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Chronic Pain Initiative
CCNC and Project Lazarus:
Chronic Pain and Community Initiative
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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What is the Chronic Pain Initiative?

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 Focus
Primary Care Physician Toolkit
Take only your own medications
Emergency Department Toolkit
Keep medications in a safe place
Care Management Toolkit
Education on dangers of opioids
Network CPI Champion
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
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Unintentional Poisoning Deaths
by County: N.C., 1999-2009
1999 - 2001
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2009 Analysis by
Injury Epemiology and Surveillance Unit
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Unintentional Poisoning Deaths
by County: N.C., 1999-2009
2002 - 2005
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2009 Analysis by
Injury Epemiology and Surveillance Unit
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Unintentional Poisoning Deaths
by County: N.C., 1999-2009
2006 - 2009
Source: N.C. State Center for Health Statistics,
Vital Statistics-Deaths, 1999-2009 Analysis by
Injury Epemiology and Surveillance Unit
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Poisonings on the Rise
NC mortality rates, unintentional and undetermined intent poisonings, 2001-2010
Mortality rate/100,000 population
14.0
12.0
10.4
10.0
8.5
8.0
6.0
10.5
11.5
10.4
11.8
10.4
8.8
6.8
5.5
4.0
2.0
0.0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
*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.
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Problem Acute in Wilkes
County
Unintentional and undetermined intent poisoning mortality rates
Wilkes County, NC 2003-2009
50
46
Mortality rate/100,000 population
45
41.6
40
35
30
25
23.9
24.5
26.9
NC
28.3
Wilkes
20
15
10
10.8
8.2 10.4
10.5 9.9
8
8.2
6.7 8.5 7.1
USA
11.5
5
0
2003 2004 2005 2006 2007 2008 2009
Source: NC SCHS, August 2009
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NC Cost of Hospitalizations
for Unintentional Poisonings
 Average cost of inpatient hospitalizations
for an opioid poisoning*:
 Number of hospitalizations for unintentional
and undetermined intent poisonings**:
$16,970
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
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Medicaid Network Patient
Case Management
100 North Carolina counties
Patients with >12 opioid scripts
and >=10 ED visits in past 12
months
#
2,256
ED Visits (average per visit cost
$2,610.00)
>12 narcotics
Cost
$5,881,160
16,172
Controlled
Substances/Overdoses
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Opioids a Rising NC Problem
Narcotics causing or contributing to fatal unintentional and undetermined
intent poisonings*: N.C. residents, 2001-2010
600
2001
513 510
500
2002
474
400
365
347
339
2003
t
2004
308 313
300
277 287
267
243
220
200
170
138
272
231
229
160
140
179
2006
2007
89
100
2005
235
179
176
152
286
2008
0
2009
Cocaine & Heroin Other and Synthetic
Opioids
Methadone
2010
*Source: NC State Center for Health Statistics; annually generated poisoning report for Project Lazarus
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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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Key Ingredients in Chronic
Pain Initiative

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
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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 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)
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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 patientsreferrals 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 Results
1. Lower Risk in the Community
2. Similar Benefit to Patients
69%
3. Improved Risk : Benefit
15% 
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)
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Alleghany
Ashe
Stokes
Granville
Alamance
Yadkin
Forsyth
Guilford
Caldwell Alexander
Davie
Madison
McDowell
Rutherford
Graham
Jackson
Macon
Tyrrell
Edgecombe
Washington
Randolph
Gaston
Chatham
Pitt
Mecklenburg
Johnston
Lee
Harnett
Stanly
Montgomery
Lenoir
Craven
Pamlico
Richmond
Anson
Hoke
Cumberland
Sampson
Jones
Duplin
Scotland
Onslow
Robeson
Bladen
Pender
Hanover
Columbus
Brunswick
Legend
AccessCare Network Sites
Community Care Plan of Eastern Carolina
AccessCare Network Counties
Community Health Partners
Community Care of Western North Carolina
Northern Piedmont Community Care
Community Care of the Lower Cape Fear
Northwest Community Care
Carolina Collaborative Community Care
Partnership for Health Management
Community Care of Wake and Johnston Counties
Community Care of the Sandhills
Community Care Partners of Greater Mecklenburg
Community Care of Southern Piedmont
Carolina Community Health Partnership
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Source: CCNC 2011
Beaufort
Greene
Wayne
Moore
Clay
Union
Dare
Wilson
Rowan
Cabarrus
Cleveland
Nash
Martin
Lincoln
Henderson
Polk
Cherokee
Catawba
Durham
Davidson
Burke
Buncombe
Bertie
Franklin
Orange
Wake
Iredell
Haywood
Hertford
Chowan
Wilkes
r
Gates
a
Rockingham Caswell Person
Halifax
Watauga
Swain
Northhampton
Warren
Surry
Hyde
Contact
 Dr. Mike Lancaster
 [email protected]
 Fred Wells Brason II
 [email protected]
 www.communitycarenc.org
 www.projectlazarus.org
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