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 Piecing Together a Strategy

Health care professionals across the continuum are trying to figure out how to handle the opioid crisis.

 


It isn’t necessary to be a weatherman to know which way the wind is blowing. And, Americans don’t have to be experts on drugs to know the opioid abuse crisis is a deadly and unique epidemic, with no barrier preventing it from affecting every part of the U.S. health care system.
 
Long term and post-acute care (LT/PAC) providers are not only not immune to the epidemic, they are increasingly dealing with the impact in how they hire employees, how they manage and store prescription drugs, and whether they invest in the specialized care it takes to manage complex addiction cases.

What Is This Crisis?

Possibly the most striking characteristic of the epidemic is the fact it has struck among populations wide and far, rural and urban, rich and poor, white, black, and Hispanic, and the young and the elderly, according to experts in the addiction field.

It is also a dual-action epidemic in that it tears apart lives from people abusing either legally prescribed painkillers or illegal street drugs like heroin. And, experts say, when one avenue to abuse is curtailed, there is a “Whack-a-Mole-like” impact for the other: Remove pathways to obtaining prescription opioids and voila, the use of heroin or synthetics promising even more severe highs and risks accelerates.

Although raw numbers only tell part of the story, they are daunting even to the most wizened behavioral health and substance abuse experts. For instance, in 2016, the latest year statistics are available, more than 64,000 drug overdose deaths occurred in the United States, with more than two-thirds of that number tied to opioids, the Centers for Disease Control and Prevention (CDC) says.

But the depth of the problem is perhaps best represented in a simple measurement. CDC said in 2015 and 2016 the U.S. life expectancy rate declined, a rare occurrence that has not happened in this nation since the early 1900s when the great influenza pandemic hit.

And, this trend won’t be easing soon, as CDC expects life expectancy to decline again when 2017 data are released later this year, with the agency blaming opioids as a triggering cause for the phenomenon.

A Drug Epidemic Like No Other

In describing why this drug crisis is unique, Richard Juman, PsyD, national director of psychological services for Knoxville, Tenn.-based TeamHealth, says above all else the opioid crisis is different in that it is iatrogenic, meaning caused by physicians.

Richard JumanTwenty-five years ago, he says, opioids were used almost exclusively for acute pain after surgery or for terminal pain, like the kind experienced by cancer patients.

“If you did a survey of physicians back then and asked them if prescribing opioids for chronic pain was a lawful and generally acceptable medical practice, about nine out of 10 would have said no,” Juman says.

“They recognized the potential for addiction, side effects, and the need for larger doses as you went along and realized eventually patients with chronic pain wanted to come off opioids and would go through withdrawal, which is not a pleasant experience.”

The scenario changed, however, when pharmaceutical companies undertook an “astonishingly effective campaign to convince physicians and other prescribers that new opioids prescribed to people with quote end quote ‘legitimate pain’ as opposed to substance misusers would not cause addiction,” he says.

The campaign eventually caused a sea change in opioid-prescribing habits because doctors came to believe “if this does not cause addiction, and is effective for pain, why would I deprive my patient of this really effective treatment? The problem is that both of those ideas are wrong,” Juman says.

No Limits to Where Opioids Are Turning Up

However the crisis came to be, the fact is there are now some 2 million to 4 million people using opioids on a regular basis in this country, he says. “And, we see this mirrored in long term care where something like one out of every seven long term care residents is regularly receiving an opioid,” Juman says.

“So, obviously, anyone who can read the paper can see it’s not something limited to any one dimension of health care, whether it is long term care, hospitals, or the outpatient setting.”

William HazelAnd, while the current opioid crisis and how to treat and respond to it are not limited to any one segment of health care, those with a long view of history know the country has seen versions of this before, according to William Hazel Jr., MD, former secretary of health and human services for the state of Virginia and current senior advisor for strategic initiatives and policies at George Mason University (GMU) in northern Virginia.

“The U.S. had an opioid crisis before World War I. It started with medical tonics, and lots of people became addicted. So, it’s not the first time a generation has battled with opioid addiction,” he says.

“What makes this one different is the volume of individuals who have become addicted or who have a substance abuse disorder. These substances are far more addictive than some others, and the brain changes quickly in response to them.”
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Providers on the Front Lines

As the push is underway to limit the clinical use of opioids in health care settings, skilled nursing and assisted living providers experience the crisis first-hand in many ways.

Lisa Volk, director of clinical and quality services, New York State Health Facilities Association (NYSHFA), and Nancy Leveille, executive director, Foundation for Quality Care, NYSFHA, say they are starting to see more residents come to member facilities with addictions to opioids, even if the problem is not readily apparent.

“We may not know it at the time, because they may be being treated for something else, and then we discover it. Or, they usually come in for a different reason, and then we discover they have a problem,” Volk says.

NYSHFA is the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) affiliate in New York.

There is also the need to be alert to visitors, residents’ family members, and facility staff who may have a drug problem.

