Becoming a leader_final


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Military Workshop-1, National Rx Drug Abuse Summit, April 2-4, 2013. Becoming A Leader in Your Community presentation by Brigadier General Rebecca Halstead (ret.), Fred Wells Brason II and Lt. Col. Dr. Anthony Dragovich

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Becoming a leader_final

  1. 1. The  First  Person  You  Must  Lead   is  You   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  2. 2. Learning  Objec8ves  •  1.  Outline  clinically-­‐effecAve,  paAent-­‐centered   treatments  for  pain  therapy  without  the  use  of   addicAve  medicaAons.  •  Discuss  how  to  bring  about  a  greater   awareness  and  access  to  these  paAent-­‐ centered  treatments.  •  InvesAgate  the  integraAon  of  partnerships   across  the  DoD  and  civilian  medicine.  
  3. 3. Disclosure  Statement  •  Consultant  for  Standard  Process  and  will  have     off-­‐label  discussion.  
  4. 4. My Background
  5. 5. My  Diagnosis  and  Treatment  
  6. 6. Deployment  to  Iraq   ACHA
  7. 7. Networking  to  Make  a  Difference   AmeriCorps   US  Dept.  of  Veteran  Affairs                 Drug  Enforcement   Standard  Process        Veterans  Health  AdministraAon   AdministraAon          Office  of  PaAent  Centered  Care  and                              Cultural  TransformaAon   Senate  Veterans  Affairs   WestCare          Intergovernmental  RelaAons   CommiXee          Center  for  Women  Veterans   NOVA/Pharmacist   Veteran/Consultant   Council  for  Women  and  Girls  NaAonal  Guard  Bureau     Nutri8on   Pain  Management       Chiroprac8c   NaAonal  InsAtutes  of  Health   Task  Force     Training   The  NaAonal  Council  for   US  Dept.  of  Health       Coaching   Behavioral  Health   and  Human  Services   NaAonal  FoundaAon  for   Women  Legislators   US  Substance  Abuse  and   Pa8ent-­‐Centered   Mental  Health  Services   Care   DAV  
  8. 8. Outcomes  •  Encouraged  •  Educated  •  Integrated  SoluAon  Requires  Integrated   Approach  •  CreaAng  HOPE  •  Inspiring  Change—Increase  Focus  on  NutriAon:   –  We  all  eat…   –  Everyday,  mulAple  Ames  a  day…   –  Significant  potenAal  to  either  get  it  a  lot  wrong  or  a   lot  right…  
  9. 9. Preventing  opioid  poisonings  Promoting  responsible  pain  management  
  10. 10. Our  Partners  and  Sponsors  
  11. 11. COLLABORATION   Project   Lazarus   believes   that   communiAes   are   ulAmately   responsible   for   their   own   health   and   that   every   drug   overdose   is   preventable.   We   are   a   non-­‐profit   organizaAon   that   provides   training   and   technical   assistance   to   community   groups   and   clinicians   throughout   North   Carolina   and   beyond.   Using   experience,   data,   and   compassion   we   empower   communiAes   and   individuals   to   prevent   drug   overdoses   and   meet   the   needs   of   those   living   with  chronic  pain.   “A  PUBLIC  HEALTH  APPROACH  TO  OVERDOSE  PREVENTION”    STATEMENT  OF  R.  GIL  KERLIKOWSKE,  DIRECTOR  OFFICE  OF  NATIONAL  DRUG   CONTROL  POLICY  EXECUTIVE  OFFICE  OF  THE  PRESIDENT        AUGUST  23,  2012  “Project  Lazarus  is  an  excep3onal  organiza3on—not  only  because  it  saves  lives  in  Wilkes  County,  but  also  because  it  sets  a  pioneering  example  in  community-­‐ based  public  health  for  the  rest  of  the  country.”  
