Reducing Prescription Opioid Misuse in North Carolina

From Healthy People 2020 Stories from the Field, a series highlighting communities across the Nation that are addressing the Leading Health Indicators (LHIs).

Prescription opioids continue to factor significantly in the epidemic of deaths from opioid overdose in the United States. In 2016, more than 46 people died each day from overdoses involving prescription opioids. In addition, more than 1,000 people a day are treated in emergency departments for not using prescription opioids as directed.

Fred Wells Brason II, President and CEO, Project Lazarus

Prescription opioid overdose hits some communities harder than others. A decade ago, Wilkes County, North Carolina—a socioeconomically depressed Appalachian community of fewer than 70,000 people—had the third-highest county death rate from drug overdose in the Nation. Prescription opioids were involved in nearly all of those deaths.

Project Lazarus launched in 2007 to create a community-based response to prescription opioid overdose in Wilkes County. Its approach relies on raising public awareness, coordinating action through coalitions, and collecting strong data. The project’s activities have been so successful that other counties in North Carolina and across the country are using the Project Lazarus Model to reduce prescription opioid misuse in their own communities.

Coordinating Community-Based Interventions

The central tenets of the Project Lazarus Model are that deaths from drug overdose are preventable and communities are responsible for their own health. In other words, a successful public health campaign to address prescription opioid overdose must involve the whole community, or “village.”

“Here’s how we look at it,” says Fred Wells Brason II, President and CEO of Project Lazarus. “In order to reach and change an individual, we need to change the village, sector by sector.”

To that end, Project Lazarus created partnerships in nearly every sector of the Wilkes County community, including health departments, governmental agencies, health-related nonprofit organizations, law enforcement, substance use treatment centers, primary care clinics, pharmacies, faith organizations, and schools and colleges.

Taking a “bottom-up” approach, the program encouraged community coalitions in each of the sectors to design overdose prevention interventions for the populations they serve. Project Lazarus provided the coordination between sectors—as well as training, education, and outreach.

The community-driven interventions included:

  • Private drug treatment centers helped create a medication-assisted opioid addiction treatment program in Wilkes County that now serves 600 clients.
  • County sheriff and police departments held drug take-back events and established permanent drop boxes so people could dispose of unused prescription opioids.
  • The Wilkes County Regional Hospital Emergency Department (ED) changed its opioid dispensing policies—for example, providers began writing prescriptions for 3- to 5-day supplies rather than 30-day supplies.
  • For primary care providers, the Chronic Pain Initiative (a coalition of Medicaid and public health organizations) created toolkits with best practices for treating pain, opioid risk assessment tools, patient-physician agreement forms, and educational materials.
  • In public schools—including 4 high schools, 4 middle schools, and 8 elementary schools—Project Lazarus created programs that not only teach kids about the risks of drug use, but also help them build the decision-making and coping skills to avoid it.

Success by the Numbers

A 2017 study comparing North Carolina data from the pre-intervention period and after an 18-month intervention period found that the following interventions were associated with lower rates of opioid overdose mortality:

  • Provider education—a 9% decrease
  • Hospital ED prescription policies—3% decrease
  • Pain patient support programs—steady decline over 6 months

The study also found that medication-assisted opioid addiction treatment was associated with lower ED visits 2 to 5 months after treatment.

Additionally, since Project Lazarus launched in 2007:

  • Wilkes County saw an average decrease of 50% for deaths involving prescription opioid overdose between 2009 and 2014.
  • From 2013 to 2016, there were more than 3,400 drug overdose reversals performed in North Carolina using naloxone distributed by the North Carolina Harm Reduction Coalition.

Preventing Overdose Fatalities

Brason is particularly proud of Project Lazarus’ efforts to improve access to naloxone, an overdose reversal medication. Data from Wilkes County had shown that more than 50% of overdose deaths occurred in people’s homes—and bystanders either didn’t recognize the signs of overdose or emergency services weren’t able to arrive soon enough.

To address this, Project Lazarus met with the North Carolina Medical Board in 2007 and convinced them to become the first state to support take-home kits for naloxone. Under the provision, patients at risk of prescription opioid overdose who watch an educational video can pick up free naloxone kits at designated pharmacies or at Project Lazarus.

Ten years later, the FDA has approved take-home naloxone devices and all 50 U.S. states have passed laws that make it easier to access naloxone. “This is a major success story,” Brason says. “Our first naloxone rescue was a Wilkes County man saving his sister’s life as she was overdosing. Since then, thousands of lives have been saved because of easier access to naloxone across the country.”

Reducing the Stigma of Addiction

When asked about challenges, Brason talks about getting the community to support medication-assisted treatment, which has been shown to help people overcome addiction and stick with treatment. “Initially, people thought, ‘It’s a drug for a drug, why can’t they just get over it?’” he says. “But over time we’ve seen a change in our community, a willingness to provide support and accept treatment in all modalities.”

Overall, the Project Lazarus Model has received broad support both locally and nationally, and the program now provides training and technical assistance to help other communities implement it. Initially, several of the counties surrounding Wilkes adopted the model, and then North Carolina rolled it out statewide—all 100 counties have implemented some aspect of the model.

Project Lazarus has also trained communities in 18 other states—including in Pennsylvania, where the House of Representatives voted unanimously in 2017 for a Project Lazarus Commission to develop a best practices model for a comprehensive, community-based effort to consolidate overdose prevention efforts.

What is Brason’s advice to communities looking at the Project Lazarus Model? “Success doesn’t mean that everybody in every corner of the community has to be on board at first,” he says. “You just begin wherever there’s energy, and then you’ll find that the rest of the community comes along and becomes a part of the solution.”

Resource for Health Professionals and Students

Want to learn more about the appropriate, safe, and effective use of opioids? Explore Pathways to Safer Opioid Use, a free training based on the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan).

This interactive tool allows users to take on the roles of various health professionals and make decisions to help prevent opioid-related ADEs.

About Stories from the Field

Each month, this series highlights how communities across the Nation are addressing the Healthy People 2020 Leading Health Indicators (LHIs). LHIs are a subset of 26 Healthy People 2020 objectives that communicate high-priority health issues. Tackling the LHIs appropriately will dramatically reduce the leading causes of death and preventable illnesses.

This month’s story features a program that is addressing the Injury and Violence LHI topic.

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