Project Lazarus

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Project Lazarus Wilkes County, North Carolina
Preventing opioid poisonings Promoting
responsible pain management
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Project Lazarus
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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
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Domestic Experience
http//www.npr.org/templates/story/story.php?story
Id17578955
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Naloxone hydrochloride (Narcan)

• Mu-opioid receptor antagonist
• Cant 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

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Naloxone ( ) in the Brain
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
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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
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Harm Reduction Coalition - NY
instructions (Spanish English)
prescription
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Chicago Recovery Alliance
IM syringe
prescription on box
10 mL vial of 0.4 mg/mL naloxone
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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.
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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.

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(No Transcript)
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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.
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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
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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 (gt 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) ___________________________
  ____________

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Intake Form

• Patient information
• Risk Factors/ Indications/ Populations (14)
• Document training
• Dispensing details

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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

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Massachusetts

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Intranasal Administration
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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

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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

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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, were not
  professionals but if we have it at hand we can
  save somebodys life with this stuff
  naloxoneits a lifesaver, theres no
  question.
• quote collected by Suzanne Carlberg-Racich,
  Chicago

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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_at_unc.edu
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Backup slides
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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)

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Heroin Poisonings in France
Source Carrieri PM, 2006, Clin Infect Dis, 43
S197-215, data from Emmanueli (slide 38)
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Heroin-related Crime in France
Source Emmanueli J, 2005, Addiction, 100
1690-1700
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Number of Fatal Poisonings by Manner of Death
NC Residents, 1997-2006
Source NC State Center for Health Statistics,
August 2007
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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
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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)

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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
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Pharmacotherapy of Pain
Also hepatic renal f(x), gastric
sprains, aches, toothache
?
?
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Unintentional Opioid Poisoning Deaths, USA,
1999-2003, 15-54 years-old
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Increasing Poisoning Mortality (USA)
Unintentional
Intentional
Undetermined Intent
Source Paulozzi L, et al. Pharmacoepidemiol Drug
Saf. 2006 Sep15(9)618-27.
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Short-acting opioids
Heroin
Methadone
Two-month moving averages of opioid overdose
deaths, imputed, 15-54 year-olds, USA
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Unintentional Poisoning Death Rates, 1999-2003