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Published in final edited form as: Int J Drug Policy. 2024 Oct 8;133:104607. doi: 10.1016/j.drugpo.2024.104607

Access and Care for People with Opioid Use Disorder in U.S. Skilled Nursing Facilities: A Policy Commentary

Shivani Nishar 1, Jon Soske 2, Rahul Vanjani 3,4, Simeon D Kimmel 5, Corinne Roma 1, Patience M Dow 1
PMCID: PMC11540742  NIHMSID: NIHMS2028426  PMID: 39383611

Abstract

Referrals for people with opioid use disorder (OUD) to skilled nursing facilities (SNFs) are increasing in the United States (U.S.). Further, legal guidance from the U.S. Department of Justice states that people with OUD cannot be discriminated against by health care institutions because of OUD or treatment with medications for OUD (MOUD). As such, SNFs are an important touchpoint for initiating or continuing MOUD, particularly amid rising drug-related overdose deaths among older adults and because people with OUD experience frailty and other geriatric syndromes at younger chronological ages. Informed by research, clinical expertise, and lived experience, this commentary describes policy and practice opportunities to help address challenges faced by people with OUD in gaining access to care and MOUD in SNFs. We propose opportunities to intervene against barriers that impede SNF placement and access to MOUD for people with OUD, including further revisions to 42 CFR Part 8 regulations to extend waivers for certification as opioid treatment programs (OTPs) to SNFs, allowing them to administer and dispense methadone in the same way as hospitals. If passed, proposed federal changes under the Modernizing Opioid Treatment Act would eliminate the requirement for methadone to be dispensed through OTPs, offering another opportunity to improve access to methadone for SNF residents. Also, we propose national and state-level investment in mobile substance use disorder services and partnerships with OTPs and hospital-based addiction consult services. We also recognize the need for more compassionate attitudes toward people with OUD in healthcare settings and discuss opportunities to address stigma. Although people with OUD are referred to SNFs for skilled care needs and not specifically for OUD care, it is essential for SNFs to be prepared to continue MOUD. It is both legally mandated and imperative that people with OUD have access to high quality and equitable SNF care.

Keywords: opioid use disorder, skilled nursing facility, nursing home, post-acute medical care, health policy

As the overdose crisis continues to worsen in the United States (U.S.), acute care related to opioid use has also increased (Salzman et al., 2020; Weiss A.J. et al., 2016). Simultaneously, there is a growing demand for post-acute care services among people with opioid use disorder (OUD) due to increases in chronic medical conditions (Han, Cotton, et al., 2022; Han, Tuazon, et al., 2022), complications of opioid use leading to lengthy hospital stays (Capizzi et al., 2020; Ronan & Herzig, 2016), and rising rates of OUD and opioid-related acute care use among adults over 65 years (Acevedo et al., 2022; Carter et al., 2019; Konakanchi & Sethi, 2023; Shoff et al., 2021). Therefore, accessible and high-quality skilled nursing facility (SNF) care for people with OUD is becoming increasingly significant (Moyo, Choudry, et al., 2024).

A SNF is an inpatient health facility, or a distinct part of an institution such as a nursing home, providing short-term skilled medical care and rehabilitation to patients following hospitalization. SNFs are critical providers of institutional post-acute care in the U.S. (Werner & Konetzka, 2018) and are receiving more referrals for people with OUD (Dineen, 2021; Han et al., 2020). However, people with OUD face significant barriers to SNF admission despite the U.S. Department of Justice clarifying that SNFs are prohibited from discriminating against people with OUD or those treated with medications for OUD (MOUD) per the Americans with Disabilities Act (ADA) (U.S. Department of Justice. The ADA and Opioid Use Disorder: Combating Discrimination Against People in Treatment or Recovery). To meet this legal mandate, SNFs must evolve to provide evidence-based care to residents of all ages who have OUD, including MOUD. Furthermore, SNFs require adequate technical and financial support to consistently provide high quality care for residents with OUD, especially since little of the funding or advocacy around OUD treatment has focused on post-acute care settings and the needs of older adults who disproportionately receive care in SNFs and who are experiencing rising overdose deaths (Humphreys & Shover, 2023).

