HHS OIG Data Brief  Ju ly 2017  OEI-02-17-00250 
 
Opioids in Medicare Part D: Concerns about Extreme Use 
and Questionable Prescribing  
 
Opioid abuse and overdose deaths are at epidemic 
Key Takeaways:  levels in the United States.  In 2015, the number of  
opioid-related deaths exceeded 33,000 for the first 
  One in three Medicare Part D 
time.1  Nearly half of these deaths involved 
beneficiaries received a 
prescription opioids.   
prescription opioid in 2016 
Opioids include narcotics intended to  manage pain 
 About 500,000 beneficiaries 
from surgery, injury, or illness.  They can create a 
received high amounts of 
euphoric effect, which makes them  vulnerable to 
opioids 
abuse and misuse (i.e., taking opioids in a way 
 Almost 90,000 beneficiaries are  other than prescribed).  Although opioids can be 
at serious risk; some received  appropriate under certain circumstances, the Office 
extreme amounts of opioids,  of Inspector General (OIG) and others are 
while others appeared to be  concerned about fraud, abuse, and misuse of 
doctor shopping  opioids, including those obtained under Medicare 
Part D.  Part D is the optional prescription drug
 About 400 prescribers had 
benefit for Medicare beneficiaries.  In 2016, it
questionable opioid prescribing 
covered 43.6 million beneficiaries.   
patterns for beneficiaries at 
This data brief is part of a larger strategy by OIG to 
serious risk 
fight the opioid crisis and address one of its top 
priority outcomesto protect Medicare 
beneficiariesand the community as a wholefrom prescription drug abuse.  Previous OIG 
work called attention to increased spending for commonly abused opioids.2  OIG has also 
highlighted the problem of drug diversionthe redirection of prescription drugs for an  illegal 
purpose, such as recreational use or resale.3 
In addition to the risk of abuse, misuse, and diversion, opioids carry a number of health risks.  
Side effects from using opioids may include respiratory depression, confusion, tolerance, and 
physical dependence.4  For seniors, long-term use of prescription opioids also increases the 
likelihood of falls and fractures.5  For these reasons, it is essential that Medicare Part D 
beneficiaries only receive medically necessary opioids in the appropriate amounts.   
Prescribers play a crucial role in ensuring that beneficiaries receive appropriate amounts of 
opioids.  To help inform  prescribers, the Centers for Disease Control and Prevention (CDC) 
1  recently published guidelines on prescribing opioids to patients with chronic pain.6  The 
guidelines recommend that prescribers use caution when ordering opioids at any dosage and 
avoid dosages that are equivalent to 90 mg or more of morphine a day.7  In addition, the Centers 
for Medicare & Medicaid Services (CMS) has initiated a number of projects to address opioid 
misuse and inappropriate prescribing.  For instance, CMS identifies Part D beneficiaries who are 
potentially overutilizing opioids and who may be in need of case management.8  Despite these 
efforts, concerns remain about beneficiaries receiving high amounts of opioids through Part D. 
This data brief builds on OIGs previous work and includes in-depth analysis of opioid 
utilization among Medicare Part D beneficiaries.9  It provides baseline data on the extent to 
which beneficiaries receive extreme amounts of opioids and appear to be doctor shopping.  
The analysis looks at the morphine equivalent dose (MED) received by each beneficiary, which 
equates all of the various opioids and strengths into one standard value.  This data brief also 
identifies prescribers who have questionable opioid prescribing patterns.   
 
