How the Opioid Crisis Stretches Into Post-Acute Care

Post-acute care (PAC) includes individuals receiving long-term care, home health care, outpatient treatment, physical therapy and rehabilitation for both physical and mental health concerns. Technically, all health organizations have branches or roots in post-acute care, but persons-served in this space are starting to become part of the opioid narrative.

According to the Centers for Disease Control and Prevention (CDC), up to 25 percent of people receiving post-acute care and taking opioids, for purposes other than cancer pain, experience the symptoms of withdrawal and opioid abuse. This contributes to more than 1,000 opioid-related overdose visits to emergency departments, and more than half of opioid overdose deaths involve a prescription opioid.

These statistics are shocking and show the impact of opioids on individuals in the post-acute care setting, such as seniors and those who recently underwent surgery or hospitalization for major health events. Moreover, prescription opioid abuse in PAC may be larger than researchers surmised.

While stopping all prescribing of opioids following major health events would be ideal, it is impractical. Therefore, health and human services (HHS), care facilities for seniors, long-term acute care, short-term care and other organizations must understand how this problem arose and what is necessary to stop it.

Major Health Events Spur Opioid Abuse

Major health events and issues, like surgery, may require opioids to treat intense, unbearable pain. Unimpeded prescribing of opioids for long-term pain management can lead to addiction. Yet, opioid abuse, including the use of heroin and opioids, can have long-term health consequences, such as pneumonia, sexual dysfunction and heart attack or arrhythmia.

Creating a constant feedback loop, recipients continue to turn to opioids to cope and manage their symptoms, reports the National Institute on Drug Abuse (NIDA). Moreover, contaminants in illicit, street opioids can cause other infections and worsening of symptoms, if not additional complications following surgery or other medical procedures.

Surgeries Found to Increase Risk of Opioid Abuse

Speaking of surgery, according to a recent study, published in the Journal of American Medical Association: Surgery, the incidence of opioid abuse after surgery and during post-acute care has become an oft-forgotten complication of health care. Approximately, 6 percent individuals who underwent any surgical procedure continued using opioids for 90 days or more after the original surgery. As reiterated by Diana Phillips of Medscape, 6 percent of individuals in need of surgery are likely to become addicted to opioid pain medication.

Prolonged use of opioids following minor and major surgeries suggests individuals use opioids for other reasons than pain management. Historically, health care professionals have assumed this use was isolated to young adults, but data from a 20-year study, published by the Healthcare Cost and Utilization Project (H-CUP), show opioid abuse affects all age groups much more than previously believed.

Opioid Abuse Affects All Age Groups

The H-CUP report highlights the hospitalization and rehospitalization rates among different age groups from 1993 to 2012 relating to opioid overdose, and the surge among rehospitalization is astounding. The rehospitalization rate among seniors aged 65-84 rose 401 percent over the study period. Among seniors over age 85, rehospitalization rates rose 419 percent.

These dramatic spikes in prevalence reveal the breadth of the opioid crisis. All adults from young adulthood through seniority are falling victim to the crisis, and part of this surge may derive from unsafe opioid prescribing practices.

For example, a 67-year-old male undergoes knee replacement surgery, and he receives opioids for pain management during recovery. The pain from the surgery continues, especially after physical therapy, so the provider increases the opioid dosage. Following multiple complaints about pain and discomfort, the health care provider increases the dosage again. This cycle grows in tandem with dependence on opioids. When the provider stops prescribing opioids, or when attempting to reduce the dosage after six months, the person-served turns to illicit drugs to manage the pain.

While this scenario seems impossible to prevent, pain from noncancer-related surgeries and other medical problems can vary and should improve with time. Depending on the person, a 30-day or 90-day supply of opioid painkillers may be much more than is necessary to manage pain. If the original prescription dispensed detailed a 90-day supply, the risk of opioid use becoming misuse or abuse increases dramatically. So, the solution may lie in better prescribing practices.