SNFs face persistent concerns about finances, staffing, and quality of care due to several compounding factors, including increased referral volumes, the COVID-19 pandemic, private equity acquisitions, and staffing shortages (Braun et al., 2021; Grabowski & Mor, 2020; Harrington et al., 2012; Moyo, Nishar, et al., 2024; Xu et al., 2020; Yang et al., 2023). Simultaneously, the growing aging population with OUD underscores the urgency of integrating comprehensive OUD treatment and recovery support within the post-acute and long-term care system (Jones et al., 2023). It is essential to prepare for existing and new waves of older adults with OUD, as well as younger individuals with OUD who could benefit from initiating or continuing MOUD and receiving recovery support when they interface with SNFs. Understanding the factors that shape SNF access and MOUD availability in SNFs can inform policy changes at the federal and local levels, as well as intervention design, generation and dissemination of best practices, and deployment of resources to improve the care and health of people with OUD.

In this commentary, our team of researchers, clinicians, and people in recovery draws upon insights gained from our research and combined professional and personal experiences to outline policy opportunities to address challenges in access to care and MOUD in SNFs. For context, we first briefly describe the challenges that this commentary seeks to help address.

Challenges in access to care and OUD treatment in SNFs

Logistical barriers to providing MOUD

MOUD, specifically methadone and buprenorphine, are evidence-based treatments for OUD that dramatically reduce the risk of overdose and death (“National Academies of Sciences, Engineering, and Medicine,” 2019). However, due to stringent federal regulations that specifically apply to methadone (Substance Abuse and Mental Health Administration, 2015), SNFs require special procedures to make this medication available to residents as they are disallowed from directly dispensing methadone (Pytell et al., 2020). Therefore, SNFs need to coordinate with an opioid treatment program (OTP) to provide methadone either by transporting a resident to the OTP or transporting methadone to the SNF under take-home flexibilities or medical exceptions granted by OTPs.

SNF crises disincentivize care for people with OUD

Financial constraints are often cited as a significant barrier in admitting people with OUD who are disproportionately insured by Medicaid (Orgera & Tolbert, 2019), U.S. public health insurance for low-income individuals, which generally reimburses SNFs at or below the actual expenditures for care. SNFs with larger Medicaid resident populations are less likely to meet minimum staffing requirements (Hawk et al., 2022) and facilities that largely rely on Medicaid reimbursement are at increased risk of closure (Feng et al., 2011). In the U.S., as in most other developed countries in the world, long-term care facilities, including SNFs (International Labour Organization. Care Work and Care Jobs for the Future of Decent Work., 2018), are facing a staffing crisis, exacerbated by staff shortages, limited staffing hours, reliance on per-diem staff, and high turnover (Bowblis et al., 2024; Heiks & Sabine, 2022). COVID-19 further intensified longstanding staffing shortages within SNFs (Wager et al., 2024).

People with OUD experience stigma in SNF admissions and care

The literature indicates that people with substance use disorders (SUDs), including OUD, are often discriminated against when seeking care in SNFs (Kimmel et al., 2021; Kimmel et al., 2022; Moyo, Nishar, et al., 2024; Wakeman & Rich, 2017) and, if admitted, they face stigma in part due to staff unpreparedness and lack of knowledge about SUDs (Yang et al., 2023). Research suggests that health care providers may have higher levels of stigma against people with SUD than the general population (McLean et al., 2024). For example, it has been established that various forms of stigma, such as stereotyping, fear of discrimination, and self-stigmatization, impacts patients in healthcare settings. When stigma is perpetuated by healthcare staff, the health of people with OUD is compromised (Livingston et al., 2012; Tsai et al., 2019).

