The Appalachian Mountain region of the United States has a high overdose death rate, mainly due to prescription opioid painkillers. Project Lazarus is a community initiative in western North Carolina that works to reduce overdose through doctor and patient education, naloxone distribution, and other measures. When the project began, the community of 68,000 had the third highest overdose rate in the United States.
At first, the idea of handing out naloxone to laypeople – whether drug users or pain patients – was controversial. This was a novel intervention that had never before been attempted in North Carolina. Physicians, pharmacists, and office managers with whom Project Lazarus staff interacted were hesitant to prescribe naloxone, and some were even hostile to the idea. But the Project Lazarus model relied on doctors prescribing naloxone to people at risk of overdose, so Project Lazarus staff knew that doctors had to feel comfortable that naloxone prescription was a normal and encouraged part of medical practice.
Partnering with medical authorities
Project Lazarus staff decided to go to the highest medical authority in North Carolina – the Medical Board. The Medical Board was initially skeptical and responded by calling a public hearing – a chance for Project Lazarus to present their case in front of the Board’s policy committee. Project Lazarus staff presented statistics on overdose in the state that were higher than national average and worse than the Medical Board had realized; described their comprehensive approach, which also includes working with schools, law enforcement, and drug treatment centers; and thoroughly reviewed risk factors for overdose, which helped the Medical Board understand the wide range of people at risk.
The response was overwhelmingly positive: “At the end the Chair of the committee pulled me aside and said, ‘When we came in here this morning, we were dead set against this. Now we no longer are so.’” Nabarun Dasgupta, a co-founder of Project Lazarus recalls. “Other members of the board went on to say that they could no longer imagine prescribing opioids without also prescribing naloxone, and that they had specific patients in mind whom they were concerned about and would follow up with. It was exhilarating to see what difference a small group of concerned citizens could make when prepared with the right kind of epidemiological data and clinical experience.”
A statement as an advocacy tool
The Medical Board issued a short statement saying that they encourage doctors to cooperate with programs like Project Lazarus to make naloxone available to those at risk. They also gave Project Lazarus space in their newsletter to describe their model. Because the newsletter is sent to all physicians licensed in North Carolina, they’ve received calls from doctors in other parts of the State who want to do something similar.
Nabarun explains that the Medical Board statement alone didn’t immediately change things, but it is a tool they use to reassure doctors: “For such an unprecedented program, having a formal vetting by the highest medical authority gave us a sense of confidence and allowed us to assuage the concerns of many of the clinicians we work with. Despite the authorization from above, effecting behavior change to actually have doctors prescribing naloxone requires one-on-one training, broad community support, and patient demand. You have to lead doctors into believing that prescribing naloxone is in the best interest of their patients. At the end of the day, the Medical Board statement is one more piece of evidence,” he explains.
Project Lazarus has been operating for six years, and the overdose death rate in its area is down 69% compared to its peak in 2008. They now distribute about 30 naloxone kits a week, and are planning to expand to the rest of the state.
Postscript: North Carolina has since enacted comprehensive overdose legislation that protects bystanders who call for emergency help during an overdose, and expands layperson access to naloxone. Project Lazarus success and the Medical Board statement helped lay the groundwork for this legislative victory.