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MAY / JUNE 2013 :: 74(3)
Chronic Pain

This issue focuses on the challenge of managing chronic pain. Commentaries present various treatment options, including opioids, nonopioid medications, surgery, and alternative therapies. Authors also address the problems of opioid misuse and abuse and discuss ways to lessen these risks. Original articles examine health professionals’ communication with adolescents about smoking, as well as children's immunization status as verified by practice records and by the North Carolina Immunization Registry.


Project Lazarus: An Innovative Community Response to Prescription Drug Overdose

Fred Wells Brason II, Candice Roe, Nabarun Dasgupta

N C Med J. 2013;74(3):259-261.PDF | TABLE OF CONTENTS

Nestled in the foothills of North Carolina near the Blue Ridge Parkway, Wilkes County is a rural area full of rich traditions that have been upheld by many generations of families. These families have learned to make the low-mountain country their home by trusting in one another and being willing to share their belongings with family members and friends. Unfortunately, when close-knit families and friends share prescription opioid medications, the entire community can suffer.

Wilkes County has a population of fewer than 70,000 people, but in 2007 it had an unintentional drug-poisoning mortality rate of 28.3 deaths per 100,000 population—the third-highest county death rate from drug overdose in the country [1]. Almost all of these Wilkes County deaths were from overdoses of prescription opioid pain relievers [2]. In 2005, members of the community, including myself, began to take notice of the county’s high unintentional drug-poisoning mortality rate. I was director and chaplain of hospice for Wilkes Regional Medical Center at the time, and I became concerned when prescribers began notifying me that they could no longer safely prescribe opioids to their hospice patients, due to medications being shared, stolen, or sold within patients’ households.

I began by investigating the relationship between doctors and patients, focusing primarily on how doctors were prescribing prescription opioid medications and how patients were using these medications. Realizing that the epidemic of overdoses was getting out of hand, I turned to the local health department, to law enforcement officials, and to hospital emergency departments for answers, but no one I contacted was able to offer a solution to the problem. I then became the chair of the Wilkes Healthy Carolinians Substance Abuse Task Force. After contacting state and federal authorities, who were also unable to provide a solution to the problem, I decided that it was time for Wilkes County to take action as a community.

The first step was to make the community aware of the problem. I began by gathering real-time data and engaging community stakeholders. Doctors, heads of school systems, law enforcement officials, medical directors, and others began helping to build public awareness of the problem. This initial step of increasing public awareness was crucial in building a coalition that would continue to serve Wilkes County in our fight against overdoses. In 2007, as the community was beginning to accept and work towards finding a solution to the problems associated with prescription opioids, our efforts were noticed by Northwest Community Care Network (NWCCN), the local network of health professionals that provides primary care for Medicaid enrollees. In 2008 NWCCN began the Chronic Pain Initiative for Wilkes County, and I was appointed to be the project director.

As other communities saw Wilkes County endeavoring to solve its prescription opioid problem, they began to ask how they could implement a similar plan. It became apparent that we needed a name for the drug overdose prevention project that the NWCCN Project Advisory Committee and I had undertaken in 2008; we chose the name Project Lazarus. Soon afterward, a public hearing was held at the North Carolina Medical Board, which resulted in the board approving and encouraging the practice of co-prescribing the opioid antidote naloxone together with opioid medications when a patient is judged to be at risk of overdosing. After this approval was obtained, Project Lazarus began to expand into other counties, and it is now operating statewide with the help of funding from the Kate B. Reynolds Charitable Trust, the North Carolina Office of Rural Health and Community Care, the Mountain Area Health Education Center, Purdue Pharma L.P., and other sources.

With help from the community, I devised a model for addressing the problems associated with prescription opioids. The model is based on 2 premises: that drug overdose deaths are preventable, and that communities are responsible for the health of their members. The model was developed in response to some of the highest drug-overdose death rates in the country; Wilkes County’s rate of drug-overdose deaths was 46.6 deaths per 100,000 population in 2009 [2]. Fortunately, implementation of the model’s 10 components has had an appreciable impact on unintentional overdose deaths, which dropped to 29.0 deaths per 100,000 population in 2010 [2] and to 14.4 deaths per 100,000 population by 2011 (unpublished report, Wilkes County Health Department).

The Project Lazarus model can be conceptualized as a wheel, with 3 core components serving as the hub of the wheel and another 7 components serving as the spokes. The components comprising the hub of the wheel are public awareness, coalition action, and data and evaluation. Once those components are in place, communities can begin adding the components that make up the spokes: community education, prescriber education, changes in hospital emergency department policies, diversion control, support for patients with chronic pain, harm reduction, and access to addiction treatment.

Building on its success in Wilkes County, Project Lazarus was subsequently implemented in other North Carolina counties, at the US Army installation at Fort Bragg, and in the Qualla Boundary (a land trust in Western North Carolina that is home to members of the Eastern Band of Cherokee Indians). During 2011 and 2012, Project Lazarus then partnered with Community Care of North Carolina, which spread the Project Lazarus model further, eventually implementing it in all 100 North Carolina counties. The Project Lazarus model has also spread to other states, including New Mexico, Ohio, Virginia, and Maine. Project Lazarus has had a large impact on the areas where it has been established, and these results have caught the attention of Director of National Drug Control Policy R. Gil Kerlikowske.

As Figure 1 shows, Wilkes County has a history of exceptionally high mortality rates from unintentional drug poisoning, chiefly from prescription opioid overdoses. However, since the implementation of Project Lazarus, unintentional drug-poisoning mortality rates have drastically decreased in Wilkes County, emergency department visits related to substance abuse have decreased, and treatment for overdose has become more accessible [3]. To provide safe access to care for patients with chronic pain, the public needs to be educated about prescription drugs, with emphasis on the fact that these drugs must be taken correctly, stored securely, disposed of properly, and never shared. In addition, prescribers should institute best-practice methods of patient assessment, teach safety education, and provide ongoing monitoring by utilizing the North Carolina Controlled Substances Reporting System along with other measures. Together, these efforts can help chronic pain patients find relief.

Financial support. Project Lazarus has received grants from Purdue Pharma L.P. and Covidien.

Potential conflicts of interest. F.W.B is an employee of Project Lazarus and serves as a consultant for Purdue Pharma L.P.

1. CDC WONDER online database, compiled from Multiple Cause of Death File 2005–2008. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed April 13, 2010.

2. Albert S, Brason FW 2nd, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 2011;12(suppl 2):S77-S85.

3. $2.6 Million announced to take Project Lazarus statewide! Project Lazarus Web site. Accessed June 3, 2013.

Fred Wells Brason II president and chief executive officer, Project Lazarus, Moravian Falls, North Carolina.
Candice Roe, BA operations assistant, Project Lazarus, Moravian Falls, North Carolina.
Nabarun Dasgupta, PhD epidemiologist, Project Lazarus, Moravian Falls, North Carolina.

Address correspondence to Mr. Fred Wells Brason II, Project Lazarus, PO Box 261, Moravian Falls, NC 28654 (