Opioid Use and Safety in United States Nursing Homes

Background: Opioids are often used in nursing homes to manage non-malignant pain, but little is known about their long-term use, initiation, and comparative safety. Methods: We used the Minimum Data Set 3.0 from 2011-2013 merged to Medicare and facility characteristics data to study opioid use and safety among older, long-stay residents. The specific aims were to examine the 1) prevalence of long-term opioid use; 2) geographic variation in the initiation of commonly used opioids (oxycodone, hydrocodone, tramadol); and 3) comparative safety of commonly used opioids and fracture hospitalizations. Results: One in seven long-stay residents were prescribed opioids long-term. There was extensive geographic variation in the initiation of commonly used opioids, with oxycodone (9.4%) initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varying most extensively across the United States, with the majority of variation in prescribing explained by state of residence. Compared to hydrocodone initiators (7.9 fracture hospitalizations per 100-person years), those initiating tramadol had lower rates of fracture hospitalizations (subdistribution hazard ratio [HRSD] = 0.67, 95% Confidence Interval [CI]: 0.56-0.80), whereas oxycodone initiators had similar rates of fracture hospitalizations (HRSD=1.08, 95% CI: 0.79-1.48). Conclusion: The prevalence of long-term opioid use was twice as common in nursing homes as community settings, with initiation patterns varying extensively by region and being strongly driven by state of residence. Although initiating tramadol was associated with lower rates of fractures than hydrocodone, questions on opioid risks and benefits remain and are especially pertinent given the high mortality rates in this population

Hospice and pain management in nursing home residents with cancer

Background: The prevalence of untreated pain in nursing home residents with cancer is unacceptably high. Hospice may increase the likelihood of receiving pain management at the end of life. Objectives: To estimate whether receipt of hospice in nursing homes increases the receipt of pain management for nursing home residents with cancer at the end of life. Methods: We conducted a cross-sectional study on a national sample of Medicare decedents who had cancer and were nursing home residents during the last 90 days of life in 2011–2012. We used the last Minimum Data Set (MDS) 3.0 assessment before death and the Medicare Beneficiary Summary File to measure hospice use, pain, and pain management at the last MDS assessment. We matched residents with cancer and in pain who received hospice care to residents in pain not receiving hospice care on nursing home facility and time from last MDS assessment to death. The primary outcomes were receipt of pharmacologic pain management including scheduled and PRN analgesics and non-pharmacologic pain management. Conditional logistic models were used to estimate the association between hospice use and pain management. Results: In matched analyses, untreated pain was uncommon (2.9% in hospice users and 5.6 in non-hospice users), though there was an absolute difference of 15.4% in scheduled analgesics use between hospice and non-hospice users (71.5% vs. 56.1%, respectively). Hospice use was associated with receipt of scheduled analgesics (adjusted Odds Ratio(aOR): 1.85, 95% Confidence Interval(CI):1.73–1.97), PRN medication (aOR: 1.31, 95% CI:1.20–1.43), and non-pharmacologic pain management (aOR: 1.18, 95% CI:1.11–1.26). Conclusions: Untreated pain at the end of life among nursing home residents with cancer was unusual. Hospice use was associated with increased pain management in nursing home residents with documented pain. Further work to examine the type and effectiveness of pain management strategies used is warranted

Triad of Suffering: Pain, Depression, and Anxiety among Newly Admitted Nursing Homes Residents

