Every morning, I participate in a 10-minute meeting with the unit case manager to review the discharge plan for my patients. We discuss their progress, destination, transportation needs, and any potential challenges. This brief meeting often sets the tone for my day. It’s deeply satisfying to learn that a patient who has been hospitalized for 154 days will finally be transferred to a nursing facility. However, it’s equally frustrating when a newly inducted methadone patient is denied a bed solely due to their medication.
One particular patient highlighted the complexities of discharge planning — a situation our case manager described as her worst nightmare. A young man, who had spent much of his youth battling opioid addiction, was admitted to the hospital with cellulitis and chronic, unrelenting pain. Homeless, uninsured, and reliant on a motorized wheelchair (which now had a broken wheel), he sought relief in the hospital. Given his history, methadone or suboxone seemed appropriate, but he had previously rejected suboxone, claiming it didn’t work for him. So, we started him on methadone.
“Why would you do that? No one will accept him now,” the discharge planner remarked. At that moment, I didn’t fully understand her concern.
Once he was medically stabilized, every nearby skilled nursing facility (SNF) refused to take him. Over the following days, facilities as far as 75 miles away also turned him down.
Now, I understood her point.
As pressure mounted from leadership to discharge patients with no clinical reason to remain admitted, the discharge plan grew increasingly complicated. We devised a plan for him to go to a shelter on Friday, pick up his methadone from the ER on Saturday and Sunday, and report to the methadone clinic for intake on Monday. Every morning, he needed to arrive at the shelter by 6 a.m. to secure a bed. Did I mention he could only ambulate with his motorized wheelchair? The one with a broken wheel. Unsurprisingly, the plan failed. The next day, he appeared at the nurses’ station with nowhere to stay. We had failed to provide him with a “safe discharge plan.”
Why?
He said it best. “They just don’t want me because of the methadone.”
The opioid epidemic has led to a surge in hospitalizations due to opioid use and its associated comorbidities, increasing the need for post-acute care services. Unfortunately, the refusal of SNFs to accept patients on medications for opioid use disorder (MOUD) is widespread — and not unusual. MOUD, which has been proven to reduce mortality and save lives, remains a significant barrier for patients who require continued care services after hospitalization. As a new senior resident at the time, I didn’t realize that refusing to admit patients on MOUD violated several federal laws, including the American with Disabilities Act, the Rehabilitation Act of 1973, and the Affordable Care Act. Substance use disorder is classified as a disability under these laws, meaning patients cannot be denied health services, including admission to SNFs. So why is this practice so pervasive?
Several factors contribute, with stigma being one of the most significant. I have witnessed firsthand how substance use has influenced patient care in my hospital. For example, Charlie signed out against medical advice (AMA) despite being bacteremic with endocarditis; Sarah was refused her oxycodone for withdrawal since the dose was deemed “too high”; and Dolores had security called on her three times in one day for room searches for paraphernalia. I, too, am guilty of making assumptions when I see methadone or buprenorphine on a patient’s medication list. Confronting stigma is challenging, but its role in hindering the safe triage, treatment, and discharge of patients has long-term consequences for both the patient and hospital system. This includes prolonged hospital stays, increased discharges AMA, and clinical decision-making that makes patients “more acceptable” to SNFs, such as transitioning to oral antibiotics earlier than desired or changing a patient’s MOUD regimen to a less effective option.
Regulatory obstacles and lack of familiarity also play a role. Education on MOUD, addiction, and the relevant federal laws is crucial to addressing these barriers. Currently, addiction medicine training is often lacking for physicians, nursing, and the facilities to which we discharge patients. In interviews with SNF faculty, many cited a lack of clinicians with addiction medicine training, unfamiliarity with MOUD, and difficulties distributing methadone due to federal regulations as common barriers. Efforts are underway to address these issues in recent years. For example, in 2022, the DEA eliminated the X-waiver for buprenorphine. In Rhode Island, opioid treatment programs (OTP) have developed initiatives to deliver pre-dosed methadone to SNFs. Other proposals include transporting patients from SNFs to the OTP for methadone distribution or collaborating with community organizations like AA or NA for additional support. Some advocates suggest expanding regulations to allow select SNFs to dispense methadone directly.
I recently read an article by several physicians outlining specific actions that physicians, patients, and hospital administration can take to ensure the rights of patients with opioid use disorder (OUD). Patients with OUD deserve equitable, evidence-based care that is free from stigma and unnecessary barriers. Since his unsuccessful discharge, my patient has only received medical care in various local EDs for his daily methadone. I’m unsure how sustainable this approach is long term, but I can’t help but wonder how different his life could have been if he had been accepted to an SNF.
How can we further advocate for those with OUD, especially in the post-hospitalization setting?
What will it take to ensure patients with opioid use disorder receive equitable care? Share in the comments.
Dr. Siya Bhagat is a second-year internal medicine resident and aspiring cardiology fellow. She enjoys playing pickleball, exploring new restaurants, and spending time with friends and family. She is a 2024–2025 Doximity Op-Med Fellow.
Names changed for privacy and confidentiality.
Collage by Jennifer Bogartz / Shutterstock