  12. 12. UnintenAonal  Poisoning  Deaths  by  County:  N.C.,  1999-­‐2009   Prepared by Project Lazarus fwith an StaAsAcs,   Source:  N.C.  State  Center   or  Health   unrestricted educational grant1from Purdue by   Vital  StaAsAcs-­‐Deaths,   999-­‐2009  Analysis   Pharmapidemiology  and  Surveillance  Unit   Injury  E LP, NED1013564/9/13 13
  13. 13. Cost  of  HospitalizaAons  for  UnintenAonal   Poisonings:  NC,  2008   •  Average  cost  of  inpaAent  hospitalizaAons      for  an  opioid  poisoning*:                $16,970.   •  Number  of  hospitalizaAons  for  unintenAonal      and  undetermined  intent  poisonings**:      5,833   •  EsAmated  costs  in  2008:  $98,986,010   Does  not  include  costs  for  hospitalized  substance  abuse   *Agency  for  Healthcare  Research  and  Quality   **  NC  State  Center  for  Health  StaAsAcs,  data  analyzed  and  prepared  by  K.  Harmon,  Injury  and   Violence  PrevenAon  Branch,  DPH,  01_19_2011   Source:  NC  CSRS  
  14. 14. Survey  Profile  of  NC  CounAes   Local  Health  Departments  89  Departments/100  CounAes   78%  Response  
  15. 15. TradiAonal  intervenAons  intended  to  prevent  drug  abuse  have  not  been   able  to  stop  overdose  deaths  in  North  Carolina.  
  16. 16. Survey: NC County Health DirectorsCommuni8es  lack  of  informa8on,  tools  and  leadership  to  prevent  ODs.   Source:    2011  Project  Lazarus  Health  Director  Survey  
  17. 17. Differences  in  opioid  uAlizaAon  suggest  complex  phenomena  that  are  independent  of   pharmacology.  Large  ciAes  have  relaAvely  fewer  people  receiving  opioids  than  small   counAes.  Areas  with  the  highest  opioid  prescribing  also  have  the  highest  poverty.   Source:  NC  CSRS  and  US  Census  
  18. 18.  THE  HUB  I.  Public  Awareness  –  is  parAcularly  important  because  there  are  widespread   misconcepAons  about  the  risks  of  prescripAon  drug  misuse  and  abuse.    It  is   crucial  to  build  public  idenAficaAon  of  prescripAon  drug  overdose  as  a   community  issue.  That  overdose  is  common  in  the  community,  and  that  this  is  a   preventable  problem  must  be  spread  widely.  II.  Coali8on  Ac8on  -­‐  A  funcAoning  coaliAon  should  exist  with  strong  Aes  to  and   support  from  each  of  the  key  sectors  in  the  community,  along  with  a  preliminary   base  of  community  awareness  on  the  issue.    CoaliAon  leaders  should  also  have  a   strong  understanding  of  what  the  nature  of  the  issue  is  in  the  community  and   what  the  prioriAes  are  for  how  to  address  it.      III.  Data  and  Evalua8on  -­‐  The  early  data  that  you  will  need  includes  certain    health  related  informaAon  like  number  of  emergency  department  visits  and    hospitalizaAons  due  to  overdose,  number  of  overdose  deaths,  number  of    providers  in  the  county  who  acAvely  use  the  PDMP,  number  of  prescripAons  and    recipients  for  opioid  analgesics  dispensed  and  other  controlled  substances.    
  19. 19. Coalition Development Community  forums   must  be  repeated  to   moAvate  the  necessary   stakeholders  to  take  acAon.  Community  coaliAons  must  be  provided  tools  to  make   their  own  strategic  plans   and  design  locally  appropriate  intervenAons.  
  20. 20. COMMUNITY   ENVIRONMENTAL Family SITUATION Peers Schools Military Medical Individual HumanTribal Biological Service Psychological Faith Social Media Spiritual Civic Courts Youth Senior Law Treatment Services Enforcement Local Gov’t/Health
  21. 21. The  WHEEL    Community  Educa8on  -­‐  efforts  are  those  offered  to  the  general  public  and  are  aimed  at  changing  the  percepAon  and    behaviors  around  sharing  prescripAon  medicaAons,  and  improving  safety    behaviors  around  their  use,  storage,  and  disposal.       “Prescrip)on  medica)on:  take  correctly,  store  securely,       dispose  properly  and  never  share.”  Prescriber  Educa8on  -­‐  Chronic  pain  is  recognized  as  a  complicated  medical    condiAon  requiring  a  substanAal  amount  of  knowledge  and  skill  for    appropriate  evaluaAon,  assessment,  and  management.  Reached  via  CME,    Lunch  and  Learn,  Grand  Rounds,  Webinars,  Medical  Case  Management        MeeAngs  –  Prescribers  Toolkit        1)    Pain  Agreements        2)    Use  of  PDMP        3)    Urine  Screens        4)    Assessment  modaliAes  -­‐  SBIRT            a.    Treatment  opAons  and  local  referral  network  
