Study points out opioid risks for patients transitioning to skilled nursing facilities

Hospital patients discharged to skilled nursing facilities often bring a high-dose painkiller prescription with them, suggesting more attention should be paid to opioid safety for those patients, research from the Oregon State University College of Pharmacy shows.

The findings are important because they shed light on an understudied aspect of the opioid-fueled public health crisis that has gripped the United States for more than two decades.

Also, 61% of the patients in the study who received an opioid prescription upon hospital discharge were older than 65—an age demographic that carries a high risk of opioid-associated harm.

"Increased efforts are likely needed to optimize opioid prescribing among patients transitioning from hospitals to skilled nursing facilities," said corresponding author Jon Furuno, an associate professor and the interim chair of the Department of Pharmacy Practice.

The study was published in Pharmacoepidemiology and Drug Safety.

Traced to over-prescribing that began in the 1990s, the opioid epidemic claims more than 40,000 American lives per year, according to the U.S. Department of Health and Human Services. Ten million people a year misuse prescription opioids, and 2 million suffer from an opioid use disorder.

"An estimated 130 people die each day in this country due to an opioid overdose," Furuno said. "And prescription opioid misuse in the United States also does economic damage of more than $78 billion per year."

Over a one-year period, Furuno and collaborators at Oregon State, Oregon Health & Science University and the University of Massachusetts Medical School looked at 4,374 hospital patients who were discharged to a skilled nursing facility—a facility for people to receive short-term, rehabilitative care or long-term residential care.

Seventy percent of the patients received an opioid prescription upon hospital discharge, and 68% of those prescriptions were for oxycodone—1.5 times as potent as morphine. Moreover, greater than half of the prescriptions had a daily morphine milligram equivalent of 90 or higher—a threshold the Centers for Disease Control and Prevention says prescribers should "avoid" or "carefully justify."

"Being a surgical patient, being female, having a diagnosis of cancer or chronic pain, and receiving an opioid on the first day of hospital admission were all independently associated with the likelihood of receiving an opioid prescription upon discharge to a skilled nursing facility," Furuno said. "For patients or residents in those facilities, opioid risks are often compounded by the fact many of them are taking multiple drugs for multiple conditions."

Also, some of those patients are frail and suffer from cognitive impairment that can make safe opioid prescribing more challenging.

"And notably, skilled nursing facility residents are also often undertreated for pain," Furuno said. "These results support the complexity and need to optimize opioid prescribing in this patient population."

Future research, he added, should look at the frequency of inappropriate opioid prescribing among patients leaving hospitals for skilled nursing facilities; prescribing practices within hospitals; and outcomes as patients go home from skilled nursing facilities.

"Complicating matters is the growing number of joint replacement and other surgical patients who receive opioid prescriptions, may stay in a skilled nursing facility for just a short time and then are discharged back into their communities," Furuno said. "Prescribers and pharmacists need to work together to ensure patients' pain is managed safely, and knowing which patients are most at risk can inform the best use of resources like medication counseling and other interventions."