Dr. Robert Rich's 2013 SLC presentation on opioid abuse & Community Care of North Carolina's program to address and treat the issue.

1. Community Care of North Carolina
Community and Practice Based Interventions
to Lessen Opioid Abuse and Opioid Overdoses

2. Credentials
 Robert L “Chuck” Rich, Jr., MD
 Medical Director for Community Care of the
Lower Cape Fear, Medicaid network
 Practicing MD in rural Bladen County, NC.
 AAFP Commission member, Health of the Public
and Science
 Chairperson AAFP workgroup re Opioids and
Pain Management
 No industry connections or sponsorships

3. Problem:
 Utilization of highly addictive opioid
medications has risen 160% in last 10 years
 NC death rate for unintentional poisonings is
11.4 per 100,000 citizens
22nd in the
country
 1140 such deaths occurring in 2011
 Deaths by motor vehicle accidents and
unintentional poisonings are almost equal in
NC.

4. Solution:
 A model of intervention in the chronic pain cycle based
on a successful integrated care pilot in Wilkes County,
NC, called Project Lazarus (PL)
 PL decreased unintentional overdose deaths in Wilkes County
by 69% from 2009 – 2011
 Community Care of NC, supported by a $2.6 million
grant from The Trust (Kate B Reynolds) and matching
funds from the Office of Rural Health, is expanding the
PL approach statewide through 3 interrelated initiatives:
 Community-Based Coalitions
 The Clinical Process
 Program Outcome Goals

5. The Kate B. Reynolds Trust
1.3 Million Dollars
NC Foundation for Advanced Health Programs
NC Office of Rural Health
Pass Through
2.6 Million Dollars – Matched
CCNC
Governor’s
Institute
UNC
IPRC
Project
Lazarus
14 CCNC
Networks
Pfizer
$
$
$
$
$

6. PL Initiative –
Community-Based Coalitions
Community-based Coalitions:
 Broaden awareness of extent and seriousness of
unintentional poisonings and chronic pain issues
 Support community involvement in prevention and
early intervention
 Comprised of broad range of community partners
 Law Enforcement
 Public Health
 Schools
 Hospitals
 Faith-Based Organizations

7. Marketing Project Lazarus

8. PL Initiative –
The Clinical Process
The Clinical Process:
 Focuses on medical assessment and treatment of
chronic pain
 Provides education on assessment criteria for
pain, safe opioid prescribing, use of CCNC’s
Provider Portal, and registration and use of the
Controlled Substance Reporting System (CSRS)
information

9. Target Audience
Prescribers:
Primary Care Physicians, Emergency Medicine, DOs, PAs,
NPs, Pain Management, Orthopedists, Dentists
Dispensers:
Pharmacists
Behavioral Health:
 CCNC Network Psychiatrists
 Community Psychiatrists
 Addiction Medicine Physicians
 Prescribers of Methadone/Buprenorphine (Suboxone)
 LME/MCO Medical Directors
 SA/MH Clinical Directors

10. Topics
 Overview of Chronic Pain and Pathophysiology
 Risk Assessment
 Treatment Planning/Written Agreements
 Legislative Changes: CSRS, Naloxone, Good Samaritan Laws
 Documentation
 Role of Pharmacists
 Monitoring for aberrant use
 Diagnosing Addiction
 Intervening for Misuse and Addiction
 Referring to Behavioral Health Specialists
 Case Studies

11. Clinical Trainings
 40 trainings over next 2 years
 20 trainings will offer 3 prescribed credits of CME AMA
Category 1 (CME trainings)
 20 trainings will offer the same content and agenda but will
not be eligible for CME credit (Pfizer-sponsored, non-CME
trainings)
 Each network will receive at least 1 CME training and 1 Pfizersponsored, non-CME training
 CPI Coordinators will assist in determining which
geographical locations within the network would most
benefit from CME vs. Pfizer-sponsored, non-CME training

12. A Guide to Rational
Opioid Prescribing
Agenda Evening Meeting:
5:30 - 6:00 Registration, Pre-Evaluation, and Dinner
6:00 - 6:10 Introduction to Seminar Objectives
6:10 - 6:30 Nature of Pain/Role of Opioids
6:30 - 7:00 Risk Stratification and Initiating Treatment
7:00 - 7:30 Case discussion 1: Getting started
7:30 - 7:45 Break – Sign up for the CSRS
7:45 - 8:15 Monitoring, Intervening & When to Stop
8:15 - 8:45 Case discussion 2: Monitoring/Adapting Treatment Plan
8:45 - 9:00 Wrap up/Next steps
*Turn in Post-Evaluation and get CME Certificate*

13. PL Initiative –
The Clinical Process
The Clinical Process:
 Makes use of toolkits with decision support and
other tools developed for:
 Primary Care Physicians
 Emergency Department Physicians
 Care Managers

14. Toolkit Contents
 Universal Precaution for
Prescribing & Algorithm for
Assessing and Managing Pain
 Pain Treatment Agreement and
Informed Consent
 Prescriber and Patient Education
Materials
 Screening Forms and Brief
Intervention – list of Community
Resources
 Format for Progress Notes
 Naloxone Prescribing
 Medication Flow Sheet
 Controlled Substance Reporting
 Personal Care Plan
System (CSRS) Application
 Local Community Resources

