Sen. Bob Casey (D-PA), chairman of the Senate Special Committee on Aging, noted that nearly 4 million older adults reported having a substance use disorder in 2022, with 1.8 million of those involving drug use. Mortality from drug overdoses among seniors also more than tripled between 2000 and 2022, he added, citing federal data. 

“Older adults are not immune to these issues, and this a growing and evolving crisis in America,” Casey said in opening the hearing, which focused both on access to opioids and gaps in care. 

“Older adults tend to be overlooked for substance use disorders in typical screenings and prevention efforts, even though they are more susceptible to developing substance use disorders than other age groups and at higher risk of undiagnosed and untreated substance use disorders,” he added. “The people, the problems and the solutions remain largely invisible to our society.”

Nursing homes are increasingly being called on to treat patients with substance use disorders, with both federal regulators and state law enforcement officials reminding facilities that they cannot turn away such patients when they are also in need of skilled care.

Some nursing homes have begun to specialize in providing such care, particularly for opioid-addicted patients requiring administration of suboxone treatments.

OIG keeps focus on needs, treatment access

Thursday’s hearing coincided with the publication of an annual brief from the Health and Human Services Office of Inspector General that examines access to treatment for opioid use disorder and the opioid overdose-reversal drug naloxone.

It found that about 52,000 Medicare enrollees experienced an opioid overdose in 2022. Of the 1.1 million enrollees who have opioid use disorder, just 18% received medication to treat that disorder. In some states, the OIG found far lower access, with Florida the worst with just 6% receiving treatment medication.

While naloxone has been an important tool in addressing the nation’s opioid crisis — one Senate witness credited with “saving countless Americans from death” — it last year became an over-the-counter medication. That could mean less affordable access for some Medicare patients, and the OIG warned CMS to make sure providers know how to educate patients and prepare for additional need.

The OIG report recognized that CMS and the department “had taken a number of actions” to increase access to suboxone and other opioid use disorder treatments. 

“However, the low percentage of enrollees receiving medication to treat their opioid use disorder calls for additional action,” the report said.

David Skoczulek, vice president of business development and communications at Connecticut-based iCare Health Network, said providing access to “patient-centered, specialized substance use treatment and care in the skilled nursing setting is critical.”

“Substance use disorder crosses all social and demographic lines,” he added. “The need for these services is not going away and it’s not even appearing to ebb over time. We will be living with the impacts of the opioid epidemic for a very long time in all aspects of healthcare, and skilled nursing care is not an exception. It’s highly prevalent and we will need increasing supports, access and coverage to provide quality care to these individuals.”

Medicare coverage gaps remain 

Much of the conversation Thursday revolved around the inability of Medicare-covered seniors to access residential treatment and other services under either traditional or managed care plans.

While commercial insurance providers in the US must provide parity in the way they cover physical health needs and behavioral health needs, the Medicare system has not been changed to reflect that standard.

“Older adults and people with disabilities deserve non-discriminatory coverage of substance use disorder and mental health treatment,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center. “We urge you to ensure that Medicare beneficiaries do not continue to be left behind.”

She pointed to the 2018 SUPPORT Act, which first added coverage of opioid use treatment to Medicare, as the start of improved treatment for opioid use disorder. This year, Congress included coverage of addiction counselors (under the umbrella of mental health counselors) and intensive outpatient treatment in its consolidated appropriations bill.

And CMS has also issued regulatory guidance and coding to make sure beneficiaries have more access to peer support specialists and community health workers, Steinberg noted. The agency also increased Medicare reimbursement for psychotherapy and office-based substance use treatment to “address barriers to provider participation,” Steinberg said.

Nursing homes, however, aren’t paid extra by the federal government for substance use disorder care provided to their residents, despite its additional staffing and safety demands and costly counseling services. State Medicaid plans, however, do in some cases help offset the cost of bringing in behavioral health professionals.

Also Thursday, Sen. Mike Braun (R-IN), the committee’s ranking member, issued a new report emphasizing concerns about the illicit opioid trade and the increasing ways seniors may interact with fentanyl-laced drugs.

“Despite [a] dramatic increase in overdoses due to synthetics, prevention messaging for older adults still reflects traditional concerns about prescription opioid misuse but does not focus on synthetics like fentanyl increasingly infecting drugs taken by older Americans,” the report stated.

But doing so poses significant policy and operational changes, and providers interested in expanding their role will need to make critical changes to staff training and development, report the authors of a new paper published in Health Affairs Thursday.

“The challenges for admitting and treating individuals with [opioid use disorder] in SNFs are many, but so are the needs,” the researchers wrote. “With appropriate planning, reimbursement, and training, SNFs can play a key role in combating the opioid crisis while also strengthening their own financial solvency.”`2

The researchers looked at two converging trends: the need for more treatment options for opioid users after hospitalization and lagging occupancy rates in skilled nursing. Some facilities have stepped in to provide post-acute care for patients recovering from opioid use and substance abuse as a tool to fill beds. 

While there has been a federal push to have more skilled nursing providers take on more substance and opioid disorder patients, not all facilities are prepared for the challenges, McKnight’s Long-Term Care News reported in September. Being under equipped or having unprepared staff could open operators to a range of related Centers for Medicare & Medicaid Services citations.

The number of overdose deaths rose from 70,630 to 106,699 in 2021, according to the National Institute on Drug Addiction. That increase is primarily attributed to a rise in opioid overdoses, which the article says has “only become dangerous since 2021.”

The Health Affairs article noted that a March public safety alert from the US Drug Enforcement Agency warned about a veterinary sedative being added to opioids to prolong the high, but the drug commonly results in users experiencing severe skin wounds. 

“Providing well-managed and supervised post-acute care for these patients within SNFs could improve their adherence and outcomes with medical and [opioid use disorder] treatments,” the authors wrote. 

But the skilled nursing workforce – both administrative and nursing – is trained to handle conditions and diseases associated with aging, and without proper and additional training, they could mistake substance use or withdrawal symptoms as behavioral problems instead of medical issues, the article said. 

The authors, all of them affiliated with the Health Management Associates consulting firm, detailed three models under which nursing homes could integrate opioid and substance use patients into their residential and care models. In the first, facilities would work with substance use disorder providers to offer treatment on site.. 

Under the second, facilities would provide on-site counseling while a nearby substance use disorder provider handles medication-assisted treatments either at a nearby facility or even in a mobile unit in the nursing home’s parking lot. The third model calls for the SNF medical team to be trained to provide the medication-assisted treatments under the direction of a substance-use disorder provider.

Facilities would also need a reimbursement model that would cover the cost of this specialized care, the article noted.