Nursing Home Residents Still Lack Buprenorphine Access

A patient whose pain and opioid use disorder were controlled with buprenorphine spent an additional month in the hospital because his skilled-nursing facility would not accept him back while he was taking it.

The 2026 perspective in the Journal of General Internal Medicine describes a 50-year-old man identified as Mr. R. His experience illustrates the clinical consequences of outdated prescribing beliefs, stigma and operational barriers in nursing facilities.

A Month-Long Delay After Clinical Improvement

Mr. R had been living in a skilled-nursing facility before acute on chronic liver disease and a septic hip led to his hospitalization. He had cirrhosis, severe chronic pain, and other medical complications.

His pain regimen included a low-dose fentanyl patch and oxycodone as needed, but his severe opioid use disorder had not been treated.

After he developed hepatic encephalopathy, a brain complication associated with liver dysfunction, clinicians adjusted his lactulose treatment. They also proposed a low-dose initiation of buprenorphine-naloxone.

The clinicians wanted to treat both his opioid use disorder and pain while reducing the cognitive risks associated with full opioid agonists.

His condition improved on a sublingual daily dose of 16 milligrams of buprenorphine and 4 milligrams of naloxone. His pain and opioid use disorder were controlled, and his encephalopathy resolved.

The nursing facility nevertheless refused his return. It said its physician was not qualified to prescribe buprenorphine.

The hospital team didn’t want to restore a regimen that had left his opioid use disorder untreated, but it could not find a discharge destination that would continue the medication. Mr. R remained hospitalized for another month.

Medication-Assisted Treatment After the X-Waiver

A clinician with an active, unrestricted DEA registration can now prescribe buprenorphine in the same manner as other controlled substances. Inpatient clinicians and facilities, including skilled-nursing facilities, were never required to hold an X-waiver to dispense and administer it.

The policy change did not produce an immediate expansion in care. According to prescribing data discussed in the perspective, the number of clinicians prescribing buprenorphine rose only marginally in 2023. The number of patients receiving it stayed relatively unchanged.

Understanding Buprenorphine

Buprenorphine is a partial mu-opioid agonist used in medication-assisted treatment for opioid use disorder. It can reduce cravings and manage withdrawal while also providing pain relief.

Its ceiling effect on respiratory depression gives it a lower overdose risk than full opioid agonists. Clinical decisions still depend on the patient’s full medical condition.

The authors considered buprenorphine appropriate for Mr. R because it treats opioid use disorder alongside chronic pain and is associated with reduced all-cause mortality. They also noted specific concerns with alternatives in his case.

Naltrexone does not provide analgesia, and it can be difficult to start in someone already taking opioid agonists. Full opioid agonists required caution because of his decompensated cirrhosis and hepatic encephalopathy.

The sublingual formulation was favored over long-acting injectable buprenorphine because of limited research in patients with cirrhosis and a relative contraindication in acute hepatic dysfunction.

Why Facilities Still Refuse Care

The authors identify “intervention stigma” as one barrier. This describes reluctance to treat opioid use disorder even when clinicians recognize that the condition is common. Limited training and health literacy can reinforce that reluctance.

Facilities may also face staff shortages, medication-storage problems, inadequate training, and low reimbursement. The authors note that people with opioid use disorder are disproportionately covered by Medicaid.

When reimbursement falls below the cost of care, financial and staffing pressures can discourage facilities from accepting patients who need medication treatment.

State rules may add dosage limits, prescription-duration caps, prior authorization, or frequent drug testing. Refusal based on medication for opioid use disorder can also raise legal concerns.

Multiple court settlements have established that such refusals may violate the Americans with Disabilities Act, which applies to public and private hospitals and skilled-nursing facilities.

Finding Medically Supervised Care

Mr. R eventually returned to his facility on buprenorphine after clinician-to-clinician discussions, hospital advocacy and the receiving facility’s review of current guidance and disability law.

His case does not show how often these refusals happen, but it demonstrates the value of addressing them before a transfer is delayed.

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