Project Lazarus

Case Study

Wilkes County, NC
Project Lazarus developed a community-based overdose prevention program that focused on increasing access to naloxone for prescription opioid users by encouraging physicians to prescribe the antidote to patients at highest risk of an overdose.

Project LazarusIn response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Wilkes County and western North Carolina that focused on increasing access to naloxone for prescription opioid users. The Wilkes County unintentional poisoning mortality rate was quadruple that of the state’s in 2009 and due almost exclusively to prescription opioid pain relievers, including Fentanyl, hydrocodone, methadone, and oxycodone.

Earlier data had shown that 80% of overdose decedents had a prescription for the medication that they died from in the months prior to death, suggesting that an intervention situated in medical practice could make up for this missed opportunity for prevention. Therefore, naloxone distribution is done through encouraging physicians to prescribe the antidote to patients at highest risk of an overdose. Those entering drug treatment and anyone voluntarily requesting naloxone also were able to receive naloxone for free. The naloxone was paid for by Project Lazarus, through grants from industry, and was available at a community pharmacy. Patients watch a DVD about overdose prevention and naloxone use in the clinic, go to the pharmacy to pick up the kit, and are encouraged to watch the video at home with friends and family.

The Project Lazarus take-home naloxone provision model works as follows. A Wilkes County resident sees a physician for routine medical care. The physician, who has been trained by Project Lazarus, identifies the patient as a naloxone priority patient, based on criteria for overdose risk (Table 3). The 14 priority groups and risk factors were derived from a review of the known etiology of opioid-induced respiratory depression and clinical insight. When patients agree to participate in Project Lazarus, they watch a 20-minute DVD in the physician’s office. The video covers patient responsibilities in pain management, storage, and disposal of opioid medications, recognizing and responding to an opioid overdose, and options for substance abuse treatment. Project Lazarus participants then go to a pre-arranged community pharmacy and pick up a free naloxone kit. The messaging in Project Lazarus materials does not dwell on the differences between “legitimate” and “illicit” users of opioids, but rather presents straightforward information that can be used to prevent an overdose fatality[1]

Project Lazarus  Naloxone Priority Groups and Risk Factors for Opioid Overdose

  1. Recent medical care for opioid poisoning/intoxication/overdose
  2. Suspected or confirmed history of heroin or nonmedical opioid use
  3. High-dose opioid prescription (≥100 mg/day morphine equivalence)
  4. Any methadone prescription for opioid naive patient
  5. Recent release from jail or prison
  6. Recent release from mandatory abstinence program or drug detox program
  7. Enrolled in methadone or buprenorphine detox/maintenance (for addiction or pain)
  8. Voluntary patient request

Any opioid prescription and known or suspected:

  1. Smoking, COPD, emphysema, asthma, sleep apnea, or other respiratory system disease
  2. Renal or hepatic disease
  3. Alcohol use
  4. Concurrent benzodiazepine use
  5. Concurrent antidepressant prescription
  6. Remoteness from or difficulty accessing medical care

Our efforts over the last two years have prevented overdose deaths in Wilkes County. In a publication in Pain Medicine, we report that the overdose death rate dropped 42 percent from 2009 to 2010, with only four overdose deaths confirmed so far in 2011. Substance abuse related emergency department admissions dropped by 15.3% from 2008 to 2010. In 2010, only 10% of fatal overdoses were the result of a prescription for an opioid analgesic from a Wilkes County prescriber, down from 82% in 2008. They found that after our one-on-one education sessions, prescribers increased their use of pain agreements and utilization of the prescription monitoring program (in Wilkes, approximately 70% of eligible physicians are signed up, versus 20% for the rest of the state). Just as importantly, prescribers reported feeling more secure treating pain and increasing doses as needed; patients responded feeling legitimized in having their pain needs addressed and found it worthwhile having explicit rules within which to seek treatment.

[1] Albert S, Brason FW 2nd, Sanford CKDasgupta NGraham JLovette BProject Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 2011 Jun;12 Suppl 2:S77-85.


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