RESULTS
 
One in three Medicare Part D beneficiaries received opioids 
in 2016 
 
In 2016, one out of every three beneficiaries received at 
least one prescription opioid through Medicare Part D.  In 
total, 14.4 million of the 43.6 million beneficiaries enrolled 
in Medicare Part D received opioids.  Medicare Part D paid 
almost $4.1 billion for 79.4 million opioid prescriptions for 
these beneficiaries.  The vast majority of these opioids  
(80 percent) were Schedule II or III controlled substances, 
meaning they have the highest potential for abuse among 
legally available drugs.10   
The most commonly prescribed opioids were tramadol, 
hydrocodone-acetaminophen (including the brand-name 
version, Vicodin), and oxycodone-acetaminophen 
(including the brand-name version, Percocet).  Part D 
beneficiaries received about 15 million prescriptions for 
tramadol 50 mg, which is a Schedule IV drug.11  
Beneficiaries also received several million prescriptions 
for various strengths of hydrocodone-acetaminophen, a 
Schedule II drug, and for oxycodone-acetaminophen 5 mg, 
another Schedule II drug. See Exhibit 2. 
Several States had higher proportions of beneficiaries receiving opioids than the Nation overall, 
which was 33 percent.  Alabama and Mississippi had the highest proportions, with almost half of 
the States Part D beneficiaries receiving at least one opioid46 percent and 45 percent, 
2  respectively.  Arkansas had 44 percent of beneficiaries 
receiving opioids, while Oklahoma, Tennessee, and 
Louisiana each had 42 percent.  The lowest proportions 
were in Hawaii (21 percent) and New York (22 percent). 
In addition, 1 in 10 Medicare Part D beneficiaries 
nationwide received opioids on a regular basis.  
Specifically, 5 million beneficiaries received opioids for 3 
months or more in 2016.  Research shows that the risk of 
opioid dependence increases substantially for patients 
receiving opioids continuously for 3 months.12  Of these 5 
million beneficiaries, 3.6 million received opioids for  
6 or more months and nearly 610,000 received opioids for 
the entire year. 
Half a million Part D beneficiaries received high 
amounts of opioids in 2016  
A total of 501,008 beneficiaries received high amounts of 
opioids through Medicare Part D in 2016.  This does not 
include beneficiaries who had cancer or were in hospice 
care.  Each of the 501,008 beneficiaries received an 
average morphine equivalent dose (MED) of greater than 
120 mg a day for at least 3 months.  MED is a measure that 
equates all the various opioids and strengths into one 
standard value.  A daily MED of 120 mg is equivalent to 
taking 12 tablets a day of Vicodin 10 mg or 16 tablets a 
day of Percocet 5 mg.  These dosages far exceed the amounts that the manufacturers recommend 
for both of these drugs.13  They also exceed the 90 mg MED level that CDC recommends 
avoiding for patients with chronic pain.14   
The most commonly prescribed opioid for beneficiaries with high amounts was oxycodone  
30 mg.  One in five beneficiaries who received a high amount of opioids had at least one 
prescription for oxycodone 30 mg.  Oxycodone is one of the prescription opioids most 
commonly involved in law enforcement cases.15 
Although beneficiaries may receive opioids for legitimate purposes, these high amounts raise 
concern.  Many experts have noted that opioid dosages should not be increased over a MED of 
90 mg a day without careful justification.16  Moreover, opioids carry other 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.17   
 
3  Almost 90,000 beneficiaries are at serious risk of opioid 
misuse or overdose 
Two groups of beneficiaries are at serious risk of  Two Groups of Beneficiaries at 
Serious Risk of Opioid Misuse or 
opioid misuse or overdose: (1) beneficiaries who 
Overdose: 
received extreme amounts of opioids and (2) 
beneficiaries who appeared to be doctor shopping.  1.  Beneficiaries who received 
extreme amounts of opioidsi.e., 
A total of 89,843 beneficiaries were in these two 
an average daily MED greater than 
groups in 2016.  Specifically, 69,563 beneficiaries 
240 mg for 12 months. 
received extreme amounts of opioids, and  
 
22,308 beneficiaries appeared to be doctor 
2.  Beneficiaries who appeared to be 
shopping (i.e., received high amounts of opioids 
doctor shoppingi.e., received a 
and had multiple prescribers and pharmacies).  A  high amount of opioids (an average 
total of 2,028 beneficiaries were in both groups.   daily MED greater than 120 mg for 
Other beneficiaries may also be at serious risk of  3 months) and had four or more 
opioid misuse or overdose, but they are not the  prescribers and four or more 
focus of this data brief.  pharmacies. 
 
