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A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina
  1. Apostolos A Alexandridis1,
  2. Agnieszka McCort1,
  3. Christopher L Ringwalt1,
  4. Nidhi Sachdeva1,2,
  5. Catherine Sanford1,
  6. Stephen W Marshall1,
  7. Karin Mack3,
  8. Nabarun Dasgupta1
  1. 1 Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2 Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch, Raleigh, North Carolina, USA
  3. 3 National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  1. Correspondence to Apostolos A Alexandridis, UNC Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; %E2%80%83%E2%80%83%E2%80%83aaa{at}


Background In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose.

Methods Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009–2012) and intervention periods (2013–2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0–6 months).

Results In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95% CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95% CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95% CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95% CI 1.08 to 1.37) but lower ED visits in time-lagged models.

Conclusions Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

  • Epidemiology
  • Surveillance
  • Poisoning
  • Outcome Evaluation
  • Time Series
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  • Contributors AAA, AM, CLR, NS, CS, SWM and ND were involved in study design. Data collection instruments were designed by AM, CLR, NS, CS and ND. AAA, AM and NS were directly involved in data collection. The analyses were conducted by AAA, ND and SWM. AAA and ND had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. KM and SWM contributed to the manuscript’s intellectual development and revisions, in addition to the other authors. All authors have given final approval of the version to be published. AAA and ND had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This evaluation study was funded by the United States Centers for Disease Control and Prevention (CDC; Cooperative Agreement 5U01CE002162-02), the Kate B. Reynolds Charitable Trust (KBR), a private foundation, and the Office of Rural Health (ORH), NC Department of Health and Human Services. The latter two entities (KBR and ORH) selected the order in which counties received funding for intervention implementation, but had no role in collection, management, analysis, and interpretation of the data; nor preparation, review, or approval of the manuscript; nor decision to submit the manuscript for publication.

  • Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

  • Competing interests KM is an employee of the United States Centers for Disease Control and Prevention, which funded the evaluation of the study.

  • Ethics approval University of North Carolina at Chapel Hill (IRB 12-2570).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data set used in analysis containing exposure and contextual variables is available for collaborative sharing upon request to the authors. For many variables public data were used and the authors can direct interested parties to the original sources. Data on prescriptions, hospital emergency department visits and drug treatment admissions can be made available for public use but require separate data use agreements directly with the NC Department of Health and Human Services, and cannot be disclosed by the authors without their written permission. Geographic identifiers for low population areas may be anonymised due to privacy concerns.

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