Inappropriate Fentanyl Prescribing Among Nursing Home Residents in the United States

Objective: We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naive prescribing. Design: Cross-sectional study. Setting: Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims. Participants: From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (>= 65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care. Measurements: We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naive," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naive fentanyl initiation using multilevel mixed effects logistic regression modeling. Results: Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naive and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages >= 95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use. Conclusion: Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naive. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired. (C) 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.