With drug overdoses among seniors surging to historic levels, nursing homes will undoubtedly be drawn further into the world of addiction treatment.
But facing additional regulatory scrutiny and consumer demand, many in the sector are still trying to figure out whether they’re prepared, how they can get up to speed quickly and if they’ve been given the right tools for the specific needs of patients with substance abuse disorders.
Simply being unable to accurately identify who among their patients has a history of substance abuse can be a barrier to comprehensive care, Jacob “Jay” Berelowitz, LNHA, program director for the Center of Excellence for Behavioral Health in Nursing Facilities, recently noted.
Though the Centers for Medicare & Medicaid Services is among the agencies pressing nursing homes to take more drug-involved patients, its own MDS does not have a built-in screening tool for substance abuse disorders. That means providers need to find their own and commit not just using it but also to adding services and capabilities that recognize the changing needs of the patient population, experts say.
“If you’re not already looking at medications for opioid use disorder, that’s very important,” Berelowitz said on a LeadingAge policy call last week. “There’s going to continue to be a growing need, a growing amount of nursing home residents coming in looking for that care.”
Members of the Special Committee on Aging this spring asked the Drug Enforcement Agency to look especially at the role of fentanyl, a powerful synthetic opioid, in drug deaths among seniors. Senators cited a JAMA study that found overdose deaths among Americans 65 and older quadrupled over the last two decades, with synthetics an increasingly common cause.
The May 30 America’s Health Rankings 2024 Senior Report also found that drug deaths among seniors continue to rise but with large disparities across demographic groups. Drug deaths increased 51%, from 7.6 to 11.5 deaths per 100,000 adults 65 and older, between 2017-2019 and 2020-2022. That meant about 7,500 more deaths than in 2017-2019, according to the Centers for Disease Prevention and Control.
While the senior drug death rate is still lower than those 25-64, the senior rate is trending upward in 34 states and the District of Columbia, the United Health Foundation-commissioned study reported. Its drug death data included unintentional deaths, suicides, homicides or undetermined deaths, aren’t missing nursing homes.
Drug abuse, the authors noted, “is especially dangerous for older adults because age-related changes in the liver reduce the ability to metabolize medications, and most older adults take one or more prescription medications.”
“Clinical strategies to prevent overdose deaths and reduce harm among older adults with opioid addiction include promoting non-medication pain management techniques, regularly reviewing older adults’ medication lists to avoid adverse drug events and following the CDC Clinical Practice Guideline for Prescribing Opioids for Pain,” they noted.
Expect more drug scrutiny
Nursing homes are immune to neither drug deaths nor other drug-related injuries. That’s been a highly charged issue for providers, given that facility staff cannot search residents’ rooms for illicit drugs, even when they suspect a patient may be abusing them.
Instead, CMS officials have told providers to assess patients for drug use and treat them as needed.
“Not every overdose is non-compliance,” CMS Director of Nursing Homes Evan Shulman told providers when the agency issued new Requirements of Participation guidance in 2022. “Should you be monitoring these individuals? Absolutely. Should you have your staff trained to look for signs and symptoms of drug use? Absolutely.”
That stance feels like a dangerous Catch-22 to some.
Adding more fuel to the fire, the Government Accountability Office said this spring that it would add an investigation of nursing facilities’ drug overdoses to its work plan, reporting its findings sometime in 2025.
“For every drug overdose that results in death, there are many more nonfatal overdoses, each one with its own emotional and economic toll,” the GAO noted. “We will determine whether selected nursing facilities complied with quality-of-care requirements and reported, investigated, and implemented corrective actions for potential illegal drug usage and significant pain medication errors involving opioid overdoses.”
CMS has also repeatedly insisted that nursing homes have an obligation to accept patients in need of skilled care, even if they have substance abuse or other behavioral needs. While some nursing homes have argued they are unprepared clinically to treat such patients, lawsuits and financial from state officials have added to the pressure to change that stance.
Proactive approach encouraged
Berelowitz, whose center was launched to support skilled nursing providers with training, resources and specific intervention strategies, encouraged providers to address the issue with a preventative approach, rather than a reactive one. He added that many facilities would benefit from conducting a community assessment to determine the local need for such services.
“Very often the answer is yes, but the types of residents may be different in different communities,” Berelowitz said. “If the answer is yes, then facilities should work on increasing their capacity to meet the needs of their community. Conducting a facility assessment as well can really help determine facility strengths and what their needs are around behavioral health.
“I think facilities do this well in other clinical areas, say in wound care and evaluating the needs of a community,” he added, pointing out how doing so might lead to investment in additional dietary interventions, wound rounds or on-site specialists. “Similarly, facilities can evaluate their behavioral health capacity and their needs and work to bridge that gap.”
Berelowitz noted that there’s been an expansion of which clinicians are allowed to prescribe such medications, requiring nursing homes to rethink the skills and training they demand of their attending physicians. Policies, procedures and screening tools are also critical as operators learn how to manage and support this new patient population, Berelowitz added.
“We really encourage nursing facilities to dedicate resources to better screening, evaluation and care planning for residents with serious mental illnesses and substance abuse disorders, as that can help limit the number of escalated situations and crises,” he said. “We can’t prevent all of them, but by doing that early planning and really getting to know the resident, a lot of times we can really prevent those crisis situations.”