15. Medical Director Leadership
 Created educational
 Advises Care Managers and
presentation for prescribers to
Quality Improvement Staff on
use with Toolkit distribution
“difficult” chronic pain
 Conducting Lunch & Learns
with “Top 20” practices in
network with high chronic pain
patient volume and other
practices indicating interest in
chronic pain education
patients or practice-related
issues via “in person”
meetings, telephonic
consultation and use of CMIS
 Presenting at CommunityCoalition stakeholder
meetings

16. Medical Director Presentation
 Typically 1 hour long
 Discussion of NC Medical Board guidelines
 Review of current NC data
 Review of provider toolkit contents including useful
forms, basic prescriber guidelines, CSRS, DMA “lockin” procedures
 Summary with Q&A

17. Chronic Pain Patient
Care Management Activities
 Provide support to patients identified by the ED
 Referrals to PCP or specialty services
 Provide care management to CPI Priority Flag patients:
 Screenings and assessment
 Medication reconciliation
 Ensure all prescribers have a medication list
 Referral to DMA narcotic lock in program if appropriate
 Counsel patient on living with chronic pain
 Assist with appropriate referrals to behavioral health
 Educate patient and caregiver re: signs and symptoms of
overdose

18. Types of Practice Interventions
 Identification of ED and Hospital Utilization
 Recommending and/or Assisting with:
 Timely follow-up PCP appointment post ED visit or hospital
admission, including home and practice visits
 Pain assessment and behavioral health screenings
 Narcotic Lock-In
 Pain contract
 Close collaboration with pain management specialist/clinic
and/or Psychiatrist/MCO providers as a TEAM effort
 CSRS registration
 Medication reconciliations and pharmacist consultations

19. PL Initiative –
Program Outcome Goals
Program Outcome Goals:
 Measured through the Injury Prevention Research
Center and include:
 Decreased mortality due to unintentional
poisonings
 Decreased inappropriate ED utilization for pain
management
 Decreased inappropriate ED utilization of
imaging with diagnosis of chronic pain
 Increased use of Provider Portal and CSRS

20. CCLCF Chronic Pain Activities
Prior to Recent Funding
 Identified 53 chronic pain patients to follow as a
cohort group
 32 practices represented
 Survey Tool created to capture static data at baseline
 Practice and patient ID blinded
 Included data snapshot of key utilization stats
 Pharmacy section
 Case Management section
 Practice section
 Identified Top 20 practices with most patient volume
associated with chronic pain

21. Cohort Data to Track
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Sum of Inpatient Mental Health Admissions
Sum of Inpatient Non-Mental Health Admissions
Sum of Emergency Department Visits
Sum of Total Medicaid Cost
Average of Total Medicaid Cost
Sum of Total Medicaid Drug Cost
Average of Total Medicaid Drug Cost
Sum of # of Pharmacies (All Fills, Not Just Opioids)
Sum of # of Opioid Fills in Past Year
Sum of # of Benzo Fills in Past Year
Sum of # of Hypnotic Fills in Past Year

22. Cohort Data at Follow Up
Data Being Tracked
Percent of Change
Sum of Inpatient Mental Health Admissions
-14 %
Sum of Inpatient Non-Mental Health Admissions
Sum of ED Visits
0%
-30 %
Sum of Total Medicaid Cost
1%
Average of Total Medicaid Cost
1%
Sum of Total Medicaid Drug Cost
-12 %
Average of Total Medicaid Drug Cost
-12 %
Sum of Number of Pharmacies (All Fills)
-22 %
Sum of Number of Opioid Fills/Past Yr
-22 %
Sum of Number of Benzo Fills/Past Yr
- 8%
Sum of Number of Hypnotic Fills/Past Yr
33 %

23. Advocacy- Medical Boards
 Often forgotten
 2013 FSMB guidelines just released with
emphasis on proper screening, documentation,
treatment plans, monitoring
 MB monitoring often preeminent in provider
thought process compared to legislation
 Advocacy avenues include MD testimony re
proposed rules, membership on MBs, case
reviews

24. Advocacy- Legislatures
 Everyone wants the problem solved- “we just
need more rules”
 “Primary care MDs do not need to be prescribing
these meds”
 PCPs handle the bulk of prescribing and do so
safely with guidelines
 Advocacy / educational materials abundant
 No need to reinvent the wheel

25. Advocacy- LegislaturesResources
 AAFP “Prescription Drug Monitoring Report”
 AAFP position paper from OAPMWG workgroup
 National conference of State Legislatures report of
“Prevention of Prescription Drug Overdose and Abuse –
State Laws”- updated 07/2013
 FSMB policy guidelines re opioid prescribing
 State level workgroups and position papers

http://www.cdc.gov/homeandrecreationalsafety/Poisoning/laws/laws.html

www.projectlazarus.org
 Pharma resources

26. Types of Laws- CDC Website
 Laws requiring a physical examination before
prescribing
 Laws requiring tamper- resistant prescription forms
 Laws regulating pain clinics
 Laws setting prescription drug limits
 Laws prohibiting “doctor shopping”/ fraud
 Laws requiring patient identification before
dispensing
 Laws providing immunity from prosecution/ mitigation
at sentencing for individuals seeking assistance
during an overdose

27. Q&A
 QUESTION AND ANSWER TIME