“We work with our nurses association [in the state of New York] that has a special program for nurses who have addiction issues. We have been identifying the rate of addiction for all health professionals, but specifically for nurses and how we may be able to spot those problems and refer them for treatment,” she says.

Beyond being on the alert for issues with the various people who are in the facility at any given time, the pair say there is a big effort in New York to more closely monitor controlled substances, which seems to be paying dividends. “It has helped to reduce over-prescribing in general,” Leveille says. “Now, with the reduction in opioid usage, we need to ensure effective pain management for our residents with post-surgical and chronic pain by utilization of less addictive medications or alternative treatment methods​.”

Nurses have consistently complained about the quantity ordered when controlled medications have been prescribed. “We are the ones who have to destroy the extra that was ordered but never used and ensure the safety of those medications by securing them in locked cabinets and counting them regularly to prevent mishandling,” Volk says.

“We have been lobbying to reduce the quantity of narcotics ordered in each prescription to reduce this waste, potential diversion, and nurses’ times managing their safety. We recommended ordering in smaller quantities and for shorter time frames that fit with the usual amount of pain management needed,” Leveille says.

Keeping Alternatives in the Forefront

For Albert Munanga, regional director of quality improvement for Seattle-based Era Living, the number of opioid-related abuse cases is not that common among the facilities he oversees, but when there is one it is usually related to post-surgery addiction.

“Once in a while we see an individual struggle. One lady who had been using opioids for no clear clinical reason became quite anxious and acted out of line. But, as soon as she takes it [the opioid], there is almost an immediate placebo effect of taking something, and then she calms down and becomes normal,” he says.

Efforts are taken to prevent opioid dependency from developing through a variety of nonpharmacological means, like participation in activities, outings, music sessions, and the like, Munanga says.

The key to these efforts is not to have residents start on opioids to begin with. “You really need to be using other avenues, unless of course the pain is very severe and it is the only thing that will work,” he says.

Caring for People with Addictions

As with any referral looking for long term or post-acute care, the process of finding a suitable setting is one that depends on the ability of the facility to care for a potential resident or patient. Discussion about the role of skilled nursing and assisted living providers in treating people with opioid addictions has increased in recent months, but providers and experts in the profession say the basics remain the same: Facilities must be able to offer the specialized care necessary for this unique population before doing so.

“Our members are committed to doing what they can to help with the opioid crisis in our nation, but challenges exist and must be addressed,” says Holly Harmon, associate vice president, quality and clinical affairs, AHCA.

“We look forward to working with the Department of Health and Human Services, Centers for Medicare & Medicaid Services [CMS], providers, and other key organizations to identify solutions that will help provide needed, quality care for individuals fighting this addiction.”

Peter Van RunkleOne of the states hardest hit by the crisis, Ohio, has seen the challenges in dealing with opioid addiction and how LT/PAC providers have considered the challenges of doing so, says Peter Van Runkle, executive director of the Ohio Health Care Association, the AHCA/NCAL affiliate in Ohio.

He says typically the referrals for this population come from a hospital and not the community at large and tend to be people who have had a rough time of it in confronting their addiction before they end up in the hospital.

As people consider their post-acute care options, many of his member providers are not able to assist since they lack the specific care qualifications required for treating patients on opioids, such as physicians who are addiction specialists.

“For the most part, members are not equipped to provide drug treatment and to handle this population,” Van Runkle says. 

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Specialized Care Required

Being able to separate the patients with opioid dependencies from the general nursing facility or assisted living population is also a factor, Van Runkle says, given the different needs of what has proven to be a younger age cohort among those with addictions.

“We have units and facilities that deal with specialized populations, but this is different and even more specialized, with the additional risks being that these patients display drug-seeking behavior, and that they will stop at nothing to get what they need goes beyond typical specialized populations we deal with,” he says.

Whether to treat or not is akin to a facility having or not having the ability to handle people on ventilators, as an example, with the proper equipment and staff training that entails. “We don’t all take ventilators [referrals], and there is nothing wrong with that,” Van Runkle says. “Yes, a facility is certified as a SNF [skilled nursing facility], but not every patient is the same or falls within our capabilities and staff competency to handle.”

It really comes down to two sets of issues with opioids in the LT/PAC setting, the substance abuse experts say. The facilities are dealing with pain management and how to treat people who may be just starting out on a post-surgical pain plan or who possibly have been prescribed opioids over a number of years. Some of these people who have been suffering from chronic pain may even have developed an addiction to opioids.

The second type of population that nursing facilities and assisted living centers are seeing is the more recent phenomenon of referrals or walk-ins who may be younger than the average LT/PAC resident or patient. These individuals may be addicted to opioids either from taking prescription drugs or illegal street drugs and are seeking care once they have been discharged from the hospital.

For the most part, “you [LT/PAC provider] are not set up to manage that type of problem. There is medically assisted treatment that is available, but I would say most of your nursing facilities really aren’t expert in that at all,” GMU’s Hazel says. “If you have people who are addicted, you have a problem you have not had before.”

For New York’s Volk, whether to treat and care for the population with opioid addictions comes down to the current CMS facility assessment process, where a facility determines whether it has the ability to serve.