  22. 22. Hospital  Emergency  Department  (ED)  Policies  -­‐  it  is  recommended  that  hospital  EDs    develop  a  system-­‐wide  standardizaAon  with  respect  to  prescribing  narcoAc      analgesics  as  described  in  the  Project  Lazarus/Community  Care  of  NC  Emergency    Department  Toolkit  for  managing  chronic  pain  paAents:      1)    Embedded  ED  Case  Manager      2)    “Frequent  fliers”  for  chronic  pain,  non-­‐narcoAc  medicaAon  and  referral      3)    No  refills  of  controlled  substances      4)    Mandatory  use  of  PDMP      5)    Limited  dosing  (10  tablets)  Diversion  Control  -­‐  SupporAng  paAents  who  have  pain,  parAcularly  those  who  are  treated    with  opioid  analgesics,  is  an  important  form  of  diversion  control:  take  correctly,  store  securely,  dispose  properly  and  never  share.        -­‐  Law  Enforcement,  Pharmacist  and  Facility  training  on  forgery,  methods  of        diversion  and  drug  seeking  behavior  Pain  Pa8ent  Support  -­‐  In  the  same  way  that  prescribers  benefit  from  addiAonal  educaAon  on  managing  chronic  pain,  the  complexity  of  living  with  chronic  pain  makes  supporAng  community  members  with  pain  important.       “Proper  medica)on  use  and  alterna)ves”  
  23. 23. Harm  Reduc8on  –  Naloxone  rescue  medica8on              to  reverse  opioid  overdose   A  script  gives  paAents  specific  language  that  they  can   use  with  their  family  to  talk  about  overdose  and  develop   an  acAon  plan,  similar  to  a  fire  evacuaAon  plan.  
  24. 24. Harm  Reduc8on  –  Naloxone  rescue  medica8on              to  reverse  opioid  overdose  The  North  Carolina  Medical  Board  has  issued  a  statement  supporAng  the  use  of  naloxone  to  prevent  overdoses:    “…The  preven)on  of  drug  overdoses  is  consistent  with  the  Board’s  statutory  mission  to  protect  the  people  of  North  Carolina.  The  Board  therefore  encourages  its  licensees  to  cooperate  with  programs  like  Project  Lazarus  in  their  efforts  to  make  naloxone  available  to  persons  at  risk  of  suffering  opioid  drug  overdose.”    AMA,  June  19,  2012    “FataliAes  caused  by  opioid  overdose  can  devastate  families  and  communiAes,  and  we  must  do  more  to  prevent  these  deaths,”  said  Dr.  Harris.  “EducaAng  both  physicians  and  paAents  about  the  availability  of  naloxone  and  supporAng  the  accessibility  of  this  lifesaving  drug  will  help  to  prevent  unnecessary  deaths.”  NADDI  supports  nasal  naloxone  The  NaAonal  AssociaAon  of  Drug  Diversion  InvesAgators  (NADDI)  has  taken  a  posiAon  to  encourage  law  enforcement  agencies  to  adopt  policies  that  would  allow  officers  to  carry  nasal  naloxone  with  them  to  administer  to  individuals  involved  in  a  an  opioid  overdose.  Proper  training  and  cerAficaAon  by  the  proper  authority  of  each  state  helps  to  ensure  proper  use  of  nasal  naloxone  on  those  in  distress  due  to  a  drug  overdose.  
  25. 25. Drug  treatment  and  Recovery  Addic8on  treatment,  especially  opioid  agonist  therapy  like  methadone  maintenance  treatment  or  office  based  buprenorphine  treatment,  has  been  shown  to  dramaAcally  reduce  overdose  risk.    Unfortunately,  access  to  treatment  is  limited  by  two  main  factors:    •  Availability  and  accessibility  of  treatment  opAons,    •  NegaAve  aqtudes  or  s8gma  associated  with  addicAon      in  general  and  drug  treatment.      
  26. 26. Can  coali8ons  help  reduce  Rx  drug  abuse?  •  CounAes  with  coaliAons  had  6.2%  lower  rate  of  ED  visits  for  substance   abuse  than  counAes  with  no  coaliAons  (but  this  could  be  due  to   random  chance)  •  However,  counAes  with  a  coaliAon  where  the  health  department  was   the  lead  agency  had  a  staAsAcally  significant  23%  lower  rate  of  ED   visits  (X2=2.15,  p=0.03)  than  other  counAes.  •  In  counAes  with  coaliAons  1.7%  more  residents  received  opioids  than   in  counAes  without  a  coaliAon.  •  Coali8ons  may  be  useful  in  reducing  the  harms  of  Rx  drug  abuse   while  improving  access  to  pain  medica8ons  at  the  same  8me.  •  More  professional  coali8ons  may  have  a  greater  impact  on  reducing   Rx  drug  harms.  
