Hospices Taking on a Bigger Role in the Opioid Crisis Response

The hospice industry has made it well known it can play a bigger part in addressing the national opioid crisis, but the role of hospices are playing may already be broader than some think.

Hospice organizations are frequently acting as a first line of support for families and loved ones of those lost to addiction through bereavement and grief counseling services—and providers aren’t reimbursed for this care.

Under the hospice Conditions of Participation (CoPs) to participate in Medicare, providers must offer bereavement services, including counseling. Without reimbursement, how these services are conducted varies widely from organization to organization based on commitments of resources.

Many hospices have taken the mission of providing grief counseling and bereavement services one step beyond their own patients, offering this care to families who were not patients, but may have been victims of the opioid crisis.

“A lot of hospices see the mission as broader than providing services to family members of folks they serve,” Edo Banach, CEO of the National Hospice and Palliative Care Organization (NHPCO), told Home Health Care News. “It turns out that if there is a shooting like at the Pulse nightclub or in Las Vegas or 9/11, an emergency of any time, it’s usually the case that the local hospice ends up providing bereavement support for first responders and individuals impacted.”

A historical legacy

Bereavement services have been a cornerstone of hospice care since the benefit was introduced, though the needs of communities have fluctuated over time, Banach said.

“As the opioid crisis has hit, the hospice community has done the same as it has for every other crisis that has occurred since the late 70s and 80s, including the HIV and AIDS [epidemic],” Banach said.

One hospice provider with a robust bereavement services program, Ohio-based Hospice of the Western Reserve, is working with other types of health care providers in the communities it operates to better serve residents afflicted by the opioid crisis.

“Collaboration with a specialty is really important in serving people,” Diane Snyder Cowan, director of Western Reserve Grief Services, told HHCN. “ … Generally speaking, these overdose deaths are not hospice deaths, but if we collaborate with addiction specialists … one of the things we’ve found is education about addition is so important for these grieving families.”

Hospice of the Western Reserve has been providing services in Northern Ohio for 40 years, serving 1,200 patients and families daily, according to Cowan. Roughly 10% to 20% of families will utilize bereavement services following the death of a loved one in hospice care, she said.

However, the opioid crisis is a different type of beast, as medication administration is also an important service performed by hospices.

“It is more compelling because opioids are a part of the kind of care that hospices provide to their population, and we feel a responsibility to make sure opioids are used appropriately for our patients,” Banach said.

A major area of contention surrounding current law related to opioids in hospice care is what happens to the medications once patients die. Medications become the responsibility of the family at that point, whereby opioids can sometimes fall into the wrong hands and add to addiction struggles.

Providers are eager to change this policy through legislation that would allow hospices to take possession of medications and destroy them after a patient’s death. One such bill, the Hospice Safe Drug Disposal Act, would authorize home-based hospices to safely dispose of unused prescriptions and controlled substances. The bill was introduced in the Senate in April.

Interventions and solutions

Not all hospices provide the same level of bereavement services, since the care is not reimbursed. Those that do consistently offer programs, including Hospice of the Western Reserve, are often supported by grants and other donations.

One issue in boosting bereavement services to help families affected by the opioid crisis is the visibility of these programs, which many lawmakers aren’t aware that hospices provide.

“It’s not hidden to social services and churches making these referrals, but it is hidden to federal policymakers because Medicare doesn’t pay for this,” Banach said. “It’s hidden because hospices are doing it and communities need it, but they are not doing it without federal government money.”

Hospice of the Western Reserve provides numerous services for grieving families, including support groups, collaborations with addiction specialists and ongoing programs. And there’s more that hospices could do in the future with more support and even technology if resources become available.

“We wouldn’t mind receiving some support or funding for this,” Banach said. “We could do more if we had some support for this.”

There are some business advantages to extending bereavement services and becoming a well-known force in a community.

“The pay-off when you are serving grieving people in your community and you help them through a tough time … it turns out when their parent needs hospice care, or someone [else], they will turn to you,” Cowan said. “It only benefits the community, and hospices should be the experts in the community.”

The benefits of bereavement services are also not as visible and not often measured, but underscore the importance of hospice as community providers, accordion to Cowan.

“What keeps me in this work is seeing how [support] groups are so transformative and how people grow and change post trauma,” Cowan said. “[You see people] grieving from an opioid death and hear stories about how their lives have changed and what they are doing now, and it gives me the chills … It makes it all worth it.”

