This is Dr. Clifford Moy, Medical Director of Behavioral Health for TMF Health Quality Institute, a nonprofit health care improvement organization in Austin, Texas.
Today, I'm with Dr. Paul Milligan, a clinical pharmacist, to discuss opioid safety in nursing home patients. Good morning, Dr. Milligan. How are you today?
Hi. Good morning, Dr. Moy. Doing well. Thanks for asking me here.
Great. Today, we want to talk a bit about the use of opioids in nursing homes for patients with pain and other symptoms. So I know this is a very broad topic. Maybe we should start first with some of the adverse events in nursing homes that are perhaps medication-related.
Yeah. That's a good place to start, I think, because there are a lot of adverse events in nursing homes, preventable harm, that occurs there. But a lot of those are medication-related. About a third of them are medication-related.
And part of that is because patients in nursing homes are on a lot of drugs, probably I think, on average, about eight drugs or more a day. And there's a lot of adverse drug events. If we just focus on adverse drug events, there's a lot of them.
Some of those numbers are saying there are 2 million of them a year. That translates to about 10 per month in an average nursing home-- so just to put it into a little bit different perspective. And then a lot of those patients are hospitalized. One out of seven of them go back to the hospital because of the adverse drug event.
And several studies have looked at whether these are preventable or not. That's always under discussion. And about a third of them are probably preventable.
Oh, I'm sorry. Go ahead.
You can probably guess what the top drugs are. The anticoagulants are common because of the bleeding. Diabetes is difficult to manage in an institution or anywhere, at home anywhere. But of course, opioids come out near the top on a lot of the studies that are done on the top drugs that occur.
In the opioid category, what seems to be the largest groups of adverse drug events? Are they from prescribing issues, administration issues, or drug-drug interaction issues?
Yeah, it's pretty well divided between those things. And they occur everywhere, prescribing, dispensing, nurses missing doses, giving the wrong dose, not monitoring patients after they increase the dose of an opioid. So it occurs at a lot of those different places, every step in there.
And so a lot of those things, we can deal with. A pharmacy spends a lot of time making sure they're given the right medications. Nurses have policies and procedures in nursing homes to go back in and reassess a patient after a dose at a certain period of time.
But I think as a provider, when a new symptom comes up for a patient, you might want to just think, is this drug-related? Is there a drug cause for any new symptom that pops up? Or at least put that in your decision analysis of whether this new symptom is caused by that.
And then we have a lot of people working in this team for consultant pharmacists. You're probably getting notes from pharmacies maybe in your charts or text messages because they're reviewing the charts to look at different signs of possible adverse drug events. That's mainly our job.
And look at drug levels. Assess renal function. You might get a note to say, there hasn't been a serum creatinine done in a while. And that's because they're looking at comparing all of these things and looking at drugs that might be cleared renally.
Just for an example about using your whole team to help with that is that some of the drugs, like fentanyl, are parenterally sometimes given. And that has a very major drug interaction with common drugs, like most of the azole antifungals, azithromycin, things like that.
And so pharmacists will look and see if those drugs are interacting. And it can really increase the serum levels of the fentanyl and cause some problems. So I would kind of use a team approach there to help reduce those adverse drug events before they occur.
That sounds great. I know that since nursing homes aren't hospitals and we don't have frequent team rounds in nursing homes, it's not an acute-care facility. How can all of these flags really be noticed adequately and promptly?
I know that you hear so much about alarm and flag fatigue in health care settings. Everything gets a flag for interactions. And providers just tend to not look at it anymore.
Yeah. So using that team approach to that is probably helpful. Again, pharmacists at nursing homes, the ones that are supplying the meds, have a duty to review the charts at a regular basis. And so they're a double-check on those because if you're entering these into a computer, most people get some alert fatigue over that.
You prescribed it a lot of times. And so those will sometimes be overlooked. But every once in a while, there's a real serious one and, again, having another set of eyes or hearing from the nurse about a new symptom that's popping up or the patient's respiration dropping or pulse ox dropping, if they measure that.