Introduction: Depression and anxiety disorders are prevalent among older adults, as is pain. These conditions are independently associated with reduced functioning and quality of life. Despite the frequent co-occurrence of all three of these disorders, little is known about the epidemiology and treatment of these disorders in nursing homes. The objectives of this study were to: 1) describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents; and 2) describe the treatment of these disorders. Methods: We used national Minimum Data Set (MDS) version 3.0 data from 2011-2012. Federally-mandated for all residents living in Medicare/Medicaid-certified nursing facilities, the MDS is a comprehensive clinical assessment including \u3e 400 items on sociodemographics, mood and behavior, symptoms, pain, clinical diagnoses, and treatments. We identified residents with MDS assessments performed at admission between 2011-2012 who were 65 years of age or older; were non-comatose; were not admitted to a swing bed provider; did not have mental retardation or developmental delays; & were able to complete a pain assessment (n = 783,826). Results: At admission, 36% of residents (n = 283,050) had a documented active diagnosis of depression (other than bipolar disorder), anxiety disorder, or both. Having pain in the last 5 days was reported by 53% of residents. Rates of self-reported pain were similar across psychiatric disorders. 60-62% of residents reporting pain received a combination of pain management interventions. More than a third of residents did not receive any psychiatric treatment. Conclusions: Many nursing home residents experience pain, depression, and anxiety at admission. Pain management is common. An improved understanding of the relationships between pain, mental health, and analgesic use is necessary since older adults, particularly those in nursing homes, are routinely excluded from clinical trials despite being at high risk for adverse effects of analgesics and other treatments

Pain and Pharmacologic Pain Management in Long-Stay Nursing Home Residents

Prior studies estimate that \u3e40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set (MDS) 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after these important initiatives of: 1) prevalence and correlates of persistent pain; and 2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in United States NHs between 2011-2012 with 2 MDS assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios estimates (APR) and 95% confidence intervals (CI).The prevalence of persistent and intermittent pain was 19.5% and 19.2% respectively but varied substantially by age, gender, race/ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated or undertreated. Racial/ethnic minorities (non-Hispanic blacks vs. whites, APR=1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs. no/mild APR=1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in five NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer

Background: Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission. Methods: Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies. Results: Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97-0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86-0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97-0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96-0.99). Conclusion: Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored

Resident and Facility-level Correlations of Long-term Opioid Use in United States Nursing Homes

Background: There is limited information on the prevalence and multilevel risk factors of long-term opioid use in older nursing home residents despite their high burden of pain and vulnerability to adverse drug events. Objectives: To estimate the prevalence and correlates of long-term opioid use in United States (US) nursing homes. Methods: We used comprehensive administrative/claims data (Minimum Data Set 3.0; Medicare Part D) from 2012 to conduct a cross-sectional study of 369,180 long-stay nursing home residents who were Medicare beneficiaries, ≥65 years old, and had no cancer. Resident factors of interest included demographics and physical/cognitive impairment, and facility factors included US census region and structural characteristics (eg, bed size, ownership). Long-term opioid use was defined as ≥90 cumulative days of opioid use during a 120 day observation window - defined using fill dates and days’. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) between resident/ facility-level characteristics and long-term opioid use. Results: Nearly one third of long-stay residents used any opioid, with 14.5% using opioids long-term. Among long-term users, 35.3% received a long-acting opioid, with 17.1% receiving high (≥90 mg/day oral morphine equivalents) daily doses. Hydrocodone (49.0%), tramadol (31.3%), and fentanyl (24.8%) were most commonly used. The prevalence of long-term use was higher in women (vs. men; aPR=1.20, 95% CI: 1.18-1.23) and those with no/mild cognitive impairment (vs. other; aPR=1.18, 95% CI: 1.16-1.20) or severe physical impairment (aPR=1.25; 95% CI: (1.22-1.27), and in government-owned nursing homes (vs. for-profit; aPR=1.10, 95% CI: 1.05-1.16). Long-term use varied by region (10.6% [Northeast] to 17.7% [Midwest]) and across facilities (median: 13.3% interquartile range: 6.7%-21.3%). Conclusions: Long-term opioid use is substantially higher in nursing home residents than what has been previously reported in community-dwelling older adults. Further investigations of opioid safety in this frail population are needed

Black-White Disparities in Pain Management among Nursing Home Residents with Cancer

