Treatment
opAons
and
local
referral
network

27. Hospital
Emergency
Department
(ED)
Policies
-­‐
it
is
recommended
that
hospital
EDs
develop
a
system-­‐wide
standardizaAon
with
respect
to
prescribing
narcoAc
analgesics
as
described
in
the
Project
Lazarus/Community
Care
of
NC
Emergency
Department
Toolkit
for
managing
chronic
pain
paAents:
1)
Embedded
ED
Case
Manager
2)
“Frequent
fliers”
for
chronic
pain,
non-­‐narcoAc
medicaAon
and
referral
3)
No
refills
of
controlled
substances
4)
Mandatory
use
of
PDMP
5)
Limited
dosing
(10
tablets)
Diversion
Control
-­‐
SupporAng
paAents
who
have
pain,
parAcularly
those
who
are
treated
with
opioid
analgesics,
is
an
important
form
of
diversion
control:
take
correctly,
store
securely,
dispose
properly
and
never
share.
-­‐
Law
Enforcement,
Pharmacist
and
Facility
training
on
forgery,
methods
of
diversion
and
drug
seeking
behavior
Pain
Pa8ent
Support
-­‐
In
the
same
way
that
prescribers
benefit
from
addiAonal
educaAon
on
managing
chronic
pain,
the
complexity
of
living
with
chronic
pain
makes
supporAng
community
members
with
pain
important.
“Proper
medica)on
use
and
alterna)ves”

28. Harm
Reduc8on
–
Naloxone
rescue
medica8on
to
reverse
opioid
overdose
A
script
gives
paAents
specific
language
that
they
can
use
with
their
family
to
talk
about
overdose
and
develop
an
acAon
plan,
similar
to
a
fire
evacuaAon
plan.
Prescribetoprevent.org

29. Harm
Reduc8on
–
Naloxone
rescue
medica8on
to
reverse
opioid
overdose
The
North
Carolina
Medical
Board
has
issued
a
statement
supporAng
the
use
of
naloxone
to
prevent
overdoses:
“…The
preven)on
of
drug
overdoses
is
consistent
with
the
Board’s
statutory
mission
to
protect
the
people
of
North
Carolina.
The
Board
therefore
encourages
its
licensees
to
cooperate
with
programs
like
Project
Lazarus
in
their
efforts
to
make
naloxone
available
to
persons
at
risk
of
suffering
opioid
drug
overdose.”
AMA,
June
19,
2012
“FataliAes
caused
by
opioid
overdose
can
devastate
families
and
communiAes,
and
we
must
do
more
to
prevent
these
deaths,”
said
Dr.
Harris.
“EducaAng
both
physicians
and
paAents
about
the
availability
of
naloxone
and
supporAng
the
accessibility
of
this
lifesaving
drug
will
help
to
prevent
unnecessary
deaths.”
NADDI
supports
nasal
naloxone
The
NaAonal
AssociaAon
of
Drug
Diversion
InvesAgators
(NADDI)
has
taken
a
posiAon
to
encourage
law
enforcement
agencies
to
adopt
policies
that
would
allow
officers
to
carry
nasal
naloxone
with
them
to
administer
to
individuals
involved
in
a
an
opioid
overdose.
Proper
training
and
cerAficaAon
by
the
proper
authority
of
each
state
helps
to
ensure
proper
use
of
nasal
naloxone
on
those
in
distress
due
to
a
drug
overdose.

30. Drug
treatment
and
Recovery
Addic8on
treatment,
especially
opioid
agonist
therapy
like
methadone
maintenance
treatment
or
office
based
buprenorphine
treatment,
has
been
shown
to
dramaAcally
reduce
overdose
risk.
Unfortunately,
access
to
treatment
is
limited
by
two
main
factors:
• Availability
and
accessibility
of
treatment
opAons,
• NegaAve
aqtudes
or
s8gma
associated
with
addicAon
in
general
and
drug
treatment.

31. Can
coali8ons
help
reduce
Rx
drug
abuse?
• CounAes
with
coaliAons
had
6.2%
lower
rate
of
ED
visits
for
substance
abuse
than
counAes
with
no
coaliAons
(but
this
could
be
due
to
random
chance)
• However,
counAes
with
a
coaliAon
where
the
health
department
was
the
lead
agency
had
a
staAsAcally
significant
23%
lower
rate
of
ED
visits
(X2=2.15,
p=0.03)
than
other
counAes.
• In
counAes
with
coaliAons
1.7%
more
residents
received
opioids
than
in
counAes
without
a
coaliAon.
• Coali8ons
may
be
useful
in
reducing
the
harms
of
Rx
drug
abuse
while
improving
access
to
pain
medica8ons
at
the
same
8me.
• More
professional
coali8ons
may
have
a
greater
impact
on
reducing
Rx
drug
harms.