  27. 27. Wilkes  County  NC  ! RESULTS   Fred  Wells  Brason  II   32  
  28. 28. The  overdose  death  rate  dropped  69%  in  two  years  auer  the  start  of  Project   Lazarus  and  the  Chronic  Pain  IniAaAve.  
  29. 29. Wilkes County Opioid Prescribing Wilkes  County  had  higher  than  state  average  opioid  dispensing  during  the   implementaAon  of  Project  Lazarus  and  the  Chronic  Pain  IniAaAve.  Access  to   prescripAon  opioids  was  not  dramaAcally  decreased.   Source:  NC  CSRS  
  30. 30. Wilkes  County  Overdose  Script  History   In  2011,  not  a  single  OD  decedent  had  an  opioid  prescripAon  from  a  Wilkes  County  prescriber.  The  fundamental  risk:benefit  raAo  for  opioids  can  be  altered  for  the  beXer   through  a  community-­‐wide  approach.  
  31. 31. NC  Statewide  CollaboraAve   Kate  B.  Reynolds  Charitable  Trust  -­‐  Office  of  Rural  Health   NC  Alliance  for  Health   Community  Care  NC   Project  Lazarus*  –  Governors  InsAtute  for  SA  –  UNC  Injury  and  PrevenAon  Research  Center  *(includes  NC  Div.  of  Public  Health  CDC  Transforma)on  Grant  and  MAHEC  CMS  Innova)ons  Grant)  NC  Medical  Board/NC  Medical  Society/NC  Hospital  AssociaAon  NC  College  of  Emergency  Physicians/Family  PracAce/Physicians  Assistants  NC  Div.  MHDDSAS/OTP’s/PDMP  SBI/NC  Sheriffs  AssociaAon  Carolinas  Poison  Center  Dental  Society  FQHC  PrevenAon  OrganizaAons  CoaliAons  
  32. 32.                           Dr.  Mike  Lancaster  Fred  Wells  Brason  II      Robert  Wood  Johnson  Community  Health  Leader  Award  2012     AddiAonal  efforts  underway  in  NM,  VA,  TN,  OH,  MD,  ME,  OK,  etc.    
  33. 33. Opera8on  OpioidSAFE  A  Collabora8ve  Effort   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  34. 34. Learning  Objec8ves  •  Demonstrate  a  collaboraAve  military/civilian   program  •  Describe  a  method  to  address  opioid   dependence  for  paAents  with  severe  pain  
  35. 35. Disclosure  Statement  •  No  disclosures  to  report  
  36. 36. Disclaimer  The  content  of  this  presentaAon  is  solely  the  opinion  and  creaAon  of  the  presenter  and  is  not  necessarily  US  Government  policy  or  opinion.  
  37. 37. OperaAon  OpioidSAFE     A  Case  IllustraAon  
  38. 38. The  Problem  •  Soldiers  •  Pain  •  Pain  Treatments  
  39. 39. OperaAon  OpioidSAFE  •  Project  Lazarus  Program  •  Comprehensive  Pain  Treatment  •  Risk  StraAficaAon  •  Opioid  Weaning/DetoxificaAon  Pathways  
  40. 40. Program  ExecuAon  •  Physician  and  Provider  EducaAon  •  PaAent  and  Family  EducaAon  •  Cultural  Molding  •  Expert  Specialty  Pain  Medicine  ConsultaAon  
  41. 41. Selected  OperaAon  OpioidSAFE  Results  •  47  paAent  enrolled  in  our  suboxone  program   •  Mean  Treatment  154  days   •  Success  rate  67.3%  •  DOD/VA  OpioidSAFE  conference   •  89  aXendees   •  100%  rated  as  Good  or  Excellent   •  87%  =    fit  their  pracAce   •  88%  =    would  change  their  pracAce    
  42. 42. Of  every  one-­‐hundred  men,  ten  shouldnt  even  be  there,  eighty   are  nothing  but  targets,  nine  are  real  fighters...We  are  lucky  to   have  them,  they  make  the  baHle...AH  but  ONE,  one  of  them  is   a  Warrior...he  will  bring  the  others  back  Heraclitus  c.  500  B.C.