“Treating addictions is a specialty,” she says. “You know, they have detox centers in many hospitals, and they have special units or inpatient/outpatient programs within their system for individuals with addictions. When working for the VA [Veterans Affairs hospital], they had specially trained staff who were competent in addiction treatment and counseling to take care of their patients.”

Leveille adds that the type of staffing stands at the core of the question for treating residents with addictions in SNFs.

“I think in the SNF you have to have competent staff experienced in addiction treatment to safely manage and care for those residents,” she says. “And, that is what our SNFs are evaluating and planning for at this time. The SNF always has the right not to admit people when they cannot provide specialized care they require, and they also must provide a safe environment for all of their residents.”

Therefore, she says, they evaluate the facility’s ability to effectively provide services based on information they have gathered about a potential resident to determine whether or not they can meet that person’s needs.

Partnering for Addiction-Related Care

There are providers that have prepared for the treatment of people with addictions as part of their business and care strategies. One is Atlas Healthcare Solutions, which operates in Ohio and has facilities in the West Chester-Cincinnati area among its locations.

Jowanna LunsfordJowanna Lunsford, senior clinical liaison and business development at Atlas, says the provider has partnered with Modern Psychiatry & Wellness in a pilot program called CMAT (Collaborative Medical and Addiction Treatment). The program starts in acute settings where addiction specialists accept individuals in need of expert care, with opioids a leading cause of referrals.

She says the health problems with these types of patients are not simple, and not necessarily based on only getting patients off opioids. “While watching this begin to evolve, we are starting to see health care issues [for this mostly younger population] from everything like spinal abscesses to heart issues like valve replacements and so many critical illnesses as a result of their addiction,” Lunsford says.

It is Lunsford’s job to decide whether Atlas can service the needs of patients currently in the acute hospital setting.

“And, while treating these folks, we are meeting the medical side of this need, but the reality is we are not treating the whole person,” she says.

That is where CMAT comes in, as the pilot is meant to treat the entire person and tackle the addiction from every angle required, which in this case centers on Atlas working with Quinton Moss, MD, the director and founder of Modern Psychiatry & Wellness, and his team.

“Atlas recognizes the need for this partnership to produce positive outcomes in care and program success,” Lunsford says.

Pilot Seeks to Treat Whole Person

The goal in working with the pilot program was to offer Atlas as a placement alternative. “We developed this pilot in select facilities, at this point only two, to meet the needs of the areas that have been overwhelmed with the crisis. It is not uncommon in the local hospitals to have a portion of the hospital floor be representative of this type of client [on opioids],” she says.

With CMAT, Atlas and its partners offer a full continuum of care for those with addictions, including the family component, which Lunsford says is critical. “If you have listened to anything going on with this, the generation that the addicts are raising is being affected, and you can see the crisis and the trickle down throughout the family,” she says.

With the continuum of care components in place, Atlas goes in and assesses patients at the hospital level.
The service basically is a collaborative with both medical and addiction treatment. “So, we are treating the whole person. Not only are we treating the medical needs they are having, but also treating the addiction,” Lunsford says.

Once the patient signs off on being committed to the program, the process begins. “The patient meets one on one with a licensed addiction expert as well because those first three days are critical to those folks,” she says.

“Medication management needs to be in place for them, and that is what the assessment program does, it assesses them for meds management, potential withdrawal, and support early for their recovery.”

Addictions Affect Life

At first, many patients with addictions may check themselves out of a program against medical advice. 
Lunsford says CMAT is improving outcomes in that regard with not only nursing care and addiction services, but a plan to eventually return patients to the community via an outpatient component that employs voluntary drug screenings and case management with social workers.

“They will be reintroduced into the community and hopefully into a program. And Modern Psychiatry & Wellness has a little bit more of an extension through what is called a Genesis Center of Excellence,” she says.

As for how patients with addictions are folded into the overall work of Atlas, Lunsford says the most obvious difference is the ages involved, with most of those in need of addiction services between 25 and 40, even though there are cases of much older residents in need of help into their 60s and 70s.

When admitted into the Atlas facility, patients are housed in a dedicated wing for their care needs, with most stays between four and eight weeks if coming in for an intravenous antibiotic.

“They are not with us a real long time, a couple of months maybe depending on their level of need,” she says. “Some of the younger folks who have continued to be addicted without receiving services [like that provided in the CMAT pilot], their health is being affected to the point we are watching them go into hospice and eventually die because they’re not able to manage that addiction.”

Lunsford says the nature of opioids has created such a huge epidemic that her experience shows it is difficult for many people to overcome their situation without intensive treatment, and that is why Atlas has stepped in, to make a difference.

“It is just so deep. I saw a woman last week, she was very, very sick. She has a seven-year-old child, and the woman’s boyfriend just died of an overdose while she was in the hospital for an illness related to her addiction,” Lunsford says.

“Meanwhile, her child was just out there, alone. Luckily, her aunt scooped her up…there is so much that revolves around this crisis. So much.”
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