| Date: | 09/12/2022 |
|---|---|
| Referenced Sources: |
105 CMR 150.00: Standards for long-term care facilities 105 CMR 700.00: Implementation of M.G.L. c.94C |
TO: Long-Term Care Facility Administrators
FROM: Elizabeth Kelley, MPH, MBA, Director, Bureau of Health Care Safety and Quality
SUBJECT: Admission of Residents on Medication for Opioid Use Disorder (MOUD) to Long-Term Care Facilities
DATE: September 12, 2022
Purpose
The purpose of this memorandum is to provide guidance for long-term care facilities (LTCF) about caring for residents who require long-term care and who are also being treated for opioid use disorder with medication for opioid use disorder (MOUD) to ensure residents receive safe, evidence-based care.
Background
Substance use disorder is a treatable illness, often chronic. People may choose different treatments and paths for their treatment and recovery. Some people use medication as part of their treatment for addiction, including for opioid use disorder. Medications for opioid use disorder include methadone, buprenorphine, and injectable naltrexone. Treatment with medication can be short-term or long-term (known as maintenance).
Individuals requiring care in a long-term care facility (LTCF) may also require treatment for opioid use disorder which may include MOUD such as methadone1, buprenorphine, or naltrexone. LTCFs are required to provide access to MOUD under 105 CMR 150.003(B) which requires LTCFs to provide care and services to meet the resident’s physical, emotional, behavioral, and social needs. Individuals eligible for admission to a LTCF shall not be denied admission on the basis of requiring treatment for opioid use disorder; the facility should admit the resident and provide for the access to administration of MOUD as directed by the resident’s OTP or OBOT/ OBAT program, or a prescriber in the LTCF.
Under the federal Drug Addiction Treatment Act (DATA), qualified physicians are permitted 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 granted to qualified physicians, nurse practitioners, and physician assistants. Please reference this web page for additional information: www.deadiversion.usdoj.gov/pubs/docs/SAMHSA_Regulations_275.pdf
As a resource for long-term care facilities, the Massachusetts Consultation Service for Treatment of Addiction and Pain (MCSTAP) is a free consultation service that supports healthcare providers in increasing their capacity for, and comfort in, using evidence-based practices to screen, diagnose, treat, and manage the care of patients in Massachusetts with chronic pain, substance use disorders, or both. Providers may call MCSTAP at 1-833-PAIN-SUD (1-833-724-6783) Monday through Friday from 9 am to 5 pm for an on-demand physician consultation on safe prescribing and managing care for adult patients with chronic pain, substance use disorders, or both.
Methadone
As part of the LTCF admission process, and prior to allowing patients to self-administer any pre-poured take-home methadone, the LTCF shall review all prescription orders, including the take-home methadone documentation obtained from the OTP, to ensure that other medications currently prescribed are not contraindicated due to interactions between methadone and the currently prescribed medications for medical conditions.
The LTCF should establish a procedure for obtaining individually labeled pre-poured take-home methadone doses from the resident’s OTP. The procedure should include instructions for transport of the medication, transfer documentation, and completion of a chain of custody form with the OTP as well as releases for care coordination between the facilities. The LTCF should 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 medication in a double-locked secure area in the nursing unit as required by 105 CMR 150.008(D), administer the medication consistent with Department of Public Health (Department) regulations at 105 CMR 700.000 and 105 CMR 150.008 and applicable federal regulations, and document each administration in the resident’s record as required by 105 CMR 150.008(C)(4). The LTCF should establish a procedure for communicating with the OTP regarding the patient’s overall well-being and convey pertinent information to the OTP regarding the patient including any new medication or updates or concerns regarding their health. This should also include a procedure for communicating with the OTP whenever possible, prior to the patient leaving the LTCF or upon discharge from the LTCF. Discussions should include whether the patient should be provided with their methadone bottles when the patient leaves the LTCF.
