Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

Abstract

Nursing homes have an ethical obligation to create facility policies and protocols that support the ethical and evidence-based treatment of individuals with opioid use disorder (OUD) and substance use disorder (SUD), A. Justine Landi, MD, urged at PALTC23, the Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine. This could mean creating partnerships with methadone clinics and other SUD providers, creating medication administration policies and procedures (including for prescribing buprenorphine), and leveraging interprofessional education and collaboration, said Dr. Landi, who is an assistant professor of medicine in the Section of Geriatrics and Palliative Medicine at the University of Chicago and faculty at the MacLean Center for Clinical Medical Ethics. The session, which focused on improving the quality of care for OUD and SUD in nursing home residents, came on the heels of significant developments for nursing homes — notably, the removal of the federal DATA X-waiver requirement for prescribing medications like buprenorphine, and the introduction by the Centers for Medicare & Medicaid Services of training-related F-tags to cover unhealthy substance use. Both changes occurred last year, and they have the potential to chip away at some of the barriers facing older adults with SUD and OUD who need care in post-acute care settings. “As of December, you do not need an X-waiver. All you need is a DEA [Drug Enforcement Administration registration] number to prescribe buprenorphine, and there’s no limit to the number of patients you can prescribe for,” said Stacie Levine, MD, CMD, another professor of medicine in the Section of Geriatrics and Palliative Medicine at the University of Chicago School of Medicine. “That’s a game changer.” And it’s a change that should spur ethical considerations, Dr. Landi said. When the “I can’t” becomes an “I won’t,” for instance, it “carries a different ethical weight — and it’s worth exploring the role of values and stigma in the ‘I won’t.’” It’s also important to consider the difference between initiating and continuing medications. “I believe a patient is entitled to treatment that has already been deemed to be indicated and appropriate, and that has already been offered and provided, and that the patient has already been proven to tolerate and is already dependent on,” said Dr. Landi. OUD in older adults is a fast-growing and underdiagnosed problem, said Dr. Levine. The number of older adults who reported misusing opioid pain relievers almost tripled from 2012 to 2019 (to 900,000), and the number who reported misusing any opioid (e.g., pain relievers, heroin, and fentanyl) increased by 29% from 2016 to 2019 (to 979,000), according to data from the Substance Abuse and Mental Health Services Administration and featured in the Agency for Healthcare Research and Quality’s “AHRQ Older Adult Opioid Initiative” (https://bit.ly/3nd7ODk). As the number of older adults with SUD — and especially OUD — increases, so does the need for OUD care in nursing homes. Skilled nursing facilities in New York City saw a 10% annual increase in referrals of older adults hospitalized with an opioid admission diagnosis between 2008 and 2014, according to a recent study described by Dr. Levine (Harm Reduct J 2020:17[1]:99). “I’m seeing [more referrals] in the University of Chicago catchment area,” she noted. Unfortunately, despite being discriminatory under the Americans With Disabilities Act of 1990, it may not be uncommon for SNFs to refuse admission to patients with an OUD, even if the OUD is being treated with medications, Dr. Levine said. She pointed to a study published in 2022 of referrals in the Boston area for post-acute medical care after OUD-associated hospitalizations. Nearly 4 out of 10 individuals were explicitly denied admission to private SNFs due to the presence of OUD or opioid agonist therapy, and more than 8 in 10 referrals were rejected overall (J Addict Med 2021;15:20–26). Notably, the investigators compared the rejection rates before and after an antidiscrimination settlement involving a Massachusetts nursing home and they found no changes. (The facility had refused to accept a patient being treated with buprenorphine.) Nursing homes that do admit patients with OUD have variable care practices, Dr. Levine said. A recently published qualitative study that she co-authored of 11 nursing homes in and around Chicago — all part of one nursing home chain — found differing admission and management protocols. For instance, some facilities require residents to self-administer medications for OUD while others allow their nurses to administer them. Some require behavioral health contracts and others don’t. Dr. Levine and her co-researchers, who interviewed 24 staff members, found common themes in facility-related barriers to providing care: staff preparedness, staff perceptions of addiction, and an overall lack of building resources. It’s “imperative,” they wrote, “to develop standardized staff education and care guidelines to improve quality and access to care for this population” and to advocate for more resources and policy changes that will allow nursing homes to offer best practice care (J Addict Med 2023;17:155–162). Another presenter, Rossana Lau-Ng, MD, MBA, CMD, assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine, has developed and assessed an interdisciplinary educational curriculum for nursing home staff that covers addiction as a medical disease, medications for OUD, the use of nonstigmatizing language, and overdose signs/symptoms. Her manuscript is in preparation. At the meeting she urged the participants, especially medical directors, to lead with an interdisciplinary approach to staff training. She shared anecdotes of valuable conversations that took place among staff members during her training sessions. For instance, a facility maintenance director who used to run a construction company said that his former employees on buprenorphine took their medications every day and “were as productive as the next guy,” which prompted a registered nurse to say, “Wow, I never thought of it that way.” Sharing such experiences is invaluable in building interprofessional collaboration competencies, said Dr. Lau-Ng. Postdoctoral trainee Zhiqiu Ye, PhD, shared her efforts to develop and pilot test a survey instrument to measure the availability, organization, and delivery of OUD/SUD services in nursing homes, under the mentorship of Dr. Levine. Such a tool should help inform the development of quality measures. Currently, “the quality of services of largely unknown and controversially measured,” said Dr. Ye, whose research was inspired in part by a 2020 paper by Dr. Lau-Ng that emphasizes that care delivery in SNFs is not set up to match the needs of older adults with OUD/SUD due to societal, regulatory, financial and educational barriers (Generations 2020;44(4): https://bit.ly/41UxCmz). “We can’t affect policy,” said Dr. Levine, “if we don’t do research.” Christine Kilgore is a freelance writer based in Falls Church, VA.