HHS-OIG Data Brief    April 2019    OEI-02-18-00224 
 
Concerns About Opioid Use in Medicare  
Part D in the Appalachian Region
  
The opioid crisis has been declared a public health emergency.  In 2016, 
Key Takeaways  there were more than 42,000 opioid-related overdose deaths in the United 
States115 deaths per day.1  Nearly 7,000 of these deaths occurred in 
 Thirty-six percent of 
5 States in the Appalachian regionAlabama, Kentucky, Ohio, Tennessee, 
Part D beneficiaries in 
five States in the  and West Virginia.  All five of these States had high opioid prescribing rates 
Appalachian region  and four reported opioid-related overdose death rates that far exceeded 
received a prescription  that of the Nation.2  Identifying patients at risk of overdose or abuse is key 
opioid in 2017; these  to addressing this crisis. 
States are Alabama, 
Kentucky, Ohio,  Opioids include narcotics intended to manage pain from surgery, injury, or 
Tennessee, and West  illness.  They can create a euphoric effect, which makes them vulnerable to 
Virginia.  abuse and misuse (i.e., taking opioids in a way other than prescribed).  
Although opioids can be appropriate under certain circumstances, the 
 Almost 49,000 
Office of Inspector General (OIG) and others are concerned about fraud, 
beneficiaries in these 
abuse, and misuse of opioids, as well as drug diversionthe redirection of 
States received high 
amounts of opioids, far  prescription drugs for an illegal purpose, such as recreational use or resale.  
exceeding levels CDC  These concerns extend to opioids obtained under Medicare Part D, the 
says to avoid.  optional prescription drug benefit for Medicare beneficiaries.  In 2017, 
Part D covered about 45 million beneficiaries.  
 Nearly 6,000 
beneficiaries in these 
In addition to these concerns, opioid use carries a number of health risks.  
States are at serious risk 
Side effects from using opioids may include respiratory depression, 
of opioid misuse or 
confusion, increased tolerance, and physical dependence.3  For seniors, 
overdose.  
long-term use of prescription opioids also increases the likelihood of falls 
 OIG is committed to  and fractures.4   
working with our 
The Centers for Disease Control and Prevention (CDC) published guidelines 
Federal and State 
partners to fight the  on prescribing opioids to patients with chronic pain.5  The guidelines 
opioid crisis and  recommend that prescribers use caution when ordering opioids at any 
protecting beneficiaries  dosage and avoid increasing dosages to the equivalent of 90 mg or more 
in these States and  of morphine a day for chronic pain.6 
throughout the Nation.  
This data brief is part of a larger strategy by OIG to fight the opioid crisis 
and protect beneficiaries from prescription drug misuse and abuse.  As part 
of this strategy, OIG is partnering with other law enforcement agencies in 
the Appalachian Regional Prescription Opioid Strike Force, bringing 
together resources and expertise to fight the opioid crisis in five States.  
   
This data brief focuses on those five States:  Alabama, Kentucky, Ohio, 
Tennessee, and West Virginia.  OIG has also released a data brief on opioid 
use in the Ohio Medicaid program.7  In addition, OIG recently issued 
factsheets that describe Tennessees and West Virginias oversight of opioid 
prescribing and monitoring of opioid use.8  OIG has also reviewed opioid 
use in Part D nation-wide and has ongoing studies focused on access to 
care.9    
 
