In 2014, nearly 19,000 Americans died of opioid overdoses, a 400% increase from 1999.1 Abuse or misuse of prescription pain relievers accounted for almost half a million emergency department visits. While opioid-related deaths, overdoses, and prescriptions have risen in parallel across the country for the last 15 years, several communities have found ways to save lives by confronting the epidemic head on.
Wilkes County, NC, had the third-highest drug overdose death rate in the United States in 2007, four times that seen in the rest of the state, according to the CDC. The following year, several community organizations united to create Project Lazarus, a program designed to reduce death and overdose rates from prescription opioid pain relievers such as fentanyl, hydrocodone, methadone and oxycodone, while continuing to meet the needs of patients with chronic pain. The program developed strategic action plans for the community, distributed tool kits, provided medical training for local providers and distributed Naloxone rescue kits to first responders and others.
Between 2009 and 2011, the overdose death rate in the country dropped 69%, despite opioid prescription rates that remained above the state average.2 Notably, while 82% of those who died in 2011 received a fatal prescription from a Wilkes County prescriber, just three years later, not one did. By 2010, 70% of the prescribers in the county had registered with the North Carolina prescription drug monitoring program.
North Carolina has rolled out Project Lazarus statewide through a partnership that includes Community Care of North Carolina’s Chronic Pain Initiative, the North Carolina Hospital Association, local hospitals and emergency departments, primary care physicians, faith-based programs and law enforcement. The coalition offers communities educational materials, financial assistance and guidance to implement the program. It also tracks pharmacies that carry naloxone, an opioid antagonist that can quickly and safely reverse the effects of an overdose.
Project Lazarus incorporated 10 components: public awareness, coalition action, data and evaluation, provider education, hospital education and policies, diversion control, pain patient support, harm reduction, addiction treatment and community education.3 The comprehensive program educated providers about alternative means of pain relief, worked with emergency departments to reduce opioid prescriptions, partnered with police departments to “take back” unused opioids and expanded addiction treatment options offered by local mental health centers.
Vermont took a different approach. Gov. Peter Shumlin devoted his entire State of the State address in 2014 to fighting opioid and opiate addiction. Recognizing that “we were doing everything wrong,” Shumlin revamped the state’s approach to drug treatment to parallel that for other chronic diseases.4 The state devoted $6.7 million to increase access to recovery programs and distributed Naloxone kits to first responders, family members and others. It also trained police and first responders to offer non-violent drug offenders and overdose survivors treatment at the point of arrest or in the immediate aftermath of a near-death experience.
The numbers speak to the program’s success. In 2015, Vermont reported that the number of individuals in medically assisted drug treatment programs had risen 40%.5 Of those who completed treatment, 75% demonstrated improved functioning. Nearly 70% of the state’s Medicaid recipients with an opioid dependence diagnosis received treatment in 2013. The state now has the highest number of behavioral health providers per 1000 adults with addictions. Vermont operates eight sites that offer methadone treatment and intensive therapy and support 60 community-based private practices which prescribe buprenorphine and offer counseling to addicts.
Proposed legislation addresses diversion, aims to increase use of the state’s prescription monitoring system, increases continuing medical education on opioids and requires physicians to ensure patients receive opioid addiction treatment with buprenorphine. Recent regulations required all prescribers of controlled substance to register with Vermont Prescription Monitoring System, conduct and document a risk assessment, consider alternative therapies and check the system for evidence of doctor shopping or possible prescription drug abuse before writing a prescription.
Despite these examples of success in combating the epidemic of prescription drug abuse, challenges to saving lives and improving access to treatment remain. Until recently, state laws have prohibited prescribing drugs to someone other than the patient who will use it. These third-party prescription restrictions keep naloxone out of the hands of first responders, family members of addicts, and others who could quickly reverse a potentially fatal overdose. Some physicians are reluctant to prescribe naloxone because of liability concerns and bystanders may not call for help when someone overdoses for fear of prosecution for possession of illegal drugs themselves. As of the third quarter of 2015, 43 states had passed legislation expanding naloxone access by specifically protecting physicians and others from legal action and passing Good Samaritan Laws to protect bystanders who call emergency responders.7
On the federal level, there are efforts to raise the number of patients a physician in private practice can treat with buprenorphine beyond the current limit of 30 in the first year and 100 thereafter. In rural areas, particularly, the limit creates a significant barrier to care for those who wish to enter treatment.
Communities that have tackled opioid and opiate addiction have recognized the need to couple medication assisted therapy and naloxone availability with a comprehensive program that provides counseling to help patients develop more effective coping skills and rebuild their lives.
Programs that take an integrated approach work, but they can be out of reach for many patients. Vermont successfully negotiated with several major payers to secure coverage for treatment and the state paid for treatment for Medicaid beneficiaries. In other communities across the country, however, patients still lack insurance coverage for addiction services, despite laws mandating parity for mental health treatment. Medicaid in many states does not pay for treatment at all. A substantial percentage of patients with addiction disorders lack insurance of any kind, making most programs inaccessible.
Building on the successful programs in Vermont and North Carolina will require decriminalization of addiction and recognition of it as a chronic disease, legislation to support broader use of medication assisted treatment, and a workable financial model that both enables patients to receive the treatment they need and attracts professionals to the field to increase capacity. We can do this.
Opioid Addiction: 2016 Facts and Figures. American Society of Addiction Medicine.
Albert S, Brason FW 2nd, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Medicine. 2011 Jun;12 Suppl 2:S77-85.
Brooks M. Project Lazarus Making Headway on Opioid Overdoses. Medscape Medical News. June 17, 2014.
Povich ES. Q&A: Vermont Gov. Peter Shumlin on Attacking the Drug Epidemic. Stateline. Pew Charitable Trusts. August 31, 2015.
Report to the Vermont Legislature: The Effectiveness of Vermont’s System of Opioid Addiction Treatment. Vermont Agency of Human Services, Department of Health. January 15, 2015.
Murray E. Lawmakers: Opiates ‘have to be’ focus of 2016 session. Burlington Free Press. January 5, 2016.
Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. The Network for Public Health Law. Updated September 2015.