Associations of Opioid Prescribing with Long-term Functional Outcomes and Mortality Rates in Older Nursing Home Residents

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Project Abstract Prescription opioid use is increasingly common in older adults in nursing home (NH) settings. A nationally representative cross-sectional study of all long-stay (i.e., ≥90 days) older NH residents published in 2018 found that one in three (32.4%) were prescribed an opioid medication for any duration, and one in seven (15.5%) were prescribed opioids for long-term use (i.e., ≥90 days). Relationships between opioid prescribing and long- term cognitive and physical functional outcomes, as well as between opioid prescribing and mortality rates, among older NH residents—perhaps the most vulnerable, highest-risk group of opioid users—are largely unexplored. The proposed nationwide study explicitly addresses these knowledge gaps through investigating opioid prescribing by duration of action (i.e., long-acting versus short-acting opioids) and their associations with long-term functional outcomes and mortality rates among older NH residents. Using the Centers for Medicare and Medicaid Services’ 2018-2019 Medicare claims (e.g., Part A, B, and D) data linked to 1) Minimum Data Set (MDS) 3.0, a federally required clinical assessment of all residents residing in Medicare- or Medicaid-certified NHs quarterly, 2) publicly available NH-level data (e.g., Certification and Survey Provider Enhanced Reporting (CASPER) and Nursing Home Compare), and 3) National Death Index (NDI) data, this proposed study features the following specific aims: 1) to examine incidence and prevalence rates of opioid use by duration of action in older NH residents; 2) to identify resident- and facility-level factors associated with opioid prescribing in NH settings; and 3) to investigate differential risks of short-acting versus long-acting opioids associated with long-term (a) changes in functional outcomes (e.g., cognitive impairment, frailty, and pain) and (b) opioid-related and all-cause mortality rates in older NH residents. To ensure a rigorous study, we will conduct sensitivity analyses by long-term use (e.g., ≥90 days), maximum daily dose (e.g., ≥90 morphine milligram equivalents), and concomitant use of opioid potentiators (e.g., benzodiazepines and gabapentinoids), using longitudinal data analyses (i.e., linear mixed modeling and survival analysis). Our study will also employ propensity-score matching and instrumental variable methods to adjust for potential observed and unobserved confounders. To date, there are two federal guidelines on opioid prescribing, but they largely overlooked older adults living in NHs. In 2019, the National Academies of Science, Engineering, and Medicine (NASEM) convened an expert panel group that framed opioid prescribing guidelines. One recommendation was to conduct research investigating the long-term health outcomes in both patient and population levels. The proposed study is timely and directly addresses this recommendation. Findings from the proposed study will further guide safer opioid use in older adults living in NH settings.