A recent McKnight’s article (“Nursing Homes may be targeted for turning away patients being treated for opioid addiction”) discussed the reluctance by skilled nursing facilities to accept residents who are being treated for opioid addiction.
While the practice of turning away these people may appear heartless, this may be necessary given some of the administrative and regulatory hurdles that exist.
For example, pharmacists are responsible for ensuring appropriate stewardship of controlled medications under F755 (Pharmacy Services), including having safeguards in place to control, account for, and reconcile the medications. There may be tremendous concern that the facilities, which usually lack an onsite pharmacy or a full-time pharmacist, would be unable to safely handle the highly regulated drug dispensing aspects of methadone for Medication-Assisted Treatment (MAT) or maintain the necessary regulatory authority required to do so.
Currently, methadone prescribed for MAT is not covered by Medicare Part D plans and retail pharmacies are prohibited from dispensing methadone for this purpose.(It may be dispensed only for pain treatment). When methadone is dispensed through an opioid treatment program, it is generally compounded into a liquid form which is given under supervision to ensure the patient ingests the medication. MAT patients typically must go to the treatment facility daily to get their dose of methadone and receive other services, such as counseling.
According to the DEA’s Diversion Control Division, patients in SNFs and other long-term care facilities can receive methadone for maintenance programs if the facility is registered with DEA as a hospital/clinic. If the facility is not registered with DEA, but the patient is currently enrolled in a licensed narcotic treatment program (NTP), the NTP may transfer medication to the facility only if there is approval from the State Methadone Authority. If the facility is not registered with DEA and the patient is not enrolled in an NTP, a practitioner may only administer methadone or other narcotic drugs to relieve acute withdrawal symptoms while arrangements for transfer to an NTP are made.
This emergency treatment exception is very limited as such therapy may be carried out only for a period of no more than three days, with no extensions or renewals. Since the practitioner cannot issue a prescription (the rule clearly states no “prescribing”) and can only administer or dispense under 21 CFR 1306.07, the pharmacy cannot dispense the drug, thereby creating another obstacle.
While methadone is generally considered the “gold standard” for MAT, other alternatives do exist.
Buprenorphine, which is available in several different products and often combined with naloxone to deter abuse, is unlike methadone in that it can be dispensed a licensed retail pharmacy for opioid addiction. Patients may get prescriptions for buprenorphine-containing products in a doctor’s office rather than at a NTP.
While methadone is a full opioid agonist, buprenorphine is a partial agonist, meaning that it has a “ceiling effect.” Taking more buprenorphine after the ceiling will not result in a greater effect for the addict.
However, a practitioner wishing to prescribe buprenorphine, must acquire and maintain certain certifications to prescribe these medications for opioid addiction. Unless a practitioner specializes in addiction treatment, the time-consuming certification process may create a barrier for the practitioner, given all of the other responsibilities that he or she may have.
This may well be the case in a typical SNF, and the question becomes: Are the attending physicians and/or medical directors willing to go through the necessary training and certification process in order to prescribe buprenorphine?
Increasingly, SNFs are accepting more and more post-acute care patients. These patients often don’t fit the customary patient profile of a “traditional” nursing home resident. Perhaps this changing profile will eventually allow for new business opportunities in which it could be both sound medical and business practice to accept MAT patients.
At present, however, this is typically not the case as Medicare does not cover MAT at all and Medicaid coverage is offered in only about 35 states. This reimbursement hurdle, combined with the lack of onsite facility resources, such as an onsite pharmacy or a full-time pharmacist, appropriate staff training and necessary licensure and certifications required to prescribe and dispense these drugs, currently makes it difficult to accept MAT patients into SNFs.
Joan Baird, PharmD, BCGP, FASCP, is Director of Pharmacy Practice and Government Affairs for the American Society of Consultant Pharmacists.
Blake Griese, JD, PharmD, is chairman of ASCP’s DEA Task Force.