Background: Racial disparities in pain management persist across healthcare settings and likely extend into nursing homes. No studies to-date have thoroughly evaluated racial disparities in cancer pain management in this setting. Methods: Using a cross-sectional study design, we compared reported pain and pharmacological pain management between non-Hispanic White and Black newly admitted nursing home residents with cancer (n=113,765) using the Minimum Data Set version 3.0. Pain management strategies considered included: use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able to, or by staff. Logistic models provided estimates of odds ratios for pain management strategies adjusted for resident factors. Results: Among nursing home residents with cancer, nearly one-third reported pain with estimates similar in Black (32.4%) and White (32.8%) residents. Estimates of pain frequency and intensity were also similar by race. While most residents received scheduled pharmacologic pain management, Whites had greater odds of receiving it than Blacks (Whites: 72.8%, Blacks: 69.3%, adjusted odds ratio Black vs. White (aOR): 0.92; 95% confidence interval (CI): 0.88-0.96). Pro re nata analgesic use was more common in Whites than Blacks (Whites: 40.1%, Blacks: 38.5%, aOR: 0.78; 95% CI: 0.75-0.81) as were non-pharmacologic approaches (Whites: 33.1%, Blacks: 25.3%, aOR: 0.70; 95 CI%: 0.67-0.73). Conclusions: While reporting of pain was similar for Black and White nursing home residents, White residents received more frequent pain management at admission. The extent to which unequal management of pain persists in nursing homes should be further explored

Association of a Communication Training Program With Use of Antipsychotics in Nursing Homes

Importance: Off-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use. Objective: To quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS. Design, Setting, and Participants: This investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from November through December 2016. Exposures: The OASIS educational program targets all NH staff (direct care and nondirect care) using a train-the-trainer model. The program goals were to reframe challenging behaviors of residents with cognitive impairment as the communication of unmet needs, to train staff to anticipate resident needs, and to integrate resident strengths into daily care plans. Main Outcomes and Measures: This study used an interrupted time series model of facility-level prevalence of antipsychotic medication use, other psychotropic medication use (antidepressants, anxiolytics, and hypnotics), and behavioral disturbances to evaluate the intervention\u27s effectiveness in participating facilities compared with control NHs in Massachusetts and New York. The 18-month preintervention (baseline) period was compared with a 3-month training period, a 6-month implementation period, and a 3-month maintenance period. Results: This study included 93 NHs enrolled in the OASIS intervention (27 of which had a high prevalence of antipsychotic use) compared with 831 nonintervention NHs. Among OASIS facilities, prevalences of atypical antipsychotic prescribing were 34.1% at baseline and 26.5% at the study end (absolute reduction of 7.6% and relative reduction of 22.3%) compared with a drop of 22.7% to 18.8% in the comparison facilities (absolute reduction of 3.9% and relative reduction of 17.2%). In the OASIS implementation phase, NHs experienced a reduction in antipsychotic use prevalence among OASIS facilities (-1.20%; 95% CI, -1.85% to -0.09% per quarter) greater than that among non-OASIS facilities (-0.23%; 95% CI, -0.47% to 0.01% per quarter), resulting in a net OASIS influence of -0.97% (95% CI, -1.85% to -0.09%; P = .03). A difference in trend was not sustained in the maintenance phase (difference of 0.93%; 95% CI, -0.66% to 2.54%; P = .48). No increases in other psychotropic medication use or behavioral disturbances were observed. Conclusions and Relevance: Antipsychotic use prevalence declined during OASIS implementation of the intervention, but the decreases did not continue in the maintenance phase. Other psychotropic medication use and behavioral disturbances did not increase. This study adds evidence for nonpharmacological programs to treat behavioral and psychological symptoms of dementia

Quantifying possible bias in clinical and epidemiological studies with quantitative bias analysis: common approaches and limitations

Bias in epidemiological studies can adversely affect the validity of study findings. Sensitivity analyses, known as quantitative bias analyses, are available to quantify potential residual bias arising from measurement error, confounding, and selection into the study. Effective application of these methods benefits from the input of multiple parties including clinicians, epidemiologists, and statisticians. This article provides an overview of a few common methods to facilitate both the use of these methods and critical interpretation of applications in the published literature. Examples are given to describe and illustrate methods of quantitative bias analysis. This article also outlines considerations to be made when choosing between methods and discusses the limitations of quantitative bias analysis