Financial and regulatory concerns affect SNF placement and care for people with OUD

SNFs are licensed and regulated by several agencies at the state and federal levels, including state health departments, Centers for Medicare and Medicaid Services (CMS), and the Joint Commission. Prior research indicates that some SNF administrators perceive that admitting people with OUD negatively impacts SNF performance and standards; contributing to inspection failures penalizable with monetary fines and lower CMS star ratings that decrease reimbursement (Moyo, Nishar, et al., 2024; Wang et al., 2020, 2021). Moreover, licensed nursing staff have reported that the extensive long-term care regulations constrain the ability to practice care creatively and exercise professional judgment in meeting the specialized needs of residents (McGilton et al., 2014). Notably, financial and regulatory concerns operate not only at the level of the SNF but are also influenced by broader structural forces such as the lack of affordable housing and insufficient access to mental health and substance use outpatient care (Han et al., 2017; Hansen et al., 2022). In Rhode Island, regulations impose fines on SNFs when a resident discharges “against medical advice” or when a resident experiencing homelessness is discharged to the street. While such penalties could be seen as encouraging creative care planning to avoid unsafe discharges from SNFs, the current regulatory framework often inhibits flexibility. For instance, the ability of SNFs to employ innovative interventions to provide MOUD is frequently constrained by administrative barriers, resource limitations, and regulatory oversight. As a result, these regulations are more likely to penalize non-compliance rather than fostering the kind of patient-centered, creative care planning needed to address the complex social and medical needs of vulnerable populations.

Opportunities to address challenges in access to care and OUD treatment in SNFs

MOUD availability in SNFs

The U.S. Department of Justice has determined that eligibility requirements excluding individuals with OUD or those receiving MOUD from SNFs violate the ADA (U.S. Department of Justice. The ADA and Opioid Use Disorder: Combating Discrimination Against People in Treatment or Recovery). Consequently, SNFs are required to equitably consider people with OUD for admission and reasonably accommodate those receiving MOUD. One way to do so is by providing buprenorphine, and swiftly developing the infrastructure to offer methadone to residents. As described earlier, SNFs are already underfunded and grappling with a worsening staffing crisis. While we recommend that SNFs build partnerships with OUD specialists who can provide consultation and support access to MOUD, it is equally crucial for states to incentivize and invest in SNFs to establish or expand at least a basic level of care and services for residents with OUD. Although people with OUD are referred to SNFs for skilled care needs rather than OUD treatment, SNFs must be equipped to continue existing OUD care and provide essential OUD services as part of their overall care offerings.

As of the end of 2022, the previously DEA-required buprenorphine X-waiver was eliminated (LeFevre et al., 2023). Additionally, new methadone policies may ease the barriers for SNFs to provide OUD treatment. Extended flexibilities for methadone take-homes have been granted in most U.S. states, making it possible for certain individuals to receive take-home doses of methadone for up to 28 days (V. Roy et al., 2024). Such flexibilities might help address concerns around limited resources to transport SNF residents to and from OTPs. For SNF residents who are already treated with methadone prior to their hospitalization, methadone can be transported from OTPs and provided in the SNF. SNFs looking to provide this care could pursue their own license as an OTP or become a designated medication unit within an existing OTP. However, achieving this status would likely require targeted grant funding. Alternatively, existing OTPs could establish a SNF division, though the initial effort might be prohibitive without substantial financial investment, as well as training and technical assistance. Recent changes to 42 CFR Part 8 (“Medications for the Treatment of Opioid Use Disorder”) made by the U.S. Substance Abuse and Mental Health Services Administration became effective in April 2024 (“Medications for the Treatment of Opioid Use Disorder,” 2024). However, the final rule did not designate SNFs as exempt from certification as an OTP in the same way that hospitals can administer and dispense methadone. Further amendments to 42 CFR Part 8 that extend the waiver for OTP certification to SNFs urgently deserve consideration.

