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.