RESULTS 
In five States in the  In 2017, more than one in three beneficiaries in five States in the 
Appalachian regionAlabama, Kentucky, Ohio, Tennessee, and West 
Appalachian region, 
Virginiareceived at least one prescription opioid through Medicare 
36 percent of  
Part D.  About 1.7 million beneficiaries received opioids out of the 
Part D beneficiaries  approximately 4.7 million who were enrolled in Medicare Part D in these 
States.  Part D paid for 10.1 million opioid prescriptions for beneficiaries in 
received a 
these States in 2017an average of 6 prescriptions per beneficiary 
prescription opioid 
receiving opioids.  Part D paid a total of $410 million for these opioids.  
in 2017  Tramadol, hydrocodone-acetaminophen, and oxycodone-acetaminophen 
were the most commonly prescribed opioids for the beneficiaries in the five 
  States during the year.10   
Of the five States, Alabama had the highest proportion of beneficiaries 
receiving opioids.  In Alabama, 44 percent of the Part D beneficiaries 
received an opioid in 2017.  Tennessee was next with 40 percent, followed 
by Kentucky with 37 percent, West Virginia with 35 percent, and Ohio with 
30 percent.  Nation-wide, 31 percent of Part D beneficiaries received a 
prescription opioid.   
Exhibit 1:  Alabama had the highest proportion of Part D 
beneficiaries receiving opioids.  
Proportion of Part D beneficiaries who 
State  received at least one opioid in 2017 
Alabama  44% 
Tennessee  40% 
Kentucky  37% 
West Virginia  35% 
Ohio  30% 
Source: OIG analysis of Medicare Part D data, 2019. 
   
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OEI-02-18-00224   
Almost 49,000 of  In 2017, a total of 48,584 beneficiaries in these 5 States in the Appalachian 
region received high amounts of opioids through Medicare Part D; this 
these beneficiaries 
number does not include beneficiaries who had cancer or were in hospice 
received high 
care.  Each of the 48,584 beneficiaries received an average morphine 
amounts of  equivalent dose (MED) of greater than 120 mg a day for at least 3 months 
opioids, far  in 2017.  MED is a measure that converts all the various opioids and 
strengths into one standard value.  A daily MED of 120 mg is equivalent to 
exceeding levels 
taking 12 tablets a day of Vicodin 10 mg or 16 tablets a day of Percocet 5 
CDC says to avoid 
mg.  These dosages far exceed the amounts that the manufacturers 
recommend for both of these drugs.11  They also exceed the MED level that 
CDC recommends avoiding for patients with chronic pain.12 
To help inform prescribers, the CDC published guidelines on prescribing 
opioids to patients with chronic pain.  The guidelines recommend that 
prescribers use caution when ordering opioids at any dosage and avoid 
increasing dosages to the equivalent of 90 mg or more MED a day for 
chronic pain.13 
The most commonly prescribed opioids for beneficiaries with high amounts 
were oxycodone-acetaminophen 10 mg and oxycodone 15 mg.  Nearly 
one-quarter of all beneficiaries who received high amounts of opioids had 
at least one prescription for oxycodone-acetaminophen 10 mg, while 
22 percent had a prescription for oxycodone 15 mg.  Eleven percent of 
beneficiaries who received high amounts of opioids had at least one 
prescription for fentanyl patch 50 mcg/hr.  Oxycodone and fentanyl are 
among the most common opioids involved in law enforcement cases.14  
Fentanyl is 80 to 100 times more powerful than morphine and is sometimes 
mixed with other drugs, such as cocaine or heroin, which increases the risk 
of overdose.15  
Although beneficiaries may receive opioids for legitimate purposes, these 
amounts raise concern.  Opioids carry health risks, including respiratory 
depression, constipation, drowsiness, and confusion.  Older adults may also 
be at an increased risk of injury, as research has shown that the risk of 
fracture may increase as drug dosage increases.16 
 
Nearly 6,000  Two groups of beneficiaries who are at serious risk of opioid misuse or 
overdose are beneficiaries who receive extreme amounts of opioidsi.e., 
beneficiaries in 
an average daily MED greater than 240 mg for 12 monthsand 
these States are at 
beneficiaries who appear to be doctor shoppingi.e., receive a high 
serious risk of  amount of opioids (an average daily MED greater than 120 mg for 
3 months) and have four or more prescribers and four or more pharmacies.  
opioid misuse or 
Other Part D beneficiaries also may be at serious risk of opioid misuse or 
overdose 
overdose but do not meet these criteria.  
 
