Substance use disorders don’t disappear just because someone enters a nursing home or other long term care setting. This is an issue that can’t be the elephant in the room; it needs to be addressed openly without judgment. When these disorders are recognized and treated, residents can enjoy better outcomes and quality of life.

“We sometimes see people coming into long term care because of their history of substance abuse. They have significant health problems and comorbidities, and they often lack family support,” said David Smith, MD, CMD, president of Geriatric Consultants in Texas. He explained that it is not uncommon for people with substance use disorders to have burned bridges with family and friends and to have neglected their own physical and mental health.

When these individuals enter long term care, there is a real opportunity for them to get help. “This is more of a controlled environment, and we can limit their access to alcohol or drugs,” said Smith. However, nursing homes and other settings need to have policies, plans, and resources to deal with substance use disorders, including opioid use disorder. For instance, he suggested, they may want to include in the admission agreement that bringing “contraband” into the facility is not allowed.

Identification and Red Flags

An individual’s history with drugs and alcohol should be addressed on admission. During this conversation, it is important that staff remain nonjudgmental and compassionate. If someone gets defensive, it may be useful to emphasize that these are standard questions that are asked of everyone.

At the same time, don’t count on everyone being open about their issues. For instance, Smith noted, “Some people may see a nursing home as an easier place to get opiates. As a result, we may see some drug-seeking behavior.”
Of course, the care team should take every pain complaint seriously, but they also need to watch for red flags. Smith offered an example: “I was examining a new resident with chronic back pain. I told her I needed her to flip over so I could examine her back, and she literally flipped right over quickly and easily without hesitancy or sign of discomfort.”

“When this kind of situation happens, it is important not to be accusatory or confrontational. It also is important to realize that if someone may be exaggerating their complaint to get opioids, that doesn’t mean that they don’t have some pain that needs to be managed,” Smith said.

In some cases, individuals may be getting drugs from other sources outside of the long term care community. “If they are getting drugs from outside, you need to determine where and how,” said Smith. Most often, he suggested, a friend or family member is bringing them in. This can be a difficult situation, he said, but you should confront them and explain that they are enabling and endangering the patient. It also will be important to have a conversation with the resident so they know that you won’t tolerate this behavior. Some organizations have residents or families sign a contract saying they won’t bring in drugs and that if they violate this agreement, there will be consequences (such as discharge without a 30-day notice).

The person’s family and friends may want to stage an intervention, Smith suggested. “This is often successful. If the person has harmed themselves to the point that they are in a nursing home or other long term care setting, an intervention can be a powerful wake-up call.”

Golden Rules and Balancing Acts

The golden rule is to believe any complaint of pain, so the focus needs to be on identifying and addressing the root cause of the discomfort. At the same time, said Smith, it is important to understand that someone who is addicted to opioids is likely to beg for dosage increases. “When you believe the patient’s pain complaint and start or increase a narcotic on a person who will prove to be an abuser, you often see no improvement in self-reported pain scores, and you see no improvement in function or you might even see worsening,” said Smith. If you are treating true pain with narcotics and start or increase it, he noted, then you will see reduced pain scores and improved function.

Kishore “Josh” Bose, PharmD, manager of clinical services at PharMerica, noted, “Pain management is a balancing act. If the patient is able to verbalize pain, you can go off a scale, but it is subjective. You need to have a clear picture of pain that is not just based on how they say they feel.” Everyone on the team needs to understand the importance of addressing pain, and every report of pain should be taken seriously.

Diagnostic Basics

Admission assessments are useful, but they rely to some degree on self-disclosure. “You might get some additional information from family members, as well as information on medical records about mental status and past use of medication,” said David W. Oslin, MD, executive director of the Stephen A. Cohen Military Family Clinic at the University of Pennsylvania. Physical indicators include conditions such as hepatitis C or cirrhotic liver, or needle tracks on various body parts.

While conversations and assessments at admission may help identify a substance use disorder, it may be necessary to pursue an evaluation by a psychiatrist, psychologist, or licensed alcohol and drug abuse counselor. Some of this may be able to be done via telehealth visits.

Some laboratory tests—including blood or urine—may be used to assess drug use, although these aren’t diagnostic of addiction.

Staff can be the eyes and ears for clinicians. They can watch for and report red flags, such as dosage increases that don’t result in improved pain or someone who seems to be moving easily even though they claim that they are in too much pain to function. Team members such as certified nurse assistants can also watch for “contraband.” It will be important to train them not to let themselves be used as enablers and to report any instance where a resident asks or demands that they bring in alcohol or drugs.

The consultant pharmacist should review any patient who has a narcotic in their medication regimen. If they make an inquiry about the drug’s use, the prescriber should heed this message and respond accordingly. In many states, such as Kentucky, pharmacists must take continuing education courses on opioid use disorder. Said Bose, “The industry is placing a focus on this and trying to take corrective steps.”

Everyone on the team should also watch for signs of withdrawal. When people enter a long term care community, they may suffer from lack of access to the drug they’re addicted to. Bose said, “They may have changes in affect—not engaging in socialization, becoming cranky and impatient, and/or displaying excessive lethargy.” If they have an opioid use disorder, and are unable to get these drugs, they may exhibit signs such as an elevated heart rate, gastrointestinal distress, flu-like symptoms, and/or high blood pressure.

How and Where to Treat

Treatments for substance use disorders are similar for younger and older people. However, noted Oslin, long term care residents are more likely to have a number of comorbidities and be taking multiple prescription medications, so drug interactions require special attention.

As with everything else in long term care, treatment must be individualized. It may be possible—and in some instances, desirable—to treat substance use disorder in house. This may include live or virtual therapy sessions; behavioral interventions; activities involving art, music, or pet therapy; and nutritional counseling. If it is determined that someone can benefit from Alcoholics Anonymous or Narcotics Anonymous, it may be possible for these organizations to come to the facility, provide a sponsor, and help with treatment. If a resident is functional enough, it may be possible to arrange for them to go out to meetings.

Detoxification, or withdrawal therapy, is a treatment option that enables the person to quickly and safely stop taking the drug they’re addicted to. This treatment may be provided onsite, or the person may need to go to a hospital or treatment center. It is important to note that withdrawal from different drugs may have different side effects, so they require a specific approach.

Detox may mean reducing the dose of the addictive drug or substituting another substance, such as methadone, buprenorphine, or a buprenorphine-naloxone combination.

When someone experiences an opioid overdose, naloxone temporarily reverses the effects of the drug. This may be administered by an emergency responder; in some states, a staff member may be able to do this. Naloxone is available as a nasal spray and in an injectable form, though both can come with a high price tag. When naloxone is used, it will be important for the person to get immediate medical care. It is important to remember that medicines aren’t a cure for the addiction, but they can assist in recovery. Nonetheless, Oslin noted that it is important to keep naloxone on hand. “Some homes have it in their code carts,” he said.

Ultimately, said Bose, “Providers need to be aware of some evidence-based resources that can help drive their decision-making and align practices.” It will be essential to “show your work” and document what was done and why, as well as what conversations were held with residents and families.

Team Tactics

In the end, said Bose, “Remember that when we approach any issue including substance use disorders, the team-based approach is best.” Each member has their role, and they need the training and skills to fulfill it. They also need to communicate and document their actions and observations promptly. ​