Chronic Pain Management Must Adapt to Curb Opioid Abuse

The problem with effective prescribing guidelines derives from misinformation and limited prescribing guidelines among doctors. This accounts for part of the recent spike in opioid abuse among middle-aged adults and seniors too, explains The Wall Street Journal. Unfortunately, the previous guidelines left broad discretion to prescribers and primary care providers (PCP). In fact, PCPs prescribed nearly 50 percent of all opioids abused in the U.S.

Among individuals who use tobacco, live with arthritis or suffer from another other chronic pain condition, the risk of opioid addiction increases further, leaving senior populations particularly susceptible. People with previous drug, tobacco or other substance abuse disorders were up to 30-percent more likely to abuse opioids for chronic pain, and arthritis sufferers were up to 50-percent more likely, report Alan Mozes of WebMD. But, better prescribing practices can help reduce this risk, so the CDC acted to create new prescribing guidelines.

New CDC Guidelines Seek to Reduce Post-Acute Care Opioid Abuse

While many of the CDC recommendations affect prescribing professionals, like doctors or nurse practitioners, all health care professionals have a duty to understand the guidelines and use them when reviewing charts of persons served or in their care following PAC admission or treatment. The new CDC opioid-prescribing guidelines include the following:

• Consider nonpharmacologic and nonopioid pharmacologic therapies for chronic pain. For example, yoga may be used to help manage low-back pain, explains National Center for Complementary and Integrative Health (NCCIH).
• Establish treatment goals. This helps prescribers set a planned outcome and duration for using opioids to manage pain.
• Discuss risks and realistic benefits of opioids for pain.Prescribers should discuss these facts with individuals before prescribing opioids.
• Start with immediate-release.Immediate-release opioids can have fewer long-term euphoric effects than delayed-release opioids.
• Prescribe the lowest dosage possible.
• Be mindful of expected pain duration, 3-7 days, which is enough for most major and minor surgeries.
• Evaluate benefits and risks or harms within 1-4 weeks of starting opioids, and taper dosage down as soon as possible.
• Re-evaluate risks periodically.Benefits and risks should be re-evaluated regularly to ensure the lowest dosage possible is used to treat pain.
• Review a person’s history of controlled substance prescriptions using state prescription drug monitoring programs (PDMP) to help prevent risk of overdose.This helps prescribers identify individuals using multiple doctors and health care centers to obtain opioid prescriptions.
• Use drug testing to identify prescribed medication use and illicit drug use that may interact with or increase the risk of addiction to opioids.
• Use evidence-based treatment for those with opioid abuse disorder,such as cognitive behavioral therapy or antidepressants to help manage addiction.

What can your organization do to help prevent opioid abuse throughout post-acute care?

The CDC guidelines can be applied in your organization to help prevent opioid abuse too. Keeping the guidelines top-of-mind, your organization should take the following steps:

• Provide proper training to staff members about new prescribing guidelines, signs of opioid abuse and facts about the opioid epidemic. This helps non-prescribing staff members act as a checks-and-balances system against individuals who do slip through the proverbial cracks, even when prescribers follow the new guidelines.
• Educate individuals receiving care about the risks of opioid misuse and abuse. Education must relatable and in lay terms. Do not confuse your community by throwing in excess medical jargon or complex terms. Keep it simple and to the point.
• Offer non-opioid therapies and treatment options for pain management. If your organization provides treatment for PAC pain management, focus on promoting non-opioid treatment options, such as yoga, meditation and physical therapies, among persons-served.
• Become active in your community. Your community has people suffering from opioid addiction, and they may not realize the extent of their problem. Be an active participant in your community, and use social media and mainstream media outlets to spread awareness about opioid addiction following PAC.
• Stay informed with CDC, NIDA and National Institutes of Health (NIH) recommendations and alerts. The NIDA publishes an updated opioid crisis-related list of alerts and trends to help all health care organizations recognize contemporary issues and risks evolving in the epidemic. Check for opioid “Emerging Trends and Alerts”often, and distribute alerts among your team members.

The opioid crisis continues to decimate lives across the country, but by working together with health care professionals from PAC, HHS and other care organizations, you can help stop the opioid epidemic.