Community Care of North Carolina & Project Lazarus:
Chronic Pain Initiative
Developing Pathways for Optimal Pain Management
Surveys show that the management of chronic pain is a top concern among primary care doctors, who along with internists and dentists write the majority of prescriptions for pain relievers. Roughly, 20 percent of prescribers prescribe 80 percent of all prescription pain relievers. The Institute of Medicine (IOM) attributes the rise in the prevalence of chronic pain over the last decade to an aging population, obesity, patient expectations for aggressive pain management, increased survivorship after injury, and greater numbers of surgical procedures (Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research). The U.S. may be spending as much as $635 billion annually to treat chronic pain, which impacts more patients in the U.S. than heart disease, cancer, and diabetes combined.
In an unfortunate corollary, this flood of narcotics is fueling what can only be called an epidemic of prescription drug overdoses. Such deaths rose five-fold between 1990 and 2007, reaching unprecedented levels. In addition to the threat of overdose, inappropriate use of pain relievers has been associated with HIV, hepatitis, and worsening mental health. Individuals abusing pain relievers tax busy hospital emergency departments and can lead doctors to order unnecessary imaging and diagnostic tests. The inappropriate use of pain medications significantly impacts the entire community.
The Chronic Pain Initiative (CPI) is a community-wide response to a problem that is devastating communities all across the nation. The CPI seeks to address these challenges through a broad partnership that includes CCNC, the North Carolina Hospital Association, local hospitals and emergency departments, local health departments, primary care doctors, faith-based programs, and law enforcement. CCNC is providing financial support and tapping into CCNC’s local networks, particularly professionals who have expertise in local conditions and resources for treatment.
To assist partners in the Chronic Pain Initiative, CCNC has developed a series of toolkits aimed at providing information and resources to key players in chronic pain treatment: care managers, emergency room physicians, and primary care providers. Kits are being distributed to Pain Initiative Coordinators in each of CCNC's 14 local networks.
The Wilkes County Experience
The CPI approach is modeled after Wilkes County's Project Lazarus. An evaluation published by members of the Project Lazarus study team found that the implementation of their program in Wilkes County generated a 47% reduction in the overdose death rate from 2009 to 2010. More recent data show that the overdose death rate in Wilkes County decreased by 69% between 2009 and 2011, from 46.0 to 14.4 per 100,000 per year (see graph below), even as the level of opioid prescribing remained above the state average. Substance abuse related ED admissions dropped by 15.3% from 2008 to 2010, in marked contrast to an increase in such admissions statewide of 6.9% over this period. Most remarkably, in 2011 not a single prescription overdose decedent received a fatal prescription from a Wilkes County prescriber, down from 82% in 2008. As of 2010, 70% of the county’s prescribers were registered with the state’s prescription drug monitoring program, compared to a statewide average of only 26%.
Data from Wilkes County suggest that the results of Project Lazarus became apparent within two years of its initiation and that strong effects were apparent by the third year. It is hoped that the impact of the statewide CPI effort will be evident even earlier, as Project Lazarus' first year was devoted to developing an organizational infrastructure and intervention techniques, which have now been refined and provided to project participants in manual form (toolkits). CCNC case managers are already working with ED staff to coordinate care for chronic pain patients and facilitate referrals for appropriate treatment of the underlying causes of chronic pain.