And then again, the communications from pharmacy and other people that are looking through the charts just all have to be evaluated. There are lots of drug interactions with warfarin, for example. And some of them are really important, and some of them are not. And those scoring systems are sometimes generous.
And depending on where your nursing home has set those pop-ups for clinical decision support, you may end up getting an enormous amount of them. And it's not unusual to just have to fly by them, especially on a drug you prescribe commonly.
Sure. It sounds like a number of cycles of improvement, including data analysis and looking at the trend data, would be helpful in trying to filter out those alerts that are most important, looking at whether some alerts are even necessary at some point.
Right. Again, I work in generally a hospital setting. And we do spend a lot of time to help prioritize those alerts and look at prevalence. But I'm sure not everybody has an opportunity to do that because we noticed we look at a number of alerts and find out that it alerted 1,000 times in the last week.
But the doctor never took action on it. There was never any change made. So a lot of times, we will suppress those alerts. But again, it's unlikely that that's happening all over.
Moving to a slightly different topic, it would seem that the most common, if not the only, reason that opioids be prescribed in the nursing home setting is to treat pain. Give us your thoughts on how big an issue pain management is in that setting.
Yes. Well, they're used a lot because there's a lot of pain in patients in nursing homes. About half of them are reporting pain. And the prevalence of using opioids in the hospital setting has doubled over the last 10 years, with at least a third of the patients in the hospitals-- in nursing homes, excuse me-- in nursing homes receiving an opioid.
And more than 15% of them take them long-term, that they're on them all the time. And then we've decreased the use of psychotropic medications in nursing homes. It has gone down, but increased in assisted living facilities, if anybody's practicing in those settings, as well.
Combine that with the fact that other sedatives that are common and psychotropic drugs and anti-epileptic drugs, they really increase the risk of an adverse drug event, especially when given with warfarin, I think. We'll talk about more drug interaction.
But the fear is that nursing home patients on opioids have a 60% increased risk of fractures. And there's a lot of falls. And again, I think we'll probably talk about that in a little bit and respiratory depression. And so that's part of an issue.
And then another issue coming to mind right now is that patients who are getting an opioid in the hospital already, they're also getting drugs like iron tablets and calcium and calcium-channel blockers and Parkinson's meds. Some of these are the medications that increase the risk of constipation.
And I know providers spend a lot of time and nurses spend a lot of time-- my wife's a nurse in a hospital. They spend a lot of time dealing with constipation. And these are just added on to the other possible drugs that are doing that.
And I guess lastly, a lot of the studies that we're going to be talking about or a lot of the treatment guidelines are complicated because when new drugs come out and when other medications come out, they exclude older patients in those studies. Most of the initial studies, anyway, are on young healthy college student patients-- excluded older patients and patients with lots of comorbidities.
Sure. As we record this today, we're hip-deep in the COVID-19 pandemic. And certainly, the public, as well as health care professionals, are starting to learn more and more about the FDA approval process for medications. It's nothing new. It's nothing to be frightened of.
But just to get a better understanding of what that means and how to communicate that with patients and families and other caregivers seems to be a vitally important task at this point so that we can really talk about what are the potential side effects of all of the meds that are prescribed.
Let me go back about pain. Obviously, patients suffer. They have a significant amount of pain. And we set an expectation that we're going to completely eliminate pain. Or how do we go about deciding what level of pain we're going to treat and how we're going to treat it?
Yeah. The decision to treat pain is pretty complicated and needs to have discussion with the patient, with the family member or somebody, because it's always a balance, as medicine is a balance between the right dose and not too much of the dose to take care of the pain, because the risks of under-treatment can even be worse.
I don't know about worse, but they could also be bad, because if you don't treat patients' pain with persistent pain, even palliative care patients with pain, it leads to depression and weight loss and functional decline, delirium. Patients in pain untreated is also not the answer.
And then sometimes, non-opioids might not be the best for some of the patients, as well, because NSAIDs in older patients have worse GI side effects and renal side effects. So it seems like what gets left lately is opiates are not a bad choice because we're familiar with them. And providers are usually used to managing them.
