Are you a health care worker? We’d love to hear from you. Email editor at northcarolinahealthnews.org
By Rose Hoban
It was a grey, wet, wintry day, raw to the bone, the kind of day that you hunker down and just get through.
But for Donna Reeves, it was more than cold and wet; it was a “Casey day.”
“Those are the days I can’t stop thinking about her,” Reeves said, fingering the locket around her neck that contains a photo of her daughter Casey, who died of an opioid overdose at the age of 20.
“It makes me so sad,” said Reeves, through tears. “It’s hard for me to know she’s out there by herself.”
A former cheerleader at North Wilkes High School, Casey was a decent student, but she left school to join the National Guard early-entry program, following her older brother, who’s in the Army.
She had started using the occasional pill with some classmates, but her habit bloomed into an addiction she hid from her parents – until she couldn’t hide it anymore. A tearful confession followed.
Casey tried checking into a voluntary rehabilitation program, but she lacked health insurance and the $6,000 it would have cost for a month’s treatment. She wouldn’t let her parents pay, instead trying to stay clean while living at home.
“I wonder sometimes: If I’d have put her somewhere against her will, she may hate me, but she’d still be here,” Reeves said.
Slowly, painfully, Casey got clean on her own. She’d been successful for several months, getting her life back together, living in her parents’ basement, slowly regaining their trust.
One Friday night in August 2006, after Casey had been clean for several months, a friend came over. Reeves thinks the friend brought some pills, and Casey succumbed to the temptation.
Her parents were upstairs.
Casey Reeves was one of the 18 people in Wilkes County who died of accidental opioid overdose in 2006. The county rate was 27.1 per 100,000 people that year. The following year, Wilkes County had the third-highest opioid overdose rate in the country: 28.5 per 100,000.
(Even though Wilkes County had only about 66,000 people at the time, epidemiologists calculate the rate as per 100,000 in order to compare counties and states equally.)
The rate in the county was running two to three times that of the rest of the state.
Around that time, Wilkes County resident and hospice chaplain Fred Brason noticed the overdose problem, in part because he met grieving families and in part because some of the patients in his hospice program had pain medications stolen by family members.
He brought the issue of opiate abuse to the attention of community leaders, but wasn’t getting much traction.
It took almost two years of pushing, Brason said, before he was able to convince many people that there was a problem.
“Unfortunately, it took having three overdoses inside of two days,” he said. “That’s when we said, ‘This has to stop.’”
Brason was asked to head a substance-abuse task force to address the issue of overdose, but the deaths kept coming. In 2009, Wilkes County was having a fatal overdose about every two weeks.
It wasn’t just people obtaining drugs illegally; some overdoses happened because someone was taking pain medication for a medical problem and took too many pills.
“Misuse is, unfortunately, patients realizing that I have more pain, I need to take more pills. So if one is good, maybe two is better,” Brason said.
But he explained that with longer-acting pain medications such as methadone (often prescribed for long-acting pain relief) or OxyContin, taking a second pill can cause a patient to overdose.
“People have a tendency to think that if I get my medication from a doctor, it should be safe,” said Kay Sanford, an injury-prevention epidemiologist who retired from state government and now does overdose-prevention work.
Throughout the 2000s, the overdose deaths in Wilkes – and in North Carolina – have overwhelmingly been from prescription painkillers.
Brason and Sanford realized there needed to be a two-pronged approach.
“You’re working with folks who get the prescriptions for chronic-pain management,” Brason said, “and you are also trying to target folks who might be getting it from grandma or buying it on the street.
“There’s going to be two different ways of approaching these two populations.”
“Opioids mess up the brain’s ability to understand the balance between oxygen and carbon dioxide – the breathing process,” Sanford said, “because the part of the brain that’s supposed to do this is affected by the opioids, and the body suddenly says, ‘I don’t have to breathe anymore.’”
By the time a person with too much of an opiate in their system is breathing once or twice a minute, an inhale can sound like a heavy snore. That respiratory depression is what causes death, because as time goes by, the user just stops breathing.
But a drug called naloxone can almost immediately reverse all of the effects of opiate drugs, both the pain relief and the respiratory depression. Naloxone forces opioid molecules off of special chemical receptors in the brain where opioid drugs act. Some call naloxone a “Lazarus” drug, because once it’s given to someone who has overdosed and stopped breathing, the person will wake up in seconds.
When Brason heard about naloxone, he asked one question: “Why don’t people have it in their homes?”
“Everybody was telling me that emergency departments use it all the time; they revive somebody who’s in an opioid overdose,” he said. “And I said to them, ‘Well, the individuals in Wilkes County are not dying of overdose in the emergency room, they’re dying of overdose at home.”
By then, Brason, Sanford and some others were forming Project Lazarus, an initiative to address the overdose problem in Wilkes County. They heard about programs around the country that distribute naloxone to heroin users as a way to reduce the chance of death by overdose, and they thought it sounded like an approach that could be used in Wilkes County.