32. Wilkes
County
NC
! RESULTS
www.projectlazarus.org
Fred
Wells
Brason
II
32

33. The
overdose
death
rate
dropped
69%
in
two
years
auer
the
start
of
Project
Lazarus
and
the
Chronic
Pain
IniAaAve.

34. Wilkes County Opioid Prescribing
Wilkes
County
had
higher
than
state
average
opioid
dispensing
during
the
implementaAon
of
Project
Lazarus
and
the
Chronic
Pain
IniAaAve.
Access
to
prescripAon
opioids
was
not
dramaAcally
decreased.
Source:
NC
CSRS

35. Wilkes
County
Overdose
Script
History
In
2011,
not
a
single
OD
decedent
had
an
opioid
prescripAon
from
a
Wilkes
County
prescriber.
The
fundamental
risk:benefit
raAo
for
opioids
can
be
altered
for
the
beXer
through
a
community-­‐wide
approach.

36. NC
Statewide
CollaboraAve
Kate
B.
Reynolds
Charitable
Trust
-­‐
Office
of
Rural
Health
NC
Alliance
for
Health
Community
Care
NC
Project
Lazarus*
–
Governors
InsAtute
for
SA
–
UNC
Injury
and
PrevenAon
Research
Center
*(includes
NC
Div.
of
Public
Health
CDC
Transforma)on
Grant
and
MAHEC
CMS
Innova)ons
Grant)
NC
Medical
Board/NC
Medical
Society/NC
Hospital
AssociaAon
NC
College
of
Emergency
Physicians/Family
PracAce/Physicians
Assistants
NC
Div.
MHDDSAS/OTP’s/PDMP
SBI/NC
Sheriffs
AssociaAon
Carolinas
Poison
Center
Dental
Society
FQHC
PrevenAon
OrganizaAons
CoaliAons

37. Information
projectlazarus.org
communitycarenc.org
Dr.
Mike
Lancaster
mlancaster@N3CN.org
Fred
Wells
Brason
II
FWBrason2@projectlazarus.org
Robert
Wood
Johnson
Community
Health
Leader
Award
2012
AddiAonal
efforts
underway
in
NM,
VA,
TN,
OH,
MD,
ME,
OK,
etc.

38. Opera8on
OpioidSAFE
A
Collabora8ve
Effort
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

39. Learning
Objec8ves
• Demonstrate
a
collaboraAve
military/civilian
program
• Describe
a
method
to
address
opioid
dependence
for
paAents
with
severe
pain

40. Disclosure
Statement
• No
disclosures
to
report

41. Disclaimer
The
content
of
this
presentaAon
is
solely
the
opinion
and
creaAon
of
the
presenter
and
is
not
necessarily
US
Government
policy
or
opinion.

42. OperaAon
OpioidSAFE
A
Case
IllustraAon

43. The
Problem
• Soldiers
• Pain
• Pain
Treatments

44. OperaAon
OpioidSAFE
• Project
Lazarus
Program
• Comprehensive
Pain
Treatment
• Risk
StraAficaAon
• Opioid
Weaning/DetoxificaAon
Pathways

45. Program
ExecuAon
• Physician
and
Provider
EducaAon
• PaAent
and
Family
EducaAon
• Cultural
Molding
• Expert
Specialty
Pain
Medicine
ConsultaAon

46. Selected
OperaAon
OpioidSAFE
Results
• 47
paAent
enrolled
in
our
suboxone
program
• Mean
Treatment
154
days
• Success
rate
67.3%
• DOD/VA
OpioidSAFE
conference
• 89
aXendees
• 100%
rated
as
Good
or
Excellent
• 87%
=
fit
their
pracAce
• 88%
=
would
change
their
pracAce

47. Of
every
one-­‐hundred
men,
ten
shouldn't
even
be
there,
eighty
are
nothing
but
targets,
nine
are
real
fighters...We
are
lucky
to
have
them,
they
make
the
baHle...AH
but
ONE,
one
of
them
is
a
Warrior...he
will
bring
the
others
back
Heraclitus
c.
500
B.C.