Addressing Addiction Challenges and Vulnerabilities in Post-Acute and Long-Term Care Settings

This podcast episode, hosted by Dr. Donal Snipes, delves into the critical and often overlooked issue of addiction prevention and treatment within post-acute care (PAC) and long-term care (LTC) facilities. It begins by defining these settings, from short-term rehabilitation after hospitalization (PAC) to various forms of long-term support like assisted living, memory care, and nursing homes. A significant portion of the discussion highlights the alarming prevalence of substance use disorders among residents, citing statistics that reveal millions of individuals in these settings meet criteria for opioid, cocaine, and alcohol use disorders, often co-occurring with other medical conditions that initially led to their admission.

The core of the presentation focuses on identifying specific triggers and vulnerabilities that make residents susceptible to substance misuse or relapse in these environments. These include the risks associated with self-administering medications like opioids and benzodiazepines, the potential for diversion of prescribed drugs, and the widespread availability of alcohol in some assisted living facilities, often protected by resident rights under the Older Americans Act. A particularly concerning point is the ingestion of hand sanitizer by individuals with alcohol use disorders due to its high ethanol content, a problem exacerbated during the pandemic.

Dr. Snipes meticulously outlines a range of vulnerabilities, categorizing them into physiological (sleep disruption, circadian rhythm disruption, hormonal changes like menopause/andropause, chronic pain, post-acute withdrawal), interpersonal (lack of support, low self-esteem, poor communication, unresolved trauma), emotional (low emotional intelligence, poor coping skills, co-occurring psychiatric disorders), and cognitive (perceived helplessness, lack of motivation, executive functioning deficits). Environmental factors, such as constant exposure to triggers and inadequate supervision, are also emphasized as significant contributors to relapse risk. The discussion underscores that many residents are not fully detoxed upon admission, leaving them vulnerable to protracted withdrawal symptoms.

The episode concludes by implicitly advocating for comprehensive screening, proactive monitoring, and tailored therapeutic interventions. While specific protocols are mentioned (e.g., pill counting, direct observation of medication intake), the broader implication is a call for a more compassionate, informed, and integrated approach to care that recognizes the complex interplay of physical, psychological, and environmental factors in addiction. The need for staff education, patient empowerment through skill-building (emotional intelligence, distress tolerance), and addressing systemic issues like the unavailability of medication-assisted therapy in some facilities are critical for improving outcomes for this vulnerable population.

"85% of them or 6 and a half million basically met criteria for opioid use disorder so that tells you that there are a lot of people in these settings that are struggling they're either in recovery from or currently dealing with an addiction."

"It's important when we meet patients who are are admitted to postacute or long-term care that we screen for co-occurring issues."

"If the person is struggling with depression or anxiety they may start self- administering their medication a little more than they're supposed to because they're self-medicating."

"Medications that are self- administered are also subject to Diversion to other people in the facility with addictions."

"Most hand sanitizers contain 60 to 95% ethanol or isop isopor alcohol to effectively kill the bugs which is a higher alcohol concentration than most most alcoholic beverages."

"Sleep disruption increases intrusive thoughts it increases irritability it increases activation of the sympathetic nervous system or the fight ORF flight part we need to address this because when people are in fight ORF flight when they have brain fog when they have intrusive thoughts it's harder to manage cravings."

"Helping people develop tools to manage their pain is really important and and chronic conditions whether it is um osteoarthritis or lupus or some other chronic condition that causes pain working with people on using pain scales working with people to help them focus on ergonomics."

"Many of these patients who are referred because of substance related injuries um haven't been detoxed for very long they detoxed in the hospital so the acute acute phase of detox has passed they are theoretically quote medically stable but their brain and their nervous system is still all out of whack."

"People who have addictions often have low what we call emotional intelligence or a low emotional quotient doesn't mean they aren't smart it means they have difficulty identifying emotions in themselves and maybe others understanding the function of of those emotions understanding where those emotions are coming from and how to deal with them."

"Lipophilic drugs are drugs that are stored in fat tissue and believe it or not opioids benzodiazapines Co Cane and cannabis are all stored in fat tissue."