Circular Letter

Circular Letter Circular Letter: DHCQ 16-11-662 - Admission of Residents on Medication Assisted Treatment for Opioid Use Disorder

Date: 11/15/2016
Organization: Bureau of Health Care Safety and Quality
Referenced Sources: 105 CMR 700.00: Implementation of MGL c.94C
105 CMR 150.00: Standards for long-term care facilities

To: Long-Term Care Facility Administrators

From: Eric Sheehan, JD, Director, Bureau of Health Care Safety and Quality

Date: November 15, 2016

Re: Admission of Residents on Medication Assisted Treatment for Opioid Use Disorder to Long-Term Care Facilities

Table of Contents

Purpose

The purpose of this circular letter is to provide guidance for long-term care facilities (LTCF) that admit residents who require skilled nursing care and who are also being treated for opioid use disorder with medication assisted treatment (MAT).

Background

Some residents requiring skilled nursing care have completed detoxification and are receiving MAT, which includes treatment with methadone, buprenorphine, or naltrexone1.  In those cases, if the resident would otherwise be eligible for admission to the LTCF, the facility is expected to admit the resident and provide for the administration of MAT as directed by the prescribing or ordering physician at the resident’s opioid treatment program (OTP) or Office Based Opioid Treatment with Buprenorphine program (OBOT).  Substance use disorder would not be the primary condition for which treatment is sought at the LTCF. This circular letter does not address the prescription of methadone for pain management, which should be handled in the same manner as any other drug prescribed for pain management.

Methadone for Medication Assisted Treatment

As part of the LTCF admission process, and prior to administering any take-home methadone, the LTCF shall review all prescription orders, including the take-home methadone documentation obtained from the OTP, to ensure that medications prescribed at the LTCF are not contraindicated due to interactions with the currently prescribed medications for medical conditions.

The LTCF shall establish a procedure for obtaining take-home methadone doses from the resident’s OTP.  The procedure shall include instructions for secure transport of the drugs, transfer documentation, and completion of a chain of custody form.  The LTCF shall ensure that all take-home methadone doses received from the OTP are properly packaged and labeled.  Once the methadone is in the custody of the LTCF, the facility shall store the drugs in a double-locked secure area in the LTCF nursing unit, administer the drugs consistent with Department of Public Health (Department) regulations at 105 CMR 700.000 and 105 CMR 150.008(D) and applicable federal regulations, and document each administration in the resident’s record.

When residents using methadone for medication assisted treatment are discharged from the LTCF, the residents may take all remaining methadone doses with them, if they have a written order from the OTP physician to do so.  If the resident dies or if the take-home medication is only available to the patient until the patient is ambulatory or the medication is discontinued, the LTCF shall destroy the medication in compliance with Drug Enforcement Administration (DEA) and the Department’s Office of Prescription Monitoring and Drug Control rules, as with all medications.

Buprenorphine for Medication Assisted Treatment

A resident who is receiving buprenorphine treatment at an OBOT from a Drug Addiction Treatment Act (DATA) waived2 physician may need to continue this treatment in a LTCF.  The resident shall continue to see a DATA waived physician for this treatment.  The prescription should be reviewed by the LTCF’s medical director, who should be in communication with the DATA waived physician, and can be filled by the pharmacy and administered in the same manner as all other prescription medications.

For patients receiving buprenorphine treatment through OTPs, the LTCF staff should follow the same protocol as described for methadone take home medication.

Extended Release Injectable Naltrexone for Medication Assisted Treatment

A resident who is receiving injectable naltrexone treatment through a prescribing physician may wish to continue this treatment in a LTCF.  The resident shall continue to see a physician for this treatment.  The prescription should be reviewed by the LTCF’s medical director and can be filled by the pharmacy and administered in the same manner as all other prescription injectable medications.  The injection is generally given once a month and can be given by a health professional who is allowed within his or her licensing scope of practice to give injections.

Use and Storage of Naloxone

Given the widespread use of opioids in LTCFs, naloxone, a schedule VI medication, shall be stored for emergencies pursuant to 105 CMR 150.008(E) and used only upon the orders of a physician or physician assistant or nurse practitioner. Administrators shall meet with the facility's Medical Director and Pharmacy service to ensure the availability of naloxone in case of an emergency and develop standing orders, pursuant to the attached Department Policy on the Use of Standing Orders for the Use of Naloxone (See Appendix A).

Contact Information

For more information, or if you have any questions on this guidance, please contact the Division of Health Care Facility Licensure and Certification via email at paul.dinatale@state.ma.us. Thank you.

Appendix A

Policy on the Use of Standing Orders for the Use of Naloxone

The Department of Public Health highly recommends that Long Term Care Facilities develop standing orders for the use of naloxone as part of their institutional practices, subject to the following conditions:

  1. The order shall be part of the institution’s policies and procedures. The policy statement shall reference current standards and/or guidelines for the use of naloxone. The accountability for development and implementation of the policy within the institution shall be clearly stated.
  2. The order for administration of medication or treatment shall be signed by the facility Medical Director. Alternatively, attending physicians often include a “standing order” to administer a medication, immunization or treatment as part of admission orders, or annual renewal of orders. This order, when written well in advance of the time the medication or treatment is administered, indicates the resident is medically cleared, and authorizes the administration.
  3. Policies shall include parameters for use, i.e., eligible individuals for whom the order is appropriate, and any restrictions or exclusions. Additionally, a screening procedure shall be developed for use at the time of administration.
  4. Policies and procedures shall include requirements for documentation in the medical record, including transcription of the order, established patient assessment and consent, and documentation of administration.
  5. Professional staff administering the medication or treatment shall conduct an immediate assessment of the patient for medical contraindications, and document the results of the assessment in the medical record, in accordance with established policies.
  1. Commonly used trade names for buprenorphine/naloxone are Suboxone®, Zubsolv®, and Bunavail®.  The commonly used trade name for buprenorphine is Subutex®. The commonly used trade name for injectable naltrexone is Vivitrol®.  See the SAMHSA link on MAT for further information.
  2. “On October 17, 2000, Congress passed the Drug Addiction Treatment Act (DATA) which permits qualified physicians to treat narcotic dependence with schedules III-V narcotic controlled substances that have been approved by the Food and Drug Administration (FDA) for that indication.

The legislation waives the requirement for obtaining a separate Drug Enforcement Administration (DEA) registration as a Narcotic Treatment Program (NTP) for qualified physicians administering, dispensing, and prescribing these specific FDA approved controlled substances. Physicians registered with the DEA as practitioners who apply and are qualified pursuant to DATA are issued a waiver (DWP) and will be authorized to conduct maintenance and detoxification treatment using specifically approved schedule III, IV, or V narcotic medications. DATA waivers are only granted to qualified physicians. Hospitals and mid-level practitioners do not qualify under the DATA.”  Please reference this web page for additional information: http://www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm

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