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ursing facilities routinely turn away patients seeking post-hospital care if they are taking medicine to treat opioid addiction, a practice that legal experts say violates the Americans with Disabilities Act.

After discharge from the hospital, many patients require further nursing care, whether for a short course of intravenous antibiotics, or for a longer stay, such as to rehabilitate after a stroke. But STAT has found that many nursing facilities around the country refuse to accept such patients, often because of stigma, gaps in staff training, and the widespread misconception that abstinence is superior to medications for treating addiction.

In Ohio — where 100 people a week died of opioid overdoses between August 2016 and August 2017 — a trade group representing more than 900 care facilities said in a written statement that none of its member facilities accepts patients who receive methadone or buprenorphine for addiction.

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In Massachusetts, another state that is reeling from a flood of opioids, a nurse case manager at Boston Medical Center said it can be “next to impossible” to find a place that will accept a patient who takes these medications.

“It’s so bad — you’re just begging and pleading with these places,” said Maureen Ferrari, a nurse case manager who for nearly a decade has worked at Boston Medical Center finding post-hospital placement for patients. She said only two nursing facilities in the Boston area accept people on addiction medicines, adding that this roadblock can harm patients and turn a two-day hospital stay into one that is a week long, driving up health care costs.

Experts say it is illegal under the ADA for a nursing facility to refuse admission simply because a patient is prescribed addiction medicines.

“It’s well-settled in the case law that people with opioid use disorder have a disability as recognized under the ADA,” said Sally Friedman, legal director of Legal Action Center, a nonprofit policy and law group based in New York City.

“Opioid addiction is a chronic disease like any other, and nursing homes should be ashamed of themselves for excluding people who are receiving the most effective form of treatment for this chronic disease,” Friedman said.

Yet the law has not been enforced when it comes to people addicted to opioids, experts say, and many nursing facilities and industry leaders seem unaware of their obligations.

“The imperative to provide people with addiction with medication has not percolated,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.

The Massachusetts Senior Care Association declined to say whether its member facilities denied admission to people on medication assisted therapy, but issued a statement from its president, Tara Gregorio, saying, “Many nursing facilities are committed to caring for patients needing Medication Assistance Therapy, but barriers exist.” Gregorio said the group was “actively working” with other organizations to address these obstacles.

The Ohio Health Care Association did not respond when asked whether it knew its member facilities’ refusal to accept such patients violated the ADA. And the American Health Care Association, a group representing 13,500 long-term and post-acute care providers nationwide, also did not respond to requests for comment.

Officials with a handful of state long-term care organizations polled by STAT, including trade groups in Wyoming and Montana, said they did not know whether facilities in their area had policies on how to continue addiction treatment among patients admitted to their facility, something experts said is unsurprising.

“There is a lot of confusion about what is legal and not legal,” said Dr. Sarah Wakeman, an addiction specialist at Massachusetts General Hospital, who added that her team faces difficulty finding post-hospitalization placement “every single day” for people who take medicine for addiction.

“There are facilities that do not understand that they are not allowed to do this,” she said.

In an effort to combat this confusion, the Massachusetts Department of Public Health in 2016 issued guidance for nursing facilities caring for patients who take medicines for addiction. The state’s circular letter asserted that care facilities must provide medication-assisted treatment for people who are already on it, and who otherwise are eligible for admission. A spokesperson said that the department addresses any concerns related to the topic that are brought to its attention, and that it reviews a facility’s policies and procedures when conducting a nursing home on-site visit. But the agency has not tracked complaints about addiction-related admission denials.

“There is a lot of confusion about what is legal and not legal. There are facilities that do not understand that they are not allowed to do this.”

Dr. Sarah Wakeman, addiction specialist at Massachusetts General Hospital

The U.S. Department of Justice has begun an investigation of detention centers that don’t make medication-assisted treatment available to inmates with addictions. And Beletsky, citing federal government sources, said a campaign to boost ADA enforcement among care facilities may be on the horizon.

It’s a move that can’t come too soon, he said. Failing to enforce the ADA for people with opioid use disorder “is a missed public health opportunity that is probably measured in lives,” Beletsky said. The Department of Justice declined to comment.

Refusing care to people on medication for addiction can have dire consequences because pressure to stop these proven treatments could open the door to relapse and overdose.

Part of the reticence to accept patients with addiction stems from unfamiliarity with the medicines used to treat them. Nursing facilities may not have a clinician licensed to prescribe buprenorphine on staff, for example, and facilities may be unaware that the patient’s primary care doctor often can continue to provide the medicine.

