A community-based effort to reduce prescription opioid misuse and abuse in Wilkes County, N.C., became a model for other cities in the U.S. after it lowered the overdose rate by nearly three-quarters over three years. Transforming Care spoke to Fred Wells Brason II, one of its founders, about how the organization approached the problem and what lessons it holds for other rural communities grappling with the issue.
While overdoses from prescription opioids are a national problem, they disproportionately affect rural communities, where emergency services are more limited, addiction treatment options are sparser, and higher rates of poverty and unemployment contribute to drug diversion and abuse.1 In 2007, one of the hardest hit areas in the U.S. was Wilkes County, N.C. Once dubbed the Moonshine Capital of the World, the county on the eastern slope of the Blue Ridge Mountains had fewer than 70,000 residents but the third-highest prescription opioid overdose rate in the nation.2 A community-based effort to reduce opioid misuse and abuse, known as Project Lazarus, cut the overdose rate by 72 percent over three years, bringing the rate close to that in the state overall. The Project Lazarus model, which has spread to more than 20 states, encourages cross-sector collaboration to address the problem, promotes public and provider education, and focuses on increasing access to treatment for chronic pain and substance abuse disorder.
Components of the Project Lazarus model include:
A 2015 study of ambulance calls in 42 states found death rates from drug overdoses were 45 percent higher in rural communities than urban ones.3
Transforming Care: You’ve been instrumental in the development of the Project Lazarus model despite not having a background in substance abuse treatment, public health, or community organizing. How did you become an advocate for this cause?
Brason: I’ve been in home health for most of my adult career. When I became the director and chaplain of our local hospice, I really started to see the problem. I was getting calls from doctors telling me they couldn’t prescribe pain medication for patients as long as they were living at home because family members were either sharing the medication or stealing it. I’d never seen anything like it. We tried hiding the medications and locking them up, and we couldn’t contain the problem. We had one patient who was selling some of her medication to leave her grandchildren some money. Another was concerned someone would hear about their condition and rob them of medications in their home. That’s when it hit me in the face.
Transforming Care: Why was the problem in Wilkes County so much worse than in other parts of the state?
Brason: Here, as in other communities, it’s a combination of social factors—poverty, trauma, depression, unemployment, and just general hopelessness. The economy plays a big role. The Pew Charitable Trusts did a study of income changes in U.S. counties between 2000 and 2014 and found Wilkes County was number two in terms of lost income.4 It started when Lowe’s Corp., which opened its first hardware store here, moved its headquarters in 2003. What was left were jobs in cattle and chicken farming and haying. Drugs became an underground economy, which wasn’t entirely new for this area. I sarcastically say we have the marvelous “M”s. We started with moonshine, then marijuana, then methamphetamine, and then medication—opioids and benzodiazepines.
Transforming Care: How did you rally the community to address the issue?
Brason: I started by asking questions, which was a bit of rabbit hole because there weren’t a lot of answers back in 2004 and 2005. Most people were not aware of the problem. The sheriff saw it and the chief of the staff in the ED saw it. But everyone else was like, “What problem?” I realized we needed to build awareness among people who weren’t directly affected but could have an influence—teachers, parents, pastors, and counselors. Awareness required connecting the dots for each to realize how they were actually affected by the problem. This we addressed by answering three key questions for each community sector: Why am I needed? What do I need to know? What needs to be done?
We used data to demonstrate the problem. Around 2007 the state’s Medicaid program started to see changes in utilization in this area—including dramatic increases in the number of prescriptions, emergency department visits, and deaths. They reached out to the public health department, and that’s how I got connected. Together with two epidemiologists—Kay Sanford, M.S.P.H., and Nabarun Dasgupta, M.P.H, Ph.D.—and Susan Albert, M.D., from the Wilkes County Public Health Department, we created a workgroup to develop an evidence-based toolkit for primary care providers, who provide the majority of care in rural communities and are managing chronic pain, which may be more common in rural areas where people are working in labor-intensive careers. We’d do lunch-and-learn sessions about appropriate opioid prescribing and encouraged use of the state’s reporting system to track patients receiving these medications. We started in 2008, and within two years every provider in the county had been trained to use the toolkit.
We also focused on linking everyone together, not only to identify people who might be diverting medication, but also to ensure that patients who needed pain treatment got it. We put a nurse case manager in the emergency department to follow the high utilizers and set up referral mechanisms that linked behavioral health providers, primary care physicians, the emergency department, and dental clinics. If a patient showed up in the ED with a toothache, they could get an immediate appointment at the dental clinic. And if a patient sought help in ED for chronic rather than acute pain, they’d get a referral. We also kept running lists of providers who were taking new patients. We didn’t see how much impact we were having until Wake Forest School of Medicine came out to evaluate the first three years of the program. We couldn’t see the forest for the trees when we were in the middle of it.
Transforming Care: What did the evaluation show?
