The American Pharmacist Association published on their website that the FDA has since 2005 warned about the risks of transdermal fentanyl patches, particularly among opioid-naive patients, but nursing homes have not completely phased out the long-acting analgesics.

FDA has since 2005 warned about the risks of transdermal fentanyl patches, particularly among opioid-naive patients, but nursing homes have not completely phased out the long-acting analgesics. A study led by Camilla Pimentel, MPH, PhD, of the University of Massachusetts Medical School analyzed a sample of Medicare patients living in long-stay facilities in 2011. Of more than 12,250 patients who received the patch within 30 days of admission that year, 9.4% had not taken opioid analgesics in the prior 60-day period.

The practice, according to Pimentel, is contrary to FDA recommendations, which indicate that the long-acting opioids “should only be given to patients who have developed tolerance to opioid medications through regular treatment with other opioids. Otherwise, they are at higher risk of unintentional fatal overdose because of respiratory depression.” Although use of the patch persists in opioid-naive patients in nursing homes, Pimentel and colleagues report in the Journal of the American Geriatric Society, use of long-acting opioids overall is down in this setting, accounting for just 5% of all long-stay Medicare nursing home residents.

http://www.painmedicinenews.com/Clinical-Pain-Medicine/Article/06-17/Use-of-Fentanyl-Patches-in-Nursing-Homes-Persists-After-FDA-Warning/41582

 

Prosecutors say three nursing home caregivers carelessly made a mistake with dangerous morphine causing a resident’s death.  The wrongful death happened in 2015 at Greenbriar Healthcare Center in Boardman.  In November of 2015, just after the death, Greenbriar Health Care was placed on a Medicaid “worst of the worst” watch list.

Johonna Hull was arrested and charged with abuse of a patient and tampering with medical records.  Brenda Lamancusa is also charged with patient abuse. Another person, who hasn’t yet been arrested, also faces charges.

The family has filed suit against the three facility employees who are accused of neglect and trying to coverup their negligence. The employees are accused of giving William Wolfe extended release morphine that had not been prescribed. He was found unresponsive the next morning and pronounced dead at the hospital.

“Evidence indicated, and the autopsy showed, that a gentleman … was mistakenly given the wrong medication … The charges are largely over not only the mistake in providing him that medication, but probably even more importantly, the lack of action that was taken by the staff at Greenbriar,” Michael McBride, an assistant Mahoning County prosecutor, said to station WKBN.

JAMA Network had another article on the overuse and abuse of anti-psychotics in nurisng homes.  In May 2011, the Office of Inspector General (OIG) released a widely publicized report, “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents,” revealing that 83% of atypical antipsychotic drug claims were prescribed for nursing home residents without a US Food and Drug Administration (FDA) indication, and that 88% of claims were related to use in residents with dementia, for whom antipsychotics are associated with an increased risk of mortality as specified in the FDA black box warning.

“Despite long-standing and widely recognized concerns about safety and efficacy, antipsychotic agents, including older “typical” agents (ie, haloperidol and chlorpromazine) and newer “atypical” agents (ie, quetiapine, risperidone, and olanzapine), have been commonly used to treat behavioral and psychological symptoms of dementia.”

This Viewpoint describes a national initiative of the Centers for Medicare & Medicaid Services (CMS) focused on the use of antipsychotics in nursing homes. These efforts have led to a 33% relative reduction (from 23.9% to 16.0%) in the prevalence of antipsychotic use among long-term nursing home residents over the past 5 years.

Percentage of Long-Term Nursing Home Residents Receiving Antipsychotic Medication, 2011-2016

New York Magazine had an article about GOP moderates worried about TrumpCare’s health care cuts affecting the opiod crisis.  “During the worst year of the HIV/AIDS crisis, 43,000 Americans lost their lives to the virus. In 2015, 52,000 died of a drug overdose. Never in recorded history had opioids killed so many Americans in a single year; the drug-induced death toll was so staggering, it helped reduce life expectancy in the United States for the first time since 1993.”

The Medicaid cuts in TrumpCare will devastate addiction resources.  Medicaid expansion accounted for 61 percent of total Medicaid spending on substance abuse treatment in Kentucky, 47 percent in West Virginia, 56 percent in Michigan, 59 percent in Maryland, and 31 percent in Rhode Island. In Ohio, the expansion accounted for 43 percent of Medicaid spending in 2016 on behavioral health, a category that includes mental health and substance abuse.

As the New York Times reports:

Republican senators from states that have been hit hard by the opioid drug crisis have tried to cushion the Medicaid blow with a separate funding stream of $45 billion over 10 years for substance abuse treatment and prevention costs, now covered by the expansion of Medicaid under the Affordable Care Act.

But that, too, is running into opposition from conservatives. They have been tussling over the issue with moderate Republican senators like Rob Portman of Ohio, Shelley Moore Capito of West Virginia and Susan Collins of Maine.

Without some opioid funding, Mr. Portman cannot vote for the bill, he said, adding, “Any replacement is going to have to do something to address this opioid crisis that is gripping our country.”

The Star-Tribune reported that Annandale Care Center “had no system, policies or procedures in place” to ensure that certain medications and some other services were being provided as prescribed.  An unnamed  nursing home resident developed internal bleeding and died after being denied crucial blood-thinning medication for 15 days, according to a state investigation that blamed the death on the facility’s procedural shortcomings.