One of the first things they did was approach the N.C. Medical Board about allowing physicians to give naloxone to people who were considered to be “at risk,” either because they were being treated for chronic pain or were known to be abusing opiates.
The board approved the plan, becoming the only medical board in the country to do so.
“They put out a position statement supporting that, saying that [naloxone] should be co-prescribed to patients who are at risk of opioid overdose,” Brason said.
A new approach
The next thing that needed to happen was to change the way physicians prescribe opioid medications. Brason and Project Lazarus’s medical director Sue Albert traveled tirelessly around Wilkes County, talking to doctors about giving prescriptions for naloxone along with prescriptions for pain medications.
For people who need it, they created kits that include a DVD, instructions, doses of naloxone in pre-filled syringes and an apparatus to put onto the syringe that allows for administering the naloxone as a nasal spray.
“You just have to screw on a little nasal atomizer. It’s a little applicator so that you can spray [the naloxone] into somebody’s nose, so you don’t have to give someone a shot,” Brason said.
He said that he’s never given anyone a shot, but that the atomizers are very easy to use. “Anybody can do it; a child can do it for an adult, an adult can do it for a child.”
Donna Reeves and her husband didn’t know about naloxone when their daughter died, but they do now. Reeves has helped Brason raise awareness in Wilkes County, getting people on board with having naloxone at home, ready to help a loved one survive until the day they decide to get clean.
Reeves said Casey probably died because she took the amount of the opioid drug that she’d gotten used to when she was using more frequently. But months of abstinence had lowered her body’s tolerance.
Her old “usual” dose was enough to kill her.
That Saturday morning, her father went down in the basement to the laundry room near Casey’s room before driving to Hickory for the day.
He heard Casey snoring and assumed she was asleep, not realizing she was slipping away.
According to Brason, more people in Wilkes County are getting the message.
He said that a young woman had called him and said, “‘Oh my goodness, my neighbor was overdosing and I ran home to get my kit, but EMS got there in time.’”
“That’s how this catches on,” he said.
The kit even comes with a refrigerator magnet with a space to write down where the kit is located in the house.
Another thing that needed to change in Wilkes County was the way emergency-room physicians prescribe opioid medications.
“In Wilkes County, you cannot go to the emergency department anymore and continue to complain of an ache and pain and continue to get narcotic prescriptions,” Brason said. “If it is going to be given to you, you are going to be given three-days’ worth and a referral to your primary-care physician.
“No more of this 30-days’ worth [just] because you stepped into the emergency room.”
Project Lazarus also has worked to encourage doctors and pharmacists to refer to the N.C. Controlled Substances Reporting System, a database that tracks those who are being prescribed controlled substances in the state.
Although the system was available, it was not being used widely to see if a patient had received a lot of opioids in a given month.
Success helps the model spread
The unintentional-overdose rate remained high in 2009, when 30 Wilkes County residents died, resulting in a rate of 46.6 per 100,000. But in 2010, the numbers began to fall.
“From 2009 to 2010, there was a 47 percent decrease in the number of deaths,” Brason said. In 2011, it dropped to 13 per 100,000.
Doctors in Wilkes County have dramatically changed the way they prescribe pain medications. Sanford said that’s reflected in the overdose statistics.
“In the past, almost all of the prescriptions involved in overdoses had come from a county doc,” she said. “But over the past three or four years, prescribing patterns for docs in Wilkes County have changed so dramatically that by 2011 none of the prescriptions that were involved in a fatal overdose had been written by a local doc in Wilkes County.
“That’s a big deal.”
Brason also said changes made by the General Assembly last year that allowed for a designated person in a doctor’s office to use the Controlled Substances Reporting System eased the way for physicians to use the database more frequently. (Legislators also substantially raised penalties for people who disregard data privacy in the system.)
Project Lazarus has slowly gained recognition around the state and the country.
Brason said at least a dozen states have adopted some of the project’s guidelines and model policies to address the problem of opioid overdose.
By the end of 2014, the Project Lazarus model of educating patients and physicians will be deployed in all of North Carolina’s 100 counties through North Carolina’s Community Care networks, the organizations that manage the care for most of the state’s Medicaid patients.
Brason also said the Mountain Area Health Education Center was working with Project Lazarus to do community outreach and organizing in multiple counties.
North Carolina’s military community has also embraced Project Lazarus principles, employing the model policies on Ft. Bragg. Brason also said the Eastern Band of Cherokee Indian Reservation has adopted the full Project Lazarus model, and that they’re seeing results.
Brason, Sanford and Donna Reeves have all spoken to officials from federal agencies, including the Food and Drug Administration, to determine what needs to be done to make naloxone more available in community settings.
When he went to the FDA hearings, Brason brought Reeves with him to testify as to the effects of opioid overdose on families and communities. It’s something Reeves has thrown herself into. She said her goal is to help keep other parents from experiencing the same kind of pain she does.
“I think of Casey every day, wondering if she’s proud of me, doing these things,” Reeves said.
“And I think she’s proud of me.”