Seniors—and senior living providers—have not been immune to the U.S. opioid crisis. As state and federal policymakers are taking steps to combat opioid addiction and overdoses, assisted living providers are concerned about maintaining appropriate access to these painkillers for residents and trying to answer tricky questions about best clinical practices.
The opioid problem has become vast in scope. In 2016, overdoses involving opioids killed more than 42,000 in the United States, according to figures from the Centers for Disease Control and Prevention (CDC). That’s a five-fold increase since 1999. About 40% of the 2016 deaths involved a prescription opioid such as oxycodone or hydrocodone.
Seniors commonly take these drugs. More than 500,000 seniors on Medicare Part D received high amounts of opioids in 2016, and one in three Part D beneficiaries received at least one opioid prescription, according to an analysis by the Department of Health and Human Services Office of Inspector (OIG).
In terms of opioid use in senior care settings, “less is known” about this group than the general population of older adults, according to a study published last fall in the Journal of the American Geriatrics Society (JAGS). The study authors found that 32.4% of nursing home residents were prescribed an opioid in 2012, and one in seven were prescribed an opioid for long-term use.
Even in less acute settings such as assisted living, seniors are on opioids long-term to control chronic pain, and providers have these residents in mind as they warily eye proposals for more restrictive prescribing policies, and do their best to track ideas under consideration by lawmakers. This week alone, there are four different hearings on the opioid crisis scheduled in the U.S. Congress.
Addicts but not abusers
Even as the industry needs to respond to evolving policies, providers are in discussion with each other to gain a firmer grasp on the issue.
It was in this spirit that industry association Argentum convened a panel on opioids at its recent Public Policy Institute in Washington, D.C. Clinical leaders with Sunrise Senior Living and Enlivant participated, and spoke with Senior Housing News in subsequent interviews.
“It was mainly information gathering for us, because we wondered, what is the impact of opioids—how they’re managed, disposed—on the senior living industry?” Argentum COO Maribeth Bersani told Senior Housing News. “The issue of ‘what is addiction?’ was a really fascinating discussion.”
Some senior living residents do meet the clinical definition of addiction, but that doesn’t necessarily mean they are good candidates for drug rehab and tapering.
“We see seniors who come into assisted living who are on an opioid drug every four hours, and they want and need it, and feel shaky without them—by the strict definition, that’s addiction,” Juli Navarrete, vice president of clinical practice for Sunrise Senior Living, told SHN. McLean, Virginia-based Sunrise operates about 260 U.S. properties, with more than 14,000 assisted living units.
However, the medications may be needed for pain caused by the complex medical conditions and co-morbidities that become more common with age. The opioids might be enabling the residents to participate in activities of daily living, socialize, and otherwise have a high quality of life.
Furthermore, assisted living providers have a regulatory obligation to manage pain, Cece Credille, senior vice president of quality services at Enlivant, told SHN. Chicago-based Enlivant operates about 240 properties, with more than 10,400 assisted living units.
Addiction is not something to take lightly, even in the senior living population, and caregivers must be tuned in to risks of overdose or inappropriate use, Navarrete and Credille agreed, noting that there is the potential for bad health outcomes related to opioid use in this population.
Yet, research has also shown that pain in older adults is often under-recognized and under-treated, as noted in a 2016 article in the Cleveland Clinic Journal of Medicine. That article emphasized that despite increasing opioid misuse, morbidity and mortality, these drugs have an important and “legitimate” place in controlling pain among seniors.
Access under threat
Finding the right balance between managing pain and curbing inappropriate opioid use is not easy, but it could become much harder if new, restrictive policies clamp down on access. That’s a top concern for Sunrise and Enlivant.
Various states are considering prescribing limits. For instance, New York’s final state budget for 2018-2019 prohibits prescribing opioids for longer than three months. Last June, a law took effect in Kentucky putting a three-day limit on opioid prescriptions for acute pain. At the federal level, the recently finalized Medicare Advantage call letter for 2019 included opioid provisions, including that Plan D sponsors limit some initial prescriptions to a 7-day period for treatment of acute pain, and implement “real-time safety edits” when dispensing opioids to chronic users.
So far, these laws and regulations have included some important carve-outs; the MA call letter excludes long-term care facilities, hospice care, palliative care, and end-of-life care from the new provisions, for instance. The New York budget states that if a patient’s medical record contains a written plan of care that adheres to accepted professional or governmental guidelines, the three-month limit can be waived.
Still, senior living providers are concerned that tighter restrictions could be on the way, and paint a picture of the operational and health-related challenges that could follow.
Opioid access is “absolutely going to be an issue,” in Navarrete’s opinion. Being unable to fill an opioid prescription for longer than three to seven days could place an unreasonable burden on senior living residents, forcing them to visit the pharmacy frequently. Or, it could force assisted living teams to constantly ask for prescriptions.
In independent living, where medication is managed more by the resident than professional caregivers, the situation would be even more complex. It might involve the resident, senior living provider, a home care agency working with the resident, a physician, and a pharmacy all having to coordinate to keep the medications flowing, Credille noted.
Electronic prescribing technologies would ease these burdens, Navarrete and Credille noted. They strenuously urge lawmakers and regulators to take a targeted approach. Credille worries about “knee-jerk reaction” policies that could leave providers scrambling to maintain access, while Navarrete warns that “casting a wide net” to address the crisis would hurt vulnerable populations.
Already, some pharmacists complain that they’re spending “hours” playing middle-man for insurers and patients due to increasing opioid scrutiny, the New York Times recently reported.
That same article highlighted patient and clinician concerns related to the new Part D changes. Constraining access for long-term opioid users could have serious health repercussions for them, including severe withdrawal and increased risk of suicide, the Times reported.
Reducing a resident’s opioid dependence is sometimes possible, but it’s far from simple, Credille and Navarrete emphasized.
“If we’re able to decrease the dosage and manage the pain in a more effective way, that’s ideal,” Credille said. “It’s done through using a combination of psychological services, behavioral management, medical services—it’s a multidisciplinary approach. It’s not easy.”
“It’s not easy” seems to sum up the situation with opioids more broadly; even beyond issues with long-term use for chronic pain, senior living providers have to take steps to prevent drug diversion and ensure proper disposal, to stop caregivers, residents or family members from stealing these medications.
While it’s uncertain what laws and regulations will be on the books in the coming months, providers can be certain that they’ll be focused on opioids for some time.
“It’s an issue we’re going to spend more time on,” Argentum’s Bersani said.
Written by Tim Mullaney