But a lot of times, we want to try some other sources, routes, kind of a layered approach, and can talk about that in a little bit, to. Don't forget ice packs. Don't forget ice packs. I talked to an emergency room doctor the other day. And he was like, if I just had more ice packs, I'd cut down my opioid use in the emergency room.
Gee, it seems like ice is a pretty common commodity these days. As a psychiatrist in assessing and treating patients with developmental disorders, we know that that particular group of patients with those disorders, if they're experiencing pain, it could lead to some mild to significant behavioral problems.
And I would assume that the same is true in nursing homes, especially those nursing homes that specialize in treating patients with cognitive disorders and have memory care units. Have you seen that?
Yeah, I think it would be the same. I don't think it would be different.
OK. Well, let's talk about how should we approach looking at other issues related to long-term use of medications or treatments with uncontrolled pain. What are some ideas that you have?
I think it's pretty well-accepted if we're going to consider an opioid that you should use the lowest practical dose of it. And short-acting agents should be used first. They're easier to titrate. They're great for acute pain. Those long-acting drugs and patches are really not to be started until you figure out what their opioid burden would be for a while.
So I think that's just kind of a general thing. And maybe that's what's done most of the time, also. But if a patient's opiate-naive, that's really a risk factor. And you really don't know how-- opioids need certain metabolism to be active ingredients. Some of them are not active until they're metabolized. Patients who metabolize slowly could have problems-- patients who metabolize the drug fast.
So I worked long in a post-surgical orthopedic surgery patients, managing their anticoagulants and opioids, too. And there were some that some of the drugs just didn't work at all and some that had to break their tablets into fourths. And so there's a wide range. And you don't know until you try.
So you need to consider your individual home's workflow, as well, if you're going to start an opioid on somebody. I think you make sure that they have a good strong nursing policy that's practiced where they're going. And check the patient right after the first dose or an increase of a dose.
I think there's lots of stuff. It's really hard to assess pain in institutionalized patients or in skilled nursing facilities because use of a standard pain assessment is pretty spotty. Some patients don't communicate well. Sometimes, self-reporting is challenging. They want to suck it up.
Or maybe they don't want to get constipated, so they say they're not in too much pain. But yet they're sweating and uncomfortable. So I think you might want to look at that a little bit, too.
And then really have to re-evaluate these patients all the time once you're starting-- this is a short-term problem. A post-surgical patient after hip surgery or something gets brought into the hospital, this is going to be on a short-term use. But again, the re-evaluation is necessary and sometimes overlooked in all kinds of settings.
We see it when people come into the hospitals from nursing homes. They're on medications that should have been discontinued because the med rec process is pretty spotty at hospitals and transitioning to those carers. We see patients coming back onto proton pump inhibitors and different things like that.
And then again, I want to stress that re-evaluation because there was a study just from last year that looked at opioids and found that a decent percent-- I think it was 10% or 12%-- of patients who had had some surgically repaired hips were still a year later getting the dose of the opioids that they had when they got out of the hospital.
So yeah, I would consider reducing the strengths or frequencies of the drugs that you have and not worry too much about withdrawal symptoms. There are a lot of studies out there showing that nursing home residents either miss doses for a few days because it was overlooked or automatically discontinued at a nursing home-- may have a policy to make you reorder them after a certain number of days.
And during all these interruptions, there were little to no reports of withdrawal symptoms in these patients for whatever reason. So I wouldn't worry too much about that, about cutting it down or even trying a trial without it.
And then I guess lastly, there are a couple of drugs that scare us a little bit. Long-acting agents again shouldn't be given until somebody's developing some tolerance, and you need to have some more.
And then a couple of drugs I think most people are familiar with-- meperidine isn't used much at all anymore, removed from a lot of hospitals' formularies. Codeine and tramadol also cause a little bit more-- they reduce the seizure threshold in patients. They cause more dizziness, more delirium. They just have unique safety profiles, especially in long-term care residents.
Dr. Milligan, thank you for discussing the opioid issue in nursing homes with us today. We wish you well, and we hope our audience has enjoyed this podcast. Thanks again.
My pleasure. Thanks for having me.
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