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Hospices Taking on a Bigger Role in the Opioid Crisis Response

Would involuntary commitment for addiction save lives?

As the opioid crisis continues to grow, the possibility of involuntary commitment for overdose patients is gaining more attention from advocates who see it as a necessary tool in the battle to save lives. However, many experts also acknowledge that there are significant legal and practical issues that still need to be addressed before the controversial strategy could be fully effective.

Involuntary commitment for patients with mental health concerns is a well-established practice in many states across the country, but using similar laws to force people with addiction disorders—who are outside the criminal court system—into substance use treatment is a much newer concept.

Many, like Charlotte Wethington, see the such a move as a powerful option to help patients who have either overdosed, so they might get the help they need to survive. Wethington, who lost her son Casey to an overdose in 2002, helped create Casey’s Law in Kentucky in 2004. The law gives parents, friends or relatives a pathway to intervene and get a patient into involuntary treatment for substance use disorders for a period of up to 360 days.

“The bottom line is you have to be alive to recover,” she says. “So, if recovery is our ultimate goal, then we need to use all the tools that we have in our toolbox to make that happen...or at least to facilitate that happening.”

An increasing number of state officials, parents and law enforcement officers have expressed interest in creating similar laws in other states.

“It’s certainly an area of great interest,” says Sherry L. Green, chief executive officer of the National Alliance for Model State Drug Law.  “We’ve received a number of requests, including from some governors and drug policy directors, to look into the possibility of drafting language for an effective civil involuntary commitment law.”

According to Green, more than half of all states that have some process written into existing laws that would allow for civil commitment; however, in some states, healthcare professionals, parents and loved ones are not aware such laws exist.

Green says this lack of knowledge is a sign that many of the laws are not being used consistently.

“A lot of states started with involuntary commitment under mental health, and that’s fairly well fleshed out at the state levels. Those mental health commitment laws tend to be used extensively, and then when they were broadened to include substance use disorders, that’s less consistent and less used,” she says.

Getting help to those in need

Residents in the state of Florida have access to the Hal S. Marchman Alcohol and Other Drug Services Act of 1993 (Marchman Act). Under this law, someone with direct knowledge of another person’s substance misuse is able to petition the court to intervene in a two-step process.

Mark Astor, JD, founder of Drug and Alcohol Attorneys in Boca Raton, Fla., says the first step is petitioning the court to have the individual involuntarily assessed for treatment. This can be done on an ex-parte basis, meaning the subject of the filing doesn’t have to be aware of the proceedings. If the assessment is granted, the sheriff’s department collects the individual and brings him or her in for assessment on a five-day hold at a treatment facility of the petitioner’s choosing.

After that, a second petition is filed to secure involuntary treatment for the individual for a period of up to 90 days, although Astor says the treatment can be extended twice if necessary. There is also a hearing, he says, adding that the individual is entitled to contest the filing and have their own counsel.
Astor sees the law as a benefit in Florida, particularly because of the large number of people who come from out-of-state for treatment, often leaving family and friends many miles away.

“The Marchman Act at least enables the family to run to the courthouse and say, ‘Judge, my kid walked out of treatment,’ and can initiate something,” he says. “I think it’s a safety net for families.”

But while Astor notes the law’s advantages, he says it is not utilized nearly enough in Florida. There continues to be a lack of knowledge among treatment centers, parents and even emergency medical personnel about the law and its potential to initiate people into what could be life-saving treatment.

Legal and practical challenges

The involuntary commitment laws face logistical hurdles as well. Jessica Hulsey Nickel, president and chief executive officer of the Addiction Policy Forum, says communities that institute such laws need to ensure they have enough providers to serve patient needs.

“How well this works really does depend on having treatment capacity available,” she says.

Many state officials, Green says, are already struggling to find enough beds for those patients who actively want help for their addiction and are ready for treatment.

“They feel like they can’t really prioritize reserving treatment beds for people who don’t really want to be there in the first place,” she says.

There’s not only a need to increase the number of treatment centers overall, but many of those facilities would also need to be secured to ensure the safety and treatment efficacy of involuntary commitment patients.

“If you are committing someone to an unsecured facility, and because it’s involuntary and you don’t have any means of actually keeping them there, they can just walk out,” Green says.

Massachusetts, which allows for civil commitment under what’s known as section 35, solved this problem by creating several locked commitment facilities.

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Would involuntary commitment for addiction save lives?