A federal push to have skilled nursing providers care for more patients with substance use and opioid use disorders faces major systemic hurdles, researchers reported this week.

Nursing home staff feel unprepared to handle patients with SUD and OUD, have critical perceptions of addiction and complain of an overall lack of resources for addiction care, researchers reported this week.

“Stigma surrounding residents with SUD/OUD exacerbates health disparities for an already vulnerable group with higher rates of comorbid conditions such as pain, polypharmacy, and geritaric syndromes that necessitate post-acute care,” researchers from the University of Chicago and Vanderbilt University wrote in The Journal of Addiction Medicine. “Standardized care protocols and staff training will be critical to close gaps and raise capacity to care for the population in nursing homes.”

While admissions denials based on drug-addiction are prohibited by the Americans with Disabilities Act, a study earlier this year put the rejection rate for one hospital’s referrals at 40%. CMS has made improving access to SUD prevention, treatment and recovery services one of its top behavioral health goals.

But interviews with 24 administrators and staff from 11 Chicago-area skilled nursing facilities featured in the study published online Wednesday show there is a long way to go in the long-term care sector.

Four of the 11 facilities had formal programming for residents with a history of addiction, admission to which required the patient to sign a behavioral contract that prohibited any illicit drug use. Five others accepted patients with diagnosed substance abuse disorder but did not have structured treatment programs. 

Across facilities, residents with substance abuse histories were widely perceived as having overall “bad behaviors” or  “taking resources” from other residents. Other concerns were that they were time-intensive, manipulative, aggressive or violent were exacerbated in environments with low staff-to-resident ratios, the researchers noted.

Admissions decisions in some facilities seem to be influenced by those perceptions.

“A common theme emerging from admission review centered around the perceived fit of this population and risk to the facility, staff, and other residents,” the researchers wrote. “Many administrators expressed reluctance to ‘mix’ populations …. Some staff expressed concern for the potential for residents to continue to use or become aggressive and agitated, thus imparting an individual risk to safety of staff and other residents.”

A growing challenge

Some facilities also showed a preference for substance users who were immobile and more dependent for care needs. Some operators said they require toxicology reports before admitting residents, while others said “inadequate” reimbursement for residents with additional diagnoses was a potential barrier to admission. 

So was getting and administering addiction treatment medications. Many facilities did not have a physician on staff permitted to prescribe buprenorphine, and methadone cannot be delivered to nursing homes.

Most also did not have the behavioral health resources needed to support regular access to  methadone treatment, or even routine counseling.

Almost all of those interviewed, however, acknowledged that SUD patients were a growing long-term care population. The researchers pointed out that there was a 53% increase in older adults seeking treatment for opioid use disorder between 2013 and 2015, and that older adults with opioid-related hospitalizations were more likely to be discharged to nursing homes than those hospitalized for other reasons.

Policy revisions and education — particularly for the nation’s geriatricians — are key to the better management of SUD care, said the researchers, who were led by Vanderbilt’s Stacie Levine, MD.

“It is imperative not only to develop standardized staff education and care guidelines to improve quality access to care for this population, but also to advocate for thoughtful and compassionate policy change that allows nursing homes to offer best practice care to their residents.”