After hospital discharge, patients treated for opioid use may be unwelcome at nursing homes

A study led by a Brown University researcher found that patients discharged from a hospital after being treated for opioid addiction, who often need a place to recover temporarily before returning home, have difficulty finding a bed in a skilled nursing care facility (Getty image)

Stigma confronting people dependent on opioids can come from many sources. But a new study led by a Brown University School of Public Health researcher reveals a perhaps unexpected place: nursing homes.

People with opioid use disorder sometimes temporarily go to skilled nursing facilities as a step-down measure following hospital stays. These rehabilitative settings can help patients avoid hospital readmission and complications from injuries, including those involving injection site wounds or infections.

Even though access to residential care is protected under the Americans with Disabilities Act (ADA), a research team led by Patience Moyo, an assistant professor of health services, policy and practice at Brown, found skilled nursing facilities in Rhode Island routinely violated ADA by refusing to admit patients recently hospitalized for opioid addiction.

Patience Moyo, an assistant professor of health services, policy and practice at Brown University, led a recently published study on nursing home administrators’ attitudes toward people with opioid use disorder. (Courtesy of Patience Moyo)

Their qualitative study, published Feb. 5 in the journal JAMA Network Open , surveyed 27 skilled nursing facilities in Rhode Island, both nonprofit and for profit. Facilities that had and had not accepted patients with opioid use disorder were recruited to better obtain a picture of administrator attitudes. The interviews took place between November 2021 through April 27, 2022, ending only shortly after the U.S. Department of Justice had clarified its stance on opioid use treatment and the ADA.

“Our study took place before affirmations of anti-discrimination protections became more widely publicized across the country, which may have allowed administrators to give voice to views that they would be more cautious in openly expressing today,” the article said.

A total of 29 participants were interviewed, including administrators, directors of nursing and admission, and one unit manager. As is typical for research studies with human subjects, the article does not contain any identifying information about participants.

Fear of violating the ADA was apparently not a concern for some interviewees, one of whom said their facility turned away 110 hospital referrals in one year. Each rejection was spurred by a patient’s history of psychiatric issues, drug use, suicidality, smoking or opioid treatment.

Refusals didn’t occur at every facility interviewed by Moyo and her team. But that was one theme Moyo and her co-authors found as they sought to discover what higher-ups at nursing facilities thought of people who used opioids and were in need of residential treatment.

“In some contexts, those hospitalizations involve serious infections, or procedures that need more time to recover from, or additional rehabilitation, and even mobility issues. Sometimes people lose mobility while they’re hospitalized,” Moyo said in a recent phone interview. “So these nursing facilities can be a place where people can get a subacute level of care.”

Typically, up to 30% of patients discharged for opioid use disorder are readmitted within 30 days. But only 16% of hospitalized patients go on to a nursing facility , Moyo said.

Said one interviewee: “I review it [the referral record], I’ll go through and weed out the obvious ‘no’s.’…If I see that they’re on methadone or Suboxone, I’m just like, ‘Nope, can’t do it.’”

Methadone and buprenorphine, or Suboxone, are used to wean people off opioids, but they proved problematic to some administrators, as the study noted that most nursing facilities don’t have clinicians available to prescribe the drug. There have been efforts at the federal level to make opioid cessation treatments more accessible, including a 2023 bill proposed by U.S. Sen. Edward Markey of Massachusetts .

Workforce shortage a factor

But for the nursing facilities, transporting patients to methadone clinics presented a logistical challenge, which ties into another of the study’s major themes: staffing shortages.

“Half the people that work in nursing homes work there for one day and then they go work in a different one,” one interviewee said. “You might train five people that might not ever be here again.”

Concerns also emerged in how opioid-using patients might affect the culture of a facility. Nursing homes, after all, are typically associated with older people and not younger people with drug-use disorders. Admins worried about potential violence or incidents from mixing a vulnerable, elderly population with younger or even older people who use opioids.

That concern applied to employees, too: “There’s certain social issues that would present more challenges than your typical skilled nursing patient,” one interviewee said.

A day in a nursing facility can cost a quarter of a day in the hospital, a clear incentive for patients, Moyo said. But administrators didn’t share that perspective, and many noted that the vast majority of opioid use disorder intakes were on Medicaid, which can provide lackluster reimbursements for such patients.

Moyo said she and her team walked away from the study more aware of the situation’s layered complexities. Facilities can “have a lot of issues with staffing and funding and are super strained already.” Add in having to train more staff on how to properly care for patients with a very different set of needs and the response, Moyo said, can be: “‘You know, we’re not going to deal with it.’ And that speaks to a broader crisis in the SNFs [skilled nursing facilities].”

“I wish there was a simpler solution, because anything that involves reimbursement is something that the state would have to address in terms of its funding towards Medicaid,” Moyo said. “It’s not so simple to just say, ‘OK, we’ll turn up the rate and make it easier to cover care for these people.’”

What could be more manageable: “creating financial incentives” for nursing facilities, who are often vigilant about their star ratings with the federal Centers for Medicare and Medicaid Services, Moyo said. Turning away Medicaid patients can affect a facility’s ratings.

“Those ratings are a way for people to shop,” Moyo said. “What our team thinks is that these star ratings need to essentially be calculated in a way that does not penalize facilities that provide care to people with OUD [opioid use disorder].”

A novel idea in the study is that of “stigma ambivalence,” coined by Jon Soske, a co-author and specialist in addiction medicine at Rhode Island Hospital.

“In some cases, participants voiced ambivalence by noting that they should not generalize about groups but still holding that these generalizations held true,” according to the study. “Stigma ambivalence made it impossible, in many cases, to distinguish between genuine concerns over possessing institutional capacity and stereotyping of individuals with OUD [opioid use disorder].”

At least one interviewee seemed more sympathetic, mentioning a 29-year-old man in her 57-bed facility that was mostly inhabited by “little, tiny old ladies.”

“So, they have no one to talk to, they have no one who understands what they’re going through,” the interviewee said. “They’ll end up staying in their room and being a little bit unsociable. And that’s a very hard thing for a person to have to go through.”

But it’s unclear whether the interviewee was referring to the young man or the elderly women.

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