In the U.S., there are also growing calls for community pharmacy dispensing of methadone which could help address gaps in methadone access for SNF residents (Jarrett et al., 2023). Other countries including France, Canada, Australia, and the United Kingdom allow licensed pharmacists to provide MOUD services (Cochran et al., 2020; Englander et al., 2024; Kimmel et al., 2020), including the dispensation of methadone, and could be role models for the U.S. should there be a regulatory shift to permit pharmacy-based methadone for OUD. The proposed U.S. Modernizing Opioid Treatment Access Act of 2023 would allow addiction physicians who work outside OTPs to prescribe methadone to treat OUD including for SNF residents (“Modernizing Opioid Treatment Access Act,” 2023). This may improve methadone access in SNFs with partnerships with addiction specialists. Clear guidance that SNFs could provide methadone directly for their residents as acute care hospitals currently do would also be an important advance in methadone access. Notably, the recent 42 CFR Part 8 final rule states that long-term care facilities can continue methadone for the management of withdrawal but only if they have a hospital or clinic Drug Enforcement Agency (DEA) license (“Medications for the Treatment of Opioid Use Disorder,” 2024). However, most SNFs are not eligible for DEA licenses because they obtain medications from contracted outpatient pharmacies.

As regulations are changed and opportunity is created for SNFs to build capacity to care for a range of people with need for SNF care and who have OUD, states must inform administrators and clinical staff of regulatory changes so that they are able to modify SNF admissions practices accordingly. States can also foster mutually beneficial ties between community-based organizations, local health systems, and SNFs in an effort to connect SNF residents to community-based recovery supports (e.g., peers coming into the SNF, linkage at time of SNF discharge). Given the anticipated growth of residents with SUDs or who are in recovery, some SNFs may even choose to hire peer recovery specialists. Another area worth exploring is the concept of collaborative practice agreements with pharmacists. Developed to improve access to care, this model could alleviate pressure on physicians by incorporating support from pharmacists and thereby improve access to MOUD for SNF residents (National Association of Boards of Pharmacy, 2021). Research has shown that pharmacist-based care via collaborative practice agreements can substantially increase retention in care among people treated with buprenorphine (DiPaula & Menachery, 2015; Wu et al., 2021).

Addressing stigma

Regulatory changes to allow improved access to buprenorphine and methadone will only improve SNF admission and care if stigma towards OUD is addressed (Christine et al., 2024; Chua et al., 2024; Huhn & Dunn, 2017; P. J. Roy et al., 2024). How to do this is not straightforward. Anti-stigma training can play an important role toward achieving more compassionate care; however, quality (e.g., content, modes of delivery, evaluation and feedback mechanisms) and context (e.g., structural environment, incentives, ongoing support) likely shape the extent and longevity of the potential benefits. Most research on training has shown small to medium effect sizes that are short lived and no evidence for the decrease of discrimination in practice (Corrigan, 2019; Wong et al., 2016). While training alone could provide SNF administrators and staff with more acceptable language, real attitudes and discriminatory practices may just be pushed “underground.” Contact interventions — engagement with a person from the stigmatized group in question — have shown more promise but appear to require status equality with the group being trained (i.e., nurses from the stigmatized group working with nurses) and a strong commitment from organizational leadership (Jorm, 2020). Contact interventions also can be damaging if done poorly. As with other forms of discrimination, legal sanction and workplace-based policies might be required to enact substantive change. This suggests addressing stigma in SNFs will require a facility-wide, if not national, strategy that combines regular training, collaboration with people with lived experience (perhaps through engaging local recovery advocacy and harm reduction organizations), enforcement of anti-discrimination legislation, facility-level policy, and unequivocal, public commitment to providing the highest quality of service to people with OUD both from national leaders and facility management.