Brason: One of the surprising things was that patient satisfaction was better, even though patients were having to submit to urine screenings, pill counts, and treatment agreements. We thought it would be the opposite. But patients were encouraged by the fact that someone was taking their pain seriously and that they were being engaged. That showed the prescribing community there was a way to safely and responsibly escalate treatment if a patient needed stronger medication. Data from North Carolina’s Office of the Chief Medical Examiner showed the overdose rate dropped from 46.6 per 100,000—four times the state average in 2009—to 11 in 2011. Where we still struggled was in getting patients into treatment for substance abuse disorder. We just didn’t have any treatment options—no walk-in clinic, no medication-assisted treatment. You could call the behavioral health helpline and get an appointment with a counselor in 21 days.
Transforming Care: What did you do to address this lack of access?
Brason: That took extensive education of the general public and physician community about the science of addiction because there was such a bias against people with substance abuse disorder and a lack of motivation to help. There was the view it’s a moral or behavioral issue—that people shouldn’t be taking or doing anything and the only treatment is abstinence. We set up a panel to talk about medication-assisted treatment but, when I brought up the word methadone, everyone’s demeanor changed. It was nasty. People said, “That’s a drug for a drug,” and, “Not in my town.” The one methadone clinic that was considering coming said, “No way, no how. We’re done here.” We were eventually able to get a provider from Asheville, which is about 100 miles to the west, to set up a satellite clinic for prescribing buprenorphine, which is used to treat opioid addiction. That was more palatable to the community because it’s prescription medication. With more education about the science of addiction and evidence-based treatment, we were able to bring methadone to the same clinic two years later. And now we have a full-fledged opioid treatment program that serves more than 500 patients. They just moved into a new facility where they can accommodate 1,000. It’s not economically viable for every community to have a methadone clinic. Office-based treatment may be the best-case scenario because these offices already exist. But physicians need training, mentoring, and support to do it.
Transforming Care: While overdose rates from prescription opioids have come down dramatically in the early years, the rate went up in North Carolina in 2015, according to Centers for Disease Control and Prevention.5 Are you seeing the same trends locally, and what’s behind the uptick?
Brason: Yes. The rate goes down some years and up others. If we look over a five-year period, the number of overdoses has gone down by about 50 percent from the all-time high. So, we’ve made great headway, but we are still not out of the woods because the social determinants of substance abuse still exist, and there is still an underground economy. We know they are not getting it locally, but people are selling. When the sheriff’s office does undercover work, they are arresting 35 and 50 people. We had one roundup of 75 people. It’s a tough issue. There’s lots of trauma and depression. How do you change that? And how do you convince a business to come to your community when they can’t hire people because no one can pass the drug tests? This is where we are at this juncture.6
Transforming Care: What advice do you give communities that seek your help?
Brason: I learned early on to encourage community leaders to get their staffs involved. I tell them I want your police officers, your hospital personnel, your school teachers. Churches are also an ally. It can’t be owned by anyone. It has to be owned by the community. I find a lot of communities get frustrated because they can’t get everyone on board at first. I tell them not to try that. To begin the process, you need to work where the energy is. It will grow and they will come to you eventually. I’ve also learned time and time again if you give people the right tools and they feel they can make a difference, they will put the energy into it.
Notes
1 CDC Grand Rounds: Prescription Drug Overdoses—a U.S. Epidemic. Morbidity and Mortality Weekly Report, Jan. 13, 2012. See http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/01/22/fewer-manufacturing-jobs-housing-bust-haunt-many-us-counties, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm, and M. Faul, M. W. Dailey, D. E. Sugerman et al., “Disparity of Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in U.S. Rural Communities,” American Journal of Public Health, July 2015, 105(Suppl 3): e26–32.
2 See http://www.northcarolinahealthnews.org/2014/02/10/saving-lives-by-preventing-overdose-in-wilkes-county/.
3 M. Faul et al.
4 T. Henderson, “Fewer Manufacturing Jobs, Housing Bust Haunt Many U.S. Counties,” Stateline, The Pew Charitable Trusts, Jan. 22, 2016. See http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/01/22/fewer-manufacturing-jobs-housing-bust-haunt-many-us-counties. Lowe’s announced plans to expand its call center operations in Wilkes County in February 2017, adding 600 jobs to the area. See: R. Craver, “Lowe’s Retail Churn Turns into Wilkesboro’s Job Gain,” Winston-Salem Journal, Feb. 18, 2017,http://www.journalnow.com/business/business_news/local/lowe-s-retail-churn-turns-into-wilkesboro-s-job-gain/article_68dad969-9b09-5770-a371-370ac4123040.html.
5 Centers for Disease Control and Prevention, Prescription Opioid Overdose Data, https://www.cdc.gov/drugoverdose/data/overdose.html.
6 As in other parts of the U.S., overdose deaths from use of fentanyl and heroin, which are more readily available and cheaper than prescription opioids, have also increased.