When residents using methadone as MOUD are discharged from the LTCF, they may take remaining methadone doses with them, as determined by the OTP’s medical director. In order to ensure continuation of methadone maintenance treatment, the LTCF should continue to communicate and collaborate with the OTP to ensure that the resident is provided with a direct referral back to their OTP immediately upon discharge from the LTCF which may include assistance with coordinating transportation. If the resident is not provided with their take-home doses on discharge from the LTCF, a “Last Dose Letter” shall be completed by the OTP and given to the patient. The chain of custody form shall be completed by the LTCF and faxed to the OTP confirming destruction of unused take-home doses of methadone. The “Last Dose Letter” will assist the patient’s admission process when transferring to a new OTP. If the resident dies or the medication is discontinued, the LTCF shall dispose of the remaining medication in accordance with Department guidance.
Buprenorphine
A resident who is receiving buprenorphine may need to continue this treatment in a LTCF. The resident shall continue to see a prescriber with an X waiver (required if seeing over 30 patients) for this treatment. The prescription shall be reviewed by the resident’s provider who must be in communication with the prescriber with an X waiver for the purpose of care coordination, and can be filled by the pharmacy and administered in the same manner as all other prescription medications. The Department encourages eligible medical providers at LTCFs to pursue DATA X waiver training, such as physicians and advanced practice prescribers, which is provided free of charge. Please see the following website for additional information:
https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
For residents receiving buprenorphine through OTPs, the LTCF staff must follow the same chain of custody protocol as described above for methadone take home medication. If the patient has an individual prescription from a DATA waivered prescriber, the chain of custody protocol is not necessary.
Extended-Release Injectable Naltrexone
A resident who is receiving injectable naltrexone treatment from a prescriber may need to continue this treatment in a LTCF. The resident shall continue to see a prescriber for this treatment. The prescription shall be reviewed by the resident’s provider 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. Naltrexone is also available as a once daily oral medication for the indication of treating alcohol or an opioid use disorder. Injectable naltrexone should not be administered to residents dependent on opioids. In the event that there is uncertainty regarding a resident’s opioid dependence providers should utilize a challenge dose of naltrexone.
Use and Storage of Naloxone
Given the widespread use of opioids in LTCFs and the surrounding communities, naloxone, a schedule VI medication, shall be stored for emergencies pursuant to 105 CMR 150.008(E). 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).
Commonly used trade names for buprenorphine/naloxone are Suboxone® and Zubsolv®. There is also a long-acting monthly injectable formulation of buprenorphine with the trade name Sublocade®. The commonly used trade name for buprenorphine is Subutex®. The commonly used trade name for injectable naltrexone is Vivitrol®. See SAMHSA’s website for MAT under “Resources” for further information
Contact Information
For more information, or if you have any questions on this guidance, please contact the Division of Quality Improvement within the Bureau of Healthcare Safety and Quality via email at DPH.BHCSQ@Mass.gov. Thank you.
Resources
Below are links to training resources:
- The Care of Residents with Opioid & Stimulant Use Disorders in Long-Term Care Settings Toolkit
- Massachusetts Consultation Service for Treatment of Addiction and Pain
- Substance Use Helpline: https://helplinema.org/
- Information for licensed substance use disorder treatment programs: https://www.mass.gov/info-details/information-for-licensed-substance-use-disorder-treatment-programs
- BSAS website on Practice Guidance documents on MAT and other relevant topics
- Relevant training programs sponsored by BSAS
- SAMHSA’s website on MAT
- Providers' Clinical Support System for Opioid Therapies
- SAMHSA' s website on resources for integrating primary care and behavioral health services
Appendix A
Policy on the Use of Standing Orders for the Use of Naloxone
The Bureau recommends that nursing homes develop standing orders for the use of naloxone, subject to the following conditions:
- 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, training and implementation of the policy within the LTCF shall be clearly stated.
- The order for administration of medication or treatment shall be signed by the facility Medical Director. Alternatively, licensed independent providers 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.
- Policies shall include parameters for use, i.e., eligible individuals for whom the order is appropriate, and any restrictions or exclusions.
- 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.
- 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.