The lack of integration of addiction treatment with other health care services presents distinct challenges for people with higher levels of OUD treatment needs who require SNF care. Since inpatient SUD treatment programs are not currently classified as medical facilities, a status that some in the SUD treatment sector defend to avoid increased regulation and cost, they do not address medical and rehabilitation needs as part of their services. Medically-enhanced addiction treatment programs should be options for people with OUD. Establishing billing mechanisms that allow addiction treatment facilities to provide certain medical services such as antibiotics and HIV care could incentivize the integration of these services. The current role for SNFs in serving the skilled medical needs of a small subgroup of referrals with higher level OUD treatment needs is an example of the way that the fragmented nature of medical and behavioral treatment services produces increased strain across agencies that greater systems and regulatory integration could address. Siloed reimbursement and regulations likely contribute to care fragmentation for people with OUD who require skilled care. For example, SNFs may be regulated at the state-level by a different government agency than the one that regulates addiction treatment services. While SNFs still need to comply with ADA, they may be getting directives from the Department of Health to improve one area of practice, and a separate behavioral health agency may have no power to enforce regulations regarding addiction services within SNFs. While it does not explain stigma or rationalize discrimination, negative outcomes for a minority of people with higher level OUD treatment needs placed in SNFs for medical issues that an addiction treatment center could not address is a form of what we have called “institutional mismatch” (Moyo, Nishar, et al., 2024). These exceptional cases have likely confused and complicated the broader discussion. Whether or not community relationships are built, there will undoubtedly need to be substantially more investment into SNF infrastructure to enable in-house OUD support such as mobile SUD services.

It appears that stigmatizing beliefs about people with OUD, coupled with institutional capacity gaps, fuel the limitation or outright denial of OUD referrals to SNFs. Holding such beliefs may damage patient-practitioner relationships and foster an environment of distrust between residents with OUD and SNF staff. Additionally, clinical care for residents with OUD might be negatively impacted if SNF staff believe such residents are prone to violence or are more behaviorally challenging than “traditional” SNF residents (Moyo, Nishar, et al., 2024). Education and training around how to provide the best clinical care for residents with OUD, combined with policy changes and strong leadership commitment, not only benefits those residents by providing them with more specific and compassionate care, but it also equips SNF staff with the tools necessary to feel more comfortable and confident in providing services.

Incentivizing access to care for people with OUD in SNFs

Structural barriers cannot be ignored as they perpetuate stigmatization of people with OUD. SNF administrators have described threats of facility closure amid persistent SNF underfunding and staffing crises as major reasons for deprioritizing admissions of people with OUD, staff training on OUD care, and MOUD services (Moyo, Nishar, et al., 2024; Yang et al., 2023). Therefore, financial incentives and regulatory changes are required to help SNFs overcome challenging market forces that administrators perceive to disincentivize admitting people with OUD and providing them access to MOUD. Although high-level and large-scale financial and regulatory changes are difficult to implement and are unlikely to occur in a short timeframe, their impact on access to care and MOUD in SNFs can be substantial. Financial incentives matter to SNFs and enhanced per diem reimbursement rates for residents with OUD and who require MOUD, especially from Medicaid, could diminish reluctance to admit people with OUD to SNFs.

While this commentary addresses opportunities to improve access to care and MOUD in SNFs, alternative models of care that can provide medical services to people with OUD deserve mention as a tool to alleviate potential strain on SNFs. For example, outpatient ambulatory parenteral antibiotics and use of outpatient infusion centers may be appropriate for a segment of people with OUD referred to SNFs. However, a quandary exists in that reductions in the volume of referrals for people with OUD to SNFs could disincentivize investment in capacity for OUD care and exacerbate discrimination toward people with OUD.

Direct relationships between hospitals and SNFs for both referrals and longitudinal care could alleviate the burden on SNF staff in facilities historically unequipped to provide OUD care and ensure some level of support in caring for SNF residents with OUD (Yang et al., 2023). Some hospitals have established a transitions of care curriculum for residents to become more aware and understanding of what it means to transition into a SNF. Others have hospital coordinators that visit SNFs monthly to assess patient outcomes and provide clinical education to SNF staff (Rahman et al., 2018). These opportunities for education in both settings may also facilitate a collective understanding of different levels of addiction care, as people who require intensive inpatient addiction care may not be best served at a SNF.