About 70,000 beneficiaries received extreme amounts of opioids  
A total of 69,563 beneficiaries received extreme amounts 
of opioids for the entire year, putting them at serious risk 
of opioid misuse or overdose.18  Each of these 
beneficiaries had an average daily MED that exceeded 240 
mg for the entire year.  This extreme amount is more than 
two and a half times the dose CDC recommends avoiding 
for chronic pain patients.  (See Exhibit 3.)  Research has 
shown that patients who receive an MED at such a level 
are at increased risk of overdose death.19   
Of note, 678 beneficiaries received even more extreme 
amounts of opioids.  These beneficiaries each received an 
average daily MED greater than 1,000 mg for the entire 
year.  In one case, a beneficiary from New Hampshire 
received 134 prescriptions for opioids from one prescriber 
in 2016, including 13 months of OxyContin 80 mg,  
13 months of OxyContin 60 mg, 13 months of OxyContin 
40 mg, 14 months of oxycodone 30 mg, and 13 months of 
fentanyl patches.   
Receiving extreme amounts of opioids raises concerns.  It 
may indicate that the beneficiary is receiving medically 
unnecessary drugs, which could be diverted for resale.  It 
4  may also indicate that the beneficiary is addicted to opioids and at risk of overdose.  
Alternatively, it may indicate that a beneficiarys identification number has been stolen or sold.     
 
 
Example of Beneficiary Receiving Extreme Amounts of Opioids 
One beneficiary in New York received 62 opioid prescriptions during the year, which is 
more than one prescription per week.  All of the prescriptions were for fentanyl or 
oxycodone.  The beneficiary had an average daily MED of over 3,130 mg for the entire 
year, which is almost 35 times the level that CDC recommends avoiding.  All but one of 
these opioids were prescribed by one family medicine physician. 
 
 
About 22,000 beneficiaries appear to be doctor shopping 
A second group of beneficiariesthose who appear to be doctor shopping (i.e., received high 
amounts of opioids and had multiple prescribers and pharmacies)are also at serious risk of 
opioid misuse or overdose.  Doctor shoppers are beneficiaries who seek medically unnecessary 
prescriptions from multiple prescribers and multiple pharmacies.  A total of 22,308 beneficiaries 
appear to be doctor shopping.  Each of these beneficiaries received a high amount of opioidsan 
average daily MED that exceeded 120 mg for at least 3 monthsand have four or more 
prescribers and four or more pharmacies in 2016.20  Typically, beneficiaries who receive opioids 
have just one prescriber and one pharmacy. 21  Although beneficiaries may receive opioids from 
multiple prescribers or pharmacies for legitimate reasons, these patterns raise concern. 
Notably, 162 beneficiaries each 
received opioids from more than  
10 prescribers and more than  
10 pharmacies in 2016.  One 
beneficiary received opioids from 
46 different prescribers and 20 
different pharmacies.  In August 
alone, this beneficiary received 11 
different opioid prescriptions from  
8 prescribers in 5 different States; 
this beneficiary filled these 
prescriptions at 6 different 
pharmacies.   
Receiving high amounts of 
opioids and having multiple 
prescribers and pharmacies may 
indicate that a beneficiary is 
seeking medically unnecessary 
5  drugs, perhaps to use them recreationally or to divert them.  It could mean that the beneficiarys 
identification number was stolen or sold.  It may also signal that the beneficiarys care is not 
being monitored or coordinated properly.  Furthermore, it may indicate that prescribers are not 
checking the beneficiarys opioid history before prescribing.  All but one State maintain 
databases, called prescription drug monitoring programs, that track prescriptions for controlled 
substances.  Prescribers can check these databases before ordering opioids to determine if the 
beneficiary is already receiving opioids ordered by other prescribers.22   
 
Examples of Beneficiaries Who Appear to be Doctor Shopping 
 
A beneficiary in Washington, D.C. received prescriptions for opioids from  
42 different prescribers and filled them at 37 different pharmacies in a year.  In a 
single month, this beneficiary received 2,330 pills from prescriptions written by just 
one prescriber.  These drugs included oxycodone, hydromorphone, and morphine.    
 
A second beneficiary in Illinois received 73 prescriptions for opioids from  
11 different prescribers and filled them at 20 different pharmacies in a year.  On 
multiple occasions, this beneficiary filled opioid prescriptions at multiple 
pharmacies on the same day.  For example, one day he filled two 30-day 
prescriptions for fentanyl patches at two nearby pharmacies and another 30-day 
prescription for morphine at a third pharmacy more than 40 miles away.   
 