The Health Department said a nurse discovered that the resident’s doses of Coumadin, a blood-thinning medication, had been stopped without a doctor’s order. A required dosage test had not been performed, and that missing information triggered an automatic entry in the resident’s electronic medication record for the drug’s administration to be halted.

In response to the finding of neglect, the home revised its policies concerning the administration of blood-thinning medication, reviewed the records of residents who receive that type of medication and briefed staff on proper procedures, the report said.

Despite treatment at one hospital and then another, the resident died about two weeks after the medication error was discovered, the report said.

Six men were taken to the hospital after paramedics responded to a report of overdoses at Columbus Manor Residential Care Home nursing home. The facility provides care for mentally ill patients.

According to the Fire Department, the overdoses involved a “PCP type” substance, but police said they could not confirm the type of drug until a toxicology report is completed.

The facility was placed on lockdown, and a full internal investigation was underway. He said all six people were back at the nursing home Thursday morning, and were doing well.

The Endocrinology Advisor had an article on the FDA’s decision to place a Black Box warning on canagliflozin drug labels to include prominent boxed warnings describing the risk to patients.

“Data from 2 large clinical trials have confirmed that treatment of type 2 diabetes with canagliflozin (Invokana®, Invokamet®, and Invokamet XR®; Janssen Pharmaceuticals, Inc.) may lead to an increased risk of leg and foot amputations, according to a US Food and Drug Administration (FDA) Drug Safety Communication.”

NPR reported on the new Propublica investigation into wasted prescription drugs at nursing homes.  Millions of dollars of perfectly useful drugs are thrown away every year instead of being recycled.  In Iowa, they have a program set up to retrieve these drugs and redistribute them to uninsured or underinsured patients for free. And they’re getting about $5 million worth of these drugs this year.

These drugs, experts say, might be wasting hundreds of millions of dollars a year.

 

The use of antipsychotic medication in nearly 100 Massachusetts nursing homes was significantly reduced when staff was trained to recognize challenging behaviors of cognitively impaired residents as communication of their unmet needs, according to a new study led by Jennifer Tjia, MD, MSCE, associate professor of quantitative health sciences. See article at News Medical.  Results of the study were published in JAMA Internal Medicine on April 17.

This study examined the rate of off-label antipsychotic use in 93 Massachusetts nursing homes enrolled in the OASIS intervention from 2011 to 2013, compared to 831 nursing homes in Massachusetts and New York who were not using that program, (although some were using a different reduction program.) Among OASIS facilities, the prevalence of antipsychotic prescriptions was cut from 34 to 27 percent after nine months, a 7 percent drop. At the comparative facilities, the prevalence of those drugs was cut from 23 to 19 percent; a 4 percent drop. No increases in other psychotropic medicine or behavioral disturbances were observed. Over the maintenance period of the intervention, however, the decreases did not continue.

This is the largest study to show that it is possible to reduce antipsychotic use in the nursing home population,” said Dr. Tjia. “This intervention focused on treating the residents as human beings with needs, not as patients with problems. We don’t medicate babies when they cry or act out, because we assume that they have a need that we need to address. However, when people with dementia are unable to communicate, the current approach medicates them when they have undesirable behaviors.”

The off-label prescription of antipsychotics for nursing home residents with dementia is common and dangerous, despite numerous studies that have shown it increases risk of stroke and death and is only minimally effective in controlling behavioral symptoms of dementia.

“The OASIS program asks nursing staff to create care plans that include what residents can do, shifting away from the model that focuses on what they can’t do,” Tjia said. “This is a fundamental shift in how to think about caring for persons with dementia and we showed that it is effective.”

“Since 1987, no fewer than 11 controlled studies have been published that report varying efficacy in reducing antipsychotics in nursing homes using a variety of approaches. The largest successful intervention enrolled 12 nursing homes; however, it was time and resource intensive. In contrast, the OASIS program reached almost 100 nursing homes, and was effective,” Tjia said.

Tjia said nursing homes using the OASIS program need to reinforce training periodically to maintain success at reducing the rate of antipsychotics.

The Conservative Review had an article by Logan Albright, a researcher for Conservative Review and Director of Research for Free the People, on the AARP’s multi-year investigation into the practices of America’s nursing homes. Below are excerpts:

In an alarming number of cases, elderly residents have been given powerful and dangerous drugs without their consent. In addition to the illegality and the moral transgressions against the residents’ autonomy, in some cases this practice has had deadly consequences.

Antipsychotic drugs are routinely used in nursing homes, often without good reason. According to research from the University of California, San Francisco, up to one in five patients in 15,500 nursing homes has been inappropriately prescribed a dangerous drug.

Patients are simply an inconvenience to staff, and keeping them drugged up makes them more manageable.  The pretense of “medical care” is used to give legitimacy to what would otherwise be a crime.

American society is now at a stage in which unproven allegations of mental incompetence can be used to rob our fellow human beings of their liberty and their dignity, with only the opinion of a so-called expert required to do so. And while the legal team of the AARP has won some commendable victories in exposing wrongful death and mistreatment of the elderly, these cases only scratch the surface of the deeper problem.

The elderly do not cease to be human. Their rights are not forfeited when they reach a certain age. That they should be so misused against their wills is a damning indictment of a system that ought not be possible in “the land of the free.”