“We have faced hurdles even when clinicians who are discharging patients stable on medications to treat opioid use disorder are willing to continue prescribing these medications while patients are recovering at facilities,” Dr. Sabrina Assoumou, an infectious disease physician at Boston Medical Center, wrote in an email.

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Treatment of addiction is also an unfamiliar process for many facilities, where resources often already are stretched thin.

“You are taking on a chronic disease that you may not have the infrastructure to deal with,” said Dr. Wes Klein, an internist and the medical director of Duffy Health, a community health center in Hyannis, Mass. “That may scare people a little bit.”

Some addiction experts have begun partnering with nursing facilities to make sure the addiction treatment a person receives in the hospital isn’t a barrier to the next step in their medical care.

Center for Behavioral Health, a group of four addiction treatment centers in Las Vegas and Reno, Nev., began offering educational sessions on medication-assisted addiction treatment for nursing facility staff when some expressed discomfort with the medicines. The sentiment stemmed largely from a lack of experience with the addiction medicines — and a common misconception that medication-assisted treatment for opioid addiction represents replacing one addiction for another.

There is a “total lack of understanding and knowledge of medication-assisted treatment,” said Dr. Lesley Dickson, an addiction psychiatrist at Center for Behavioral Health. “Most doctors don’t even seem to know what it is.”

Krista Hales, the group’s program director, now regularly travels to facilities in the area, providing at least one educational session per month.

The reaction, Hales said, has been “surprisingly positive.”

“Most people go off of the stigmatized version of medication-assisted addiction treatment,” Hales said. “Then when you throw out what it really is — the raw data, the patient success stories — they are like, ‘Maybe this isn’t what I thought it was.’”

Wakeman’s team, too, recently began a partnership with two area nursing homes. The team provides prescriptions for patients admitted to the facilities so they can continue to take methadone and buprenorphine, and offers guidance if questions arise about proper dosages or other logistics.

“We need to think about how to help these facilities and how to support them in caring for a population they are not used to caring for,” Wakeman said. The needs of patients with addiction, many of whom may be younger than those who traditionally have stayed in nursing homes, “may be different from what facilities have historically thought about.”

The story has been updated with a statement from the Massachusetts Senior Care Association.

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  • There are many reasons that a nursing home may reject a person who is recovering from addiction.
    1. Nursing home do not have physicians available to prescribe suboxone, which requires a special license and used in recovery.
    2. Many of the folks who are in the recovery status have other issues, e.g. they are young (under 40), have multiple psycho-social problems, e.g. homeless, no family involvement, that the nursing homes are not staffed to assist. Some have pending legal issues and need support that is beyond the ability of the staff who have a focus on older adults/resources.
    3. If the individual has Medicaid, there is a very short window for the nursing home to muster help for this person. Ongoing care and support for the individual is essential. There are no specific services for those with addiction in a nursing home, e.g. group counseling, individual counseling help with resources beyond the stay.
    4. Many younger adults do not want to follow the rules within the nursing home. And nursing homes are also focused on resident’s rights which allow visitors and do not have the focus of substance use treatment facilities. Thus, you might have a person ordering liquor delivered, friends dropping off substances. Staff is not allowed in a nursing home to go through a resident’s possessions.
    5. Younger people often object to sharing a room with an elderly person. This presents difficulties as most residents in nursing homes are over 70.
    The perception of the nursing home is that it can manage any and all types of challenges that a resident may present. This is not the case at all. Federal regulations and the payment system is aimed at chronic physical illness of older adults. Mental health, substance use is not a focus and generally more of a challenge than most facilities can manage well.

  • Multiple nursing homes and long term care facilities in Rhode Island, where I practice, accept patients on maintenance medications. However, federal regulation prohibits long term care pharmacies from providing maintenance medications for opioid abuse disorders(and no you can’t get around the regulation by writing for chronic pain on the methadone prescription because the analgesic properties of the drug requires dosing several times a day as opposed to the maintenance properties permitting once daily dosing). The facilities have to insure that the medications will be made available from one of several specialty treatment clinics, ex: CODAC, etc. BEFORE the patient is accepted into the building. If not, it is very possible that the patient will miss doses of the maintenance medication with adverse effects. Most of the patients have prior relationships with one of several specialty clinics, who will, in most instances contract with the facility to provide the medications on a daily basis.

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