Developing processes for hospitals and SNFs to discuss referrals would allow for more explanation and less stigmatization of patient histories and needs. Improving communication and referral protocols as well as reinstilling trust in hospital-SNF relationships are all worthwhile efforts as the need for acute and post-acute care among people with OUD grows. Optimizing the timeliness, quality, and transparency of information sharing between discharging hospitals and SNFs can be facilitated by integrating SNFs into hospital information systems (Rahman et al., 2018). Some hospitals may choose to have SNF liaisons in-house, enabling SNFs to play a role in the hospital discharge and transfer process from the beginning (Valverde et al., 2021). Additionally, given that safe transitions for residents who no longer meet the SNF level of care are a key factor in SNF admissions decisions (Moyo, Nishar, et al., 2024), partnerships of SNFs with personnel or state agencies knowledgeable about community resources such as housing may be beneficial. Overall, financial and other incentives could increase enthusiasm among SNFs to admit people with OUD and develop capacity to provide MOUD. With a higher volume of SNFs providing OUD services, disparities in SNF choice and quality could be mitigated as people with OUD are typically referred and discharged to lower quality SNFs relative to people without OUD (Kimmel et al., 2022; Moyo, Choudry, et al., 2024).

In conclusion, efforts at the federal, state, and local levels to address the growing overdose crisis in the U.S. must include SNFs as a touchpoint for OUD treatment. Though efforts to enforce legal precedent under the ADA are essential, SNFs also could benefit from incentives and additional support to be able to consistently provide equitable and evidence-based care for people with OUD who require SNF services. We focused this commentary on SNFs which attend to short-term skilled care needs; however, the discussed opportunities to advance access to MOUD also extend to long-term nursing home residents. As people with OUD and who are treated with MOUD age, it is imperative to ensure their access to MOUD following transitions to institutional settings of care. To improve care for people with OUD in SNFs and long-term care facilities, a multi-pronged effort including technical assistance, carefully planned anti-stigma training, and clinical partnerships will need to be paired with regulatory and policy changes.

HIGHLIGHTS.

  • Hospitalized patients with OUD are increasingly referred to nursing facilities (SNFs)

  • Providing access to medications for OUD in SNFs is medically and legally essential

  • Regulatory, financial, and social barriers hamper care for people with OUD in SNFs

  • Multi-level efforts to improve OUD treatment and reduce overdoses must include SNFs

  • Anti-stigma training, technical/clinical support, and regulatory changes are needed

ACKNOWLEDGMENTS

This work was funded by grant R21DA053518 from the National Institute on Drug Abuse (NIDA) and the Irene B. Diamond Fund from Brown University. The funders did not have a role in the study design; data collection, analysis and interpretation of data; writing of the report; and decision to submit the article for publication. Dr. Soske was supported by the Systems of Care Fellowship at the Center for Complexity, Rhode Island School of Design (RISD). Dr. Kimmel was supported by NIDA (K23DA054363) and a Chobanian and Avedisian Boston University School of Medicine Career Investment Award.

Funding Source:

This work was supported by grant R21DA053518 from the National Institute on Drug Abuse (NIDA) and the Irene B. Diamond Fund from Brown University. The funders did not have a role in the study design; data collection, analysis and interpretation of data; writing of the report; and decision to submit the article for publication.

Footnotes

Declaration of interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Dr. Kimmel reports consulting for Bureau of Substance Addiction Services in the Massachusetts Department of Public Health. He is supported by NIDA K23DA054363 and the Boston University Department of Medicine Career Investment Award. Dr. Soske reported support from the Systems of Care Fellowship at the Center for Complexity, Rhode Island School of Design (RISD). Other authors have no disclosures.

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