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OEI-02-18-00224   
In 5 States in the Appalachian region, 5,929 beneficiaries were in one of 
these two groups in 2017 and, therefore, at serious risk.  This does not 
include beneficiaries who had cancer or were in hospice care.  Specifically, 
4,556 beneficiaries received extreme amounts of opioids in these States 
and 1,451 beneficiaries appeared to be doctor shopping.  A total of 
78 beneficiaries were in both groups.  See Appendix A for data on Part D 
beneficiaries in the Appalachian region receiving opioids.   
Most of the beneficiaries at serious risk were under the age of 65.  These 
individuals may have qualified for Medicare because they have disabilities 
or end-stage renal disease.  Seventy-five percent of beneficiaries at serious 
risk were under 65 years old, 21 percent were between 65 and 75, and 4 
percent were over 75.17 
 
Examples of Beneficiaries at Serious Risk of Opioid Misuse or Abuse 
 
A beneficiary from Ohio received more than a years supply of fentanyl 
patches and over 3,000 pills containing oxycodone in 2017.  This 
beneficiary had a total of 54 opioid prescriptions from 5 prescribers and 
4 pharmacies, giving him an average daily MED of more than 1,100 mg 
for the year.  This is 12 times the amount CDC recommends avoiding.   
_______________________________________________________ 
A beneficiary from Tennessee had an average daily MED that topped 
1,400 mg for the year, which is over 15 times the amount CDC 
recommends avoiding.  This beneficiary also had 5 prescribers and used 
5 pharmacies in 2017.  She received 27 opioid prescriptions totaling more 
than 6,000 pills, almost all of which contained two high strengths of 
oxycodone, 80mg and 30mg.   
_______________________________________________________ 
In the first month of 2017, a beneficiary in Kentucky received 5 opioid 
prescriptions amounting to 22 pills per day.  These prescriptions included 
1-month supplies each of three strengths of oxycodone (80 mg, 30 mg, 
and 20 mg), methadone 10 mg and Subsys (a fentanyl spray).  This 
beneficiary went on to receive a total of 54 opioid prescriptions during 
the year, resulting in an average daily MED that exceededby 17 times
the level that CDC says to avoid.  Over the course of the year, he 
received more than 6,400 pills containing oxycodone.   
_______________________________________________________ 
A beneficiary in West Virginia used 15 pharmacies to fill opioid 
prescriptions from 22 prescribers.  The prescribers were in 10 different 
States:  Georgia, Maryland, Michigan, Missouri, New Hampshire, New 
York, Ohio, Virginia, Vermont, and West Virginia.    
 
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OEI-02-18-00224   
CONCLUSION 
Opioid abuse and overdose deaths are at epidemic levels in the United 
States.  In five States in the Appalachian regionAlabama, Kentucky, Ohio, 
Tennessee, and West Virginia36 percent of Part D beneficiaries received 
a prescription opioid in 2017.  In comparison, 31 percent of Part D 
beneficiaries nation-wide received a prescription opioid.  Almost 49,000 of 
beneficiaries in the 5 States received amounts that far exceed manufacturer 
recommendations and the levels that CDC says to avoid.  Raising additional 
concern, nearly 6,000 beneficiaries in these States are at serious risk of 
opioid misuse or overdose because they received extreme amounts of 
opioids, or they appeared to be doctor shopping.   
The use of opioids described in this study may indicate that opioids in the 
Appalachian region are being prescribed for medically unnecessary 
purposes and then diverted for resale or recreational use.  It may also 
indicate that the beneficiary is receiving poorly coordinated care or that the 
beneficiarys care may need to be reassessed.  In addition, it raises 
questions as to whether prescribers are checking State prescription drug 
monitoring databases or whether these databases have current 
information.   
The severity of the crisis makes it imperative that the Department of Health 
and Human Services (the Department), including the Centers for Medicare 
& Medicaid Services (CMS) and OIG, continue to work with its partners to 
address this epidemic.  As the Department has highlightedstrengthening 
public health surveillance, advancing the practice of pain management, 
improving access to treatment and recovery services, targeting availability 
and distribution of overdose-reversing drugs, and supporting cutting-edge 
researchall need to be part of the strategy to fight the opioid crisis in the 
Appalachian region and the Nation.18 
OIG is committed to fighting the opioid crisis and protecting beneficiaries 
from prescription drug abuse and misuse.  We are working with our law 
enforcement partners to bring resources and expertise to these five States 
through the Appalachian Regional Prescription Opioid Strike Force.  The 
mission of the Strike Force is to prevent patient harm and identify and 
investigate healthcare fraud related to medically unnecessary prescribing 
and illegal distribution of opioids, with a particular focus on medical 
professionals.  
OIG also recently released an opioid analysis toolkit to assist our public and 
private sector partners.19  The toolkit provides detailed step-by-step 
instructions for using prescription drug data to identify patients who are at 
risk of opioid misuse or overdose.  In addition, OIG is conducting a series of 
reviews on opioid utilization in Medicaid and producing factsheets on 
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     5 
OEI-02-18-00224   
selected States oversight of opioid prescribing and monitoring of opioid 
use.20  OIG also has ongoing reviews about key opioid initiatives at the 
Department, including access to buprenorphine for opioid use disorder; 
controls on opioid treatment programs, and grants for prescription drug 
monitoring programs.  
Further, OIG supports States efforts nation-wide to combat the opioid 
crisis.  OIG supports States efforts to implement and enforce strong 
prescription drug monitoring programs that require prescribers and 
pharmacies to check the State database before prescribing and dispensing 
opioids.  Further, we encourage States to provide greater access to these 
data, including sharing these data with entities such as State Medicaid 
agencies.  We also encourage States to analyze these data to help identify 
patients who may be at risk and to promote appropriate opioid prescribing 
practices.  For example, States could provide reports to prescribers about 
their opioid prescribing patterns.  By working together and expanding our 
efforts, we can help curb the opioid crisis in our Nation. 
   
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OEI-02-18-00224   
METHODOLOGY  
We based this data brief on an analysis of prescription drug event (PDE) 
records for Part D drugs.  This data brief includes prescriptions that 
beneficiaries in five States in the Appalachian regionAlabama, Kentucky, 
Ohio, Tennessee, and West Virginiareceived through Part D.  It does not 
include prescriptions paid through other programs, prescriptions paid for in 
cash, or illicitly purchased drugs.  Part D sponsors submit a PDE record to 
CMS each time a drug is dispensed to a beneficiary enrolled in their plans.  
Each record contains information about the drug and beneficiary, as well as 
the identification numbers for the pharmacy and the prescriber.   
We matched PDE records to data from the First DataBank, National Claims 
History File, Part C Encounter Data, CDCs Morphine Milligram Equivalent 
(MME) conversion file, National Plan and Provider Enumeration System 
(NPPES), and the National Council for Prescription Drug Programs (NCPDP) 
database to obtain descriptive information about the drugs, beneficiaries 
and pharmacies.  First DataBank contains information about each drug, 
such as the drug name, strength of the drug, and therapeutic class (e.g., an 
opioid.)  The National Claims History File contains claims data from 
Medicare Parts A and B, including diagnoses codes.  Part C Encounter Data 
contains medical claims data, including diagnosis codes, for beneficiaries 
enrolled in Medicare Advantage plans.  CDCs MME conversion file contains 
information about each opioids drug morphine milligram equivalence.21  
NPPES contains information about prescribers, such as their name and 
address.  The NCPDP database contains information about pharmacies, 
such as their names and addresses.  For the purposes of this study, we use 
the term prescription to mean one PDE record. 
Analysis of Part D Opioid Utilization and Spending 
We identified all PDE records for opioids that beneficiaries received in 
2017.22  We calculated the total number of Part D beneficiaries in Alabama, 
Kentucky, Ohio, Tennessee, and West Virginia who received opioids in 
2017.23  For beneficiaries in these five States, we then calculated the total 
number of opioid prescriptions paid for by Part D in 2017 and the average 
number of opioid prescriptions per beneficiary.  We also calculated the 
proportion of beneficiaries who received opioids in each of these States in 
2017.  We based this analysis on the PDE records and Medicare enrollment 
data.   
Beneficiary Analysis  
Next, we determined the amount of opioids that each beneficiary in these 
five States received in 2017.  To do this, we calculated each beneficiarys 
average daily morphine equivalent dose (MED).24  The MED converts 
opioids of different ingredients, strengths, and forms into equivalent 
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     7 
OEI-02-18-00224   
milligrams of morphine.  It allows us to sum dosages of different opioids to 
determine a beneficiarys daily opioid level.   
To calculate each beneficiarys average daily MED, we first calculated the 
MED for each prescription (i.e., PDE record).25  To do this, we used the 
following equation: 
(Strength per unit)(Quantity dispensed)(MME conversion factor)
MED=  
(Days supply)
Next, we summed each beneficiarys MED for each day of the year based 
on the dates of service and days supply on each PDE record.  We refer to 
this as the daily MED.  We excluded from this analysis beneficiaries with a 
diagnosis of cancer or a hospice stay at any point in 2017.26   
We analyzed the MED data using the same criteria that we used in our 
previous national analyses of Part D data from 2016 and 2017.27  We began 
by determining the extent to which beneficiaries received high amounts of 
opioids.  To do this, we calculated each beneficiarys average daily MED 
over each 90-day period in 2017.  We determined that a beneficiary 
received high amounts of opioids if he or she exceeded an average daily 
MED of 120 mg for any 90-day period and had received opioids for 90 or 
more days in the year.  We used these criteria because they closely align 
with the criteria used by CMS in 2016 and 2017 for its Overutilization 
Monitoring System.28  The MED of 120 mg also exceeds the level CDC 
recommends avoiding for patients with chronic painan MED of 90 mg.    
We then determined the extent to which beneficiaries received extreme 
amounts of opioids.  We calculated each beneficiarys average daily MED 
over the entire year.  We considered a beneficiary who exceeded an 
average daily MED of 240 mg for the entire year and had received opioids 
for 360 days or more to have received an extreme amount of opioids.    
Next, we determined the extent to which beneficiaries appeared to be 
doctor shopping.  To do this, we calculated the total number of prescribers 
and pharmacies from which each beneficiary received opioids in 2017.  We 
considered beneficiaries to have appeared to be doctor shopping if they 
exceeded an average daily MED of 120 mg for any 90-day period, received 
opioids for 90 or more days in the year, and received opioids from four or 
more prescribers and four or more pharmacies.   
Limitations 
This analysis is based on Part D prescription drug event records; it is not 
based on a review of medical records.  The analysis does not include data 
on opioids that beneficiaries may have received from sources other than 
Part D.  
 
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     8 
OEI-02-18-00224   
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
   
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     9 
OEI-02-18-00224   
APPENDIX A:  DATA ON PART D BENEFICIARIES 
IN THE APPALACHIAN REGION RECEIVING 
OPIOIDS  
Exhibit A-1: Almost 49,000 beneficiaries in 5 States in the Appalachian region 
received high amounts of opioids, far exceeding levels CDC says to avoid.* 
  Number of  
Beneficiaries 
  in 2017   
Beneficiaries who received amounts that far exceed levels     
48,584 
CDC says to avoid 
Source: OIG analyses of Medicare Part D data, 2019. 
* These five States are Alabama, Kentucky, Ohio, Tennessee, and West Virginia. 
 
 
Exhibit A-2: Nearly 6,000 beneficiaries in these States are at serious risk of opioid misuse  
or overdose.* 
  Number of  
Beneficiaries 
  in 2017   
Beneficiaries who received an extreme amount of opioids    4,556   
Beneficiaries who appear to be doctor shopping    1,451   
Total beneficiaries at serious risk    5,929**   
Source: OIG analyses of Medicare Part D data, 2019. 
* These five States are Alabama, Kentucky, Ohio, Tennessee, and West Virginia. 
** A total of 78 beneficiaries were in both groups in 2017. 
 
   
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OEI-02-18-00224   
ACKNOWLEDGMENTS 
Miriam Anderson served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Margaret Himmelright and Jason Kwong.  
Office of Evaluation and Inspections staff who provided support include 
Adam Freeman.  We would also like to acknowledge the contributions of 
other Office of Inspector General staff, including Robert Gibbons and 
Lauren McNulty. 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 
General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. 
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OEI-02-18-00224   
ENDNOTES
 
1 See Holly Hedegaard, Margaret Warner, and Arialdi M. Minino, CDC, National Center for Health Statistics (NCHS), 
NCHS Data Brief 294, Drug Overdose Deaths in the United States, 19992016 and supplement tables, December 2017.  
Accessed at https://www.cdc.gov/nchs/data/databriefs/db294.pdf and 
https://www.cdc.gov/nchs/data/databriefs/db294_table.pdf#page=1 on February 26, 2019. 
2 In 2016, the opioid prescribing rate nation-wide was 66.5 prescriptions per 100 persons.  Alabama (121 prescriptions 
per 100 persons), Tennessee (107.5), Kentucky (97.2), West Virginia (96.0), and Ohio (75.3) all had higher prescribing 
rates than that of the Nation.  In total, there were 6,864 opioid-related overdose deaths in these 5 States in the 
Appalachian region in 2016.  The age-adjusted opioid-related overdose death rate was 13.3 per 100,000 persons for 
the Nation in 2016.  West Virginia (43.4 deaths per 100,000 persons), Ohio (32.9), Kentucky (23.6), and Tennessee 
(18.1) all had higher rates than the Nation.  Alabama reported a rate of 7.5.  See CDC, Annual Surveillance Report of 
Drug-Related Risk and Outcomes, 2017.  Accessed at https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-
surveillance-report.pdf on February 27, 2019.  See National Institute on Drug Abuse, Opioid Summaries by States, 
February 2018.  Accessed at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/ on 
February 20, 2019. 
3 Diane L. Chau, Vanessa Walker, Latha Pai, et al., Opiates and Elderly: Use and Side Effects, Clinical Interventions in 
Aging 3, no. 2 (2008): 276.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/ on February 26, 
2019.  Also see CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, Morbidity and 
Mortality Weekly Report (MMWR): Recommendations and Reports 65, no. 1, March 18, 2016.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on February 26, 2019. 
4 Kathleen W. Saunders, Kate M. Dunn, Joseph O. Merrill, et al., Relationship of Opioid Use and Dosage Levels to 
Fractures in Older Chronic Pain Patients, Journal of General Internal Medicine 25, no. 4 (2010): 310315.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842546/ on February 26, 2019. 
5 These guidelines provide recommendations for prescribing opioids for chronic pain outside of cancer treatment, 
palliative care, and end-of-life care.  See CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 
2016. MMWR Recommendations and Reports 65, no. 1, March 18, 2016, 149.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on February 26, 2019. 
6 Ibid. p. 16.  The CDC guidelines recommend that prescribers avoid increasing opioids to morphine equivalent 
dosages of greater than or equal to 90 mg a day or carefully justify the decision to increase to this level.   
7 OIG, Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing, OEI-05-18-00010, July 2018. 
8 OIG, Factsheet: Tennessee's Oversight of Opioid Prescribing and Monitoring of Opioid Use, A-04-18-00124, February 
2019.  Also see OIG, Factsheet: West Virginias Oversight of Opioid Prescribing and Monitoring of Opioid Use, A-03-18-
03302, March 2019. 
9 OIG, Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing, OEI-02-17-00250, July 
2017.  OIG, Opioid Use in Medicare Part D Remains Concerning, OEI-02-18-00220.  For information about studies 
related to access to care, see OIG, Work Plan, 2019 at https://oig.hhs.gov/reports-and-
publications/workplan/index.asp. 
10 The five most commonly dispensed opioids included tramadol 50 mg, hydrocodone-acetaminophen  
10-325 mg, hydrocodone-acetaminophen 5-325 mg, hydrocodone-acetaminophen 7.5-325 mg, and oxycodone-
acetaminophen 10-325 mg. 
11 According to the manufacturer labels, the maximal daily dose for Percocet 5 mg is 12 tablets and the daily dosage 
for Vicodin 10 mg should not exceed 6 tablets.  For more information about Percocet, see Endo Pharmaceuticals, 
PERCOCET (Oxycodone and Acetaminophen Tablets, USP), p. 2.  Accessed at 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/040330s015,040341s013,040434s003lbl.pdf; for Vicodin, 
see page 20 at http://www.rxabbvie.com/pdf/vicodin_apap_300mg_hydrocodone_5mg-7_5mg-10mg_PI.pdf.  
 
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     12 
OEI-02-18-00224   
 
12 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. MMWR Recommendations and 
Reports 65, no. 1, March 18, 2016, 149.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on 
February 26, 2019. 
13 Ibid, p. 16. 
14 U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information System, 
2017 Annual Report, 2018.  Accessed at 
https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-Drug-AR2017.pdf  on 
March 1, 2019. 
15 U.S. Drug Enforcement Administration, Drug Facts - Fentanyl.  Accessed at https://www.dea.gov/factsheets/fentanyl 
on March 1, 2019. 
16 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR Recommendations and 
Reports 65, no. 1, March 18, 2016, pp. 13, 44. 
17 In addition to people over the age of 65, Medicare is available to younger people with disabilities and those with 
end-stage renal disease. U.S. Department of Health and Human Services (HHS), Who Is Eligible for Medicare?  
Accessed at https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html on 
February 26, 2019. 
18 HHS, Strategy to Combat Opioid Abuse, Misuse and Overdose: A Framework Based on the Five Point Strategy.  
Accessed at https://www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-
508compliant.pdf on February 27, 2019. 
19 OIG, Toolkit:  Using Data Analysis To Calculate Opioid Levels and Identify Patients At Risk of Misuse or Overdose, OEI-
02-17-00560, June 2018.  
20 See OIG, Work Plan, 2019 at https://oig.hhs.gov/reports-and-publications/workplan/index.asp.  
21 These files contain MME conversion factors for each National Drug Code.  MED and MME are interchangeable 
terms.   
22 To identify PDE records for opioids, we matched the NDCs on the PDE records with two filesFirst DataBank and 
CDCs MME conversion file.   
23 We used the beneficiarys address on the PDE record to identify the State.  For beneficiaries who resided in more 
than one State during the year, we included the beneficiary in the analysis for each of those States. 
24 For more information on calculating opioid dosage, see CDC, Calculating Total Daily Dose of Opioids for Safer 
Dosage.  Accessed at https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf on February 26, 2019. 
25 To ensure that we included all opioids received by each beneficiary in 2017, we included opioids dispensed in 2016 
with days of use in 2017.  Also, for beneficiaries who resided in more than one State during the year, we included all 
the opioids they received regardless of where they resided.  Note that we did not include PDE records for injection, 
intravenous, and intrathecal opioids because CDC does not publish MME conversion factors for these opioids.  We 
also did not include opioids indicated for medication-assisted treatment. 
26 We identified beneficiaries with a cancer diagnosis or hospice stay using CMSs National Claims History File and 
Part C Encounter data.   
27 OIG, Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing, OEI-02-17-00250, 
July 2017.  OIG, Opioid Use in Medicare Part D Remains Concerning, OEI-02-18-00220. 
28 Through 2017, CMSs Overutilization Monitoring System identified beneficiaries who had a daily MED of 120 mg for 
90 days plus 4 or more prescribers and 4 or more pharmacies.  Note that the guidance uses the term more than 3 
prescribers and more than 3 pharmacies which is the equivalent to 4 or more prescribers and 4 or more 
pharmacies.  The criteria for the Overutilization Monitoring System changed in 2018.  See CMS, Announcement of 
Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies 
and Final Call Letter and Request for Information, April 2017.  Accessed at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2018.pdf on February 26, 2019.  
Data Brief:  Concerns About Opioid Use in Medicare Part D in the Appalachian Region     13 
OEI-02-18-00224