Saturday, July 9, 2011

Project Lazarus: Solving Opioid Problems Sensibly

Project Lazarus While much has been said and written about problems associated with opioid analgesics, relatively little has been effectively done as yet to stem the tide of misuse, abuse, overdoses, and deaths. Rather than waiting for federal or state agencies to come to their rescue, one rural coalition took control themselves in developing a successful opioid overdose prevention program. This truly demonstrates the power of the community for solving its own public health problems.

As described in a recent special supplement to the journal Pain Medicine, Wilkes County, located in Western North Carolina, had one of the highest accidental drug-overdose death rates in the country and quadruple that found elsewhere in the state [Albert 2011]. Such fatalities in this rural area (population 66,500) were due almost exclusively to prescription opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone.

Employment in Wilkes County often involves physically demanding jobs and a large population suffers the consequences of work-related injuries, so there is a substantial burden of chronic pain. Persons dying from drug overdoses were in their late 30s on average and many decedents had considerable comorbid health conditions, including respiratory, circulatory, and metabolic disorders. Often opioids were used for both medical and nonmedical reasons and decedents exceeded their physiologic tolerance, either directly or in combination with other licit or illicit substances. More than half of overdose deaths occurred in home settings, where emergency medical care was never called because bystanders did not know how to recognize signs of overdose or what to do in an emergency.

In response, beginning in 2005, community organizations came together to assess and address the problems. An important outcome was development of a community-based overdose prevention program called “Project Lazarus.” It involves 5 components: (1) community activation and coalition building; (2) monitoring and gathering surveillance data; (3) prevention of overdoses; (4) use of rescue medication by community members for reversing overdoses; and (5) evaluating project components.

Important components of this program include education of primary care providers in managing chronic pain and safe opioid prescribing, largely through the creation of a training tool kit and face-to-face meetings. Patients and their families also are educated on opioid safety and handling overdose emergencies, and, most critically, they are provided take-home intranasal naloxone (with instructions on its use) for overdose rescue. [This application of naloxone has been described in a previous Pain-Topics UPDATE here and in an article here.]

As the authors describe the program…

“At the center of Project Lazarus is the understanding that communities are ultimately responsible for their own health and that active participation from a coalition of community partners is required for a successful public health campaign. …. Community activation describes the concrete actions required to bring communities together to develop a health promotion scheme and to build long-term social capital. The Project Lazarus model is based on previous research on community activation for health promotion, which indicates that the following organizations are the most important for successful public health campaigns: health department, schools, governmental agencies, hospitals, primary care clinical practices, churches, and newspapers; the following organizations have also been identified as having a role in health promotion in nonurban areas: television stations, health-related nonprofits, substance abuse treatment centers, and colleges.”

Preliminary unadjusted data from the program revealed that the overdose death rate decreased 38%, from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. Supporting the idea of a community-level effect, there also has been a decrease in the number of fatal-overdose victims who received prescriptions for the substance implicated in their overdose from a Wilkes County physician. Specifically, in 2008, 82% of decedents had received a prescription for an implicated substance from Wilkes prescribers, declining to 10% in 2010.

The authors observe that, while it is too early to draw a conclusion from these numbers alone, the incidences and nature of prescription opioid overdose deaths in Wilkes County changed significantly during the intervention. The data are indicative of a positive response from community-based prevention efforts; for example, Wilkes County did not have the increases in overdose deaths that nearly every other county in North Carolina experienced.

COMMENTARY: We have previously questioned whether actions to date by various government agencies have been genuinely helpful when it comes to controlling problems of opioid misuse, abuse, diversion, overdose, and mortality. Along with that we have advocated for greater involvement by communities and families in addressing those issues at the grass roots level, and the Project Lazarus initiative does just that.

Even in the best of circumstances, overmedication or overdose crises can occur with opioid medications. An essential component of Project Lazarus, in our opinion, has been the provision of intranasal naloxone, free of charge, to patients and their families along with every long-term prescription of an opioid analgesic (along with necessary training in its use). This antidote can be easily and safely administered by any family member to reverse otherwise fatal respiratory depression due to overdose while waiting for emergency help to arrive. It can save lives, and we look forward to further data from the Lazarus team to substantiate the extent of that.

The article authors concede that further evaluation of Project Lazarus is required to understand localized effects of their interventions and how they might best be replicated in other areas. For example, the 72% decline in overdose fatalities involving locally-prescribed analgesics raises the question of whether there was a change in prescribing habits due to widespread education, or were overdose victims procuring opioids in other areas of the state or in neighboring states?

In any event, this remarkable community-based project has been organized and run by only a relatively small group of highly dedicated individuals. And, from what we know, it also has been largely underfunded since the outset but continues to grow successfully — it can and should be considered as an inspiration and model for other communities to follow and build upon. The Project Lazarus website can be accessed at: (still under construction).

REFERENCE: Albert S, Brason II F, Sanford CK, et al. Project Lazarus: Community-Based Overdose Prevention in Rural North Carolina. Pain Medicine. 2011(Jun);12(Suppl s2):S77-S85 [article here].