 
 
A bout 400 prescribers had questionable opioid prescribing 
 
patterns for beneficiaries at serious risk 
In total, 115,851 prescribers ordered opioids for at least one beneficiary at serious risk of opioid 
misuse or overdose (i.e., a beneficiary who has received extreme amounts or appeared to be 
doctor shopping).  The vast majority of these prescribers each ordered opioids for only one or 
two of these beneficiaries.  Some prescribers ordered for many more.  A total of 401 prescribers 
stand out as having questionable prescribing patterns; these prescribers ordered opioids for the 
highest numbers of beneficiaries at serious risk.  The patterns of these 401 prescribers are far 
outside the norm and warrant further scrutiny.       
Specifically, 198 prescribers ordered opioids for a high number of beneficiaries who received 
extreme amounts, while 264 prescribers ordered opioids for a high number of beneficiaries who 
appeared to be doctor shopping.  Sixty-one prescribers ordered opioids for high numbers from 
both groups of beneficiaries at serious risk.  In total, prescribers with questionable patterns wrote 
256,260 opioid prescriptions for beneficiaries at serious risk, costing Part D a total of  
$66.5 million. 
   
6  Nearly 200 prescribers each ordered opioids for dozens of beneficiaries who 
received extreme amounts of opioids  
There were 198 prescribers with questionable prescribing patterns for beneficiaries who received 
extreme amounts of opioids.  Each of these prescribers ordered opioids for at least  
44 beneficiaries who received extreme amounts.  As noted earlier, beneficiaries who receive 
extreme amounts of opioids are at serious risk.  They each had an average daily MED of more 
than 240 mg for the entire year and did not have cancer or hospice care.  CDC recommends 
avoiding a daily MED of more than 90 mg, but beneficiaries with extreme amounts are receiving 
more than two and a half times that amount.   
Although high amounts of opioids may be necessary for some patients, questionable prescribing 
patterns may indicate that the prescriber is ordering medically unnecessary drugs.  These drugs 
may be diverted for resale or recreational use.  Furthermore, beneficiaries who receive extreme 
amounts of opioids are at serious risk of misuse or overdose; therefore, it is important for 
prescribers to pay close attention to the amount of these drugs that they order and the frequency 
in which they order them.   
Fifteen prescribers stand out.  Each ordered opioids for more than 98 beneficiaries who received 
extreme amounts during the year.  In one case, a prescriber in Missouri wrote an average of  
31 opioid prescriptions each for 112 beneficiaries.  Half of these beneficiaries had an average 
daily MED that exceeded 375 mg for the entire year.  Another prescriber in Indiana wrote an 
average of 24 opioid prescriptions each for 108 beneficiaries who received extreme amounts; 
these drugs cost Part D $1.1 million. 
 
Examples of Prescribers with Questionable Prescribing Patterns for Beneficiaries 
Who Received Extreme Amounts of Opioids 
 
One Florida physician repeatedly ordered extreme amounts of opioids for multiple 
beneficiaries.  For one beneficiary in a single day, this physician ordered three 
opioidsoxycodone and two different forms of fentanylthat had a daily MED of 
1,239 mg.  In total, this physician prescribed opioids to 125 beneficiaries who 
received extreme amounts.  Part D paid $1.6 million for these drugs.   
 
A family medicine physician in Texas wrote 1,199 opioid prescriptions for  
103 beneficiaries.  For one beneficiary, this physician wrote 27 opioid prescriptions
9 months each of oxycodone, methadone, and hydrocodone-acetaminophen.  For 
another beneficiary, this physician wrote 24 opioid prescriptions8 months each of 
oxycodone, morphine, and hydrocodone-acetaminophen.  In total, Part D paid 
$192,000 for opioids prescribed by this physician for beneficiaries who received 
extreme amounts.   
 
   
7  Over 260 prescribers each ordered opioids for numerous beneficiaries who 
appeared to be doctor shopping  
There were 264 prescribers with questionable prescribing patterns for beneficiaries who 
appeared to be doctor shopping.  These beneficiaries received high amounts of opioids and had  
four or more prescribers and four or more pharmacies.  Each of the 264 prescribers ordered 
opioids for at least 21 of these beneficiaries.  Like beneficiaries who receive extreme amounts, 
beneficiaries who appear to be doctor shopping are at serious risk of opioid misuse or overdose.   
Questionable prescribing may indicate that beneficiaries are receiving poorly coordinated care 
and could be in danger of overdose or dependence.  It may also mean that prescribers are not 
checking the State prescription drug monitoring databases, or that these databases do not have 
current data.  Another possibility is that the prescribers identification was sold or stolen and is 
being used for illegal purposes.  Questionable patterns also raise significant concern that 
prescribers may be operating pill mills.  A pill mill is a doctors office, clinic, or health care 
facility that routinely prescribes controlled substancessuch as oxycodoneoutside the scope 
of professional practice and without a legitimate medical purpose. 
Eighteen prescribers stand out in that each ordered opioids for more than 45 beneficiaries who 
appeared to be doctor shopping.  Of note, four physicians in the same practice in Texas each 
ordered opioids for more than 56 beneficiaries who appeared to be doctor shopping.  
 
 
Example of Prescribers with Questionable Prescribing Patterns for Beneficiaries  
Who Appear to be Doctor Shopping 
 
Four practitioners from the same practice in Wisconsin1 physician and 3 nurse 
practitionerseach prescribed opioids to more than 136 beneficiaries who appeared 
to be doctor shopping.  Together, these practitioners wrote 2,823 opioid prescriptions 
during the year for beneficiaries who appeared to be doctor shopping, costing Part D 
$336,000.  Two-thirds of these prescriptions1,885were for oxycodone, a 
commonly diverted drug.   
 
   
 
Nurse practitioners and physician assistants make up one-third of the prescribers 
with questionable prescribing patterns for beneficiaries at serious risk   
One-third (133 of 401) of the prescribers who had questionable prescribing patterns for 
beneficiaries at serious risk were nurse practitioners or physician assistants.  In total, 81 of these 
prescribers were nurse practitioners and 52 were physician assistants.  Most of the nurse 
practitioners specialized in family or adult health and just two specialized in acute care.     
 
8  CONCLUSION
 
In 2016, one out of every three beneficiaries received a prescription opioid through Medicare 
Part D.  Half a million of them received high amounts of opioidsan average daily MED of  
120 mg for at least 3 months of the year.  Even more concerning, almost 90,000 beneficiaries are 
at serious risk of misuse or overdose.  These include beneficiaries who received extreme 
amounts of opioidsmore than two and a half times the level that CDC recommends avoiding
for the entire year.  They also include beneficiaries who appeared to be doctor shopping (i.e., 
received high amounts of opioids and had multiple prescribers and pharmacies).  Moreover, 401 
prescribers had questionable prescribing patterns for beneficiaries who are at serious risk.  These 
patterns are far outside the norm and warrant further scrutiny.   
Ensuring the appropriate use and prescribing of opioids is essential to protecting the health and 
safety of beneficiaries and the integrity of Part D.  The extreme use of opioids and apparent 
doctor shopping described in this study put beneficiaries at risk and may indicate that opioids are 
being prescribed for medically unnecessary purposes and then diverted for resale or recreational 
use.  It may also indicate that beneficiaries are receiving poorly coordinated care.   
Prescribers play a key role in combatting opioid misuse.  They must be given the information 
and tools needed to appropriately prescribe opioids when medically necessary.  States 
prescription drug monitoring programs can provide invaluable information to prescribers about a 
patients opioid prescription history.  Prescribers must be vigilant about checking the State 
monitoring databases to ensure that their patients are receiving appropriate doses of opioids and 
to better coordinate patient care.  At the same time, we must address prescribers with 
questionable prescribing patterns for opioids to ensure that Medicare Part D is not paying for 
unnecessary drugs that are being diverted for resale or recreational use.  
But focusing on prescribers alone is not enough.  A multifaceted approach is necessary.  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.23   
OIG is committed to fighting the opioid crisis and protecting beneficiaries from prescription drug 
abuse and misuse.  It has formed a multidisciplinary team dedicated to addressing this issue.  As 
a part of that effort, we will work with our law enforcement partners and CMS to follow up on 
the specific prescribers who we identified in this review.  We will also continue to conduct 
investigations and reviews that address the ongoing problems created by opioid misuse.  In 
addition to enforcement, we will identify other approaches to support prevention and treatment 
efforts.  We are also committed to conducting reviews to improve the efficiency and 
effectiveness of the broader Department efforts.   
In addition, we are committed to forging expanded partnerships among Federal agencies, States, 
and private sector partners.  We specifically call on Part D sponsors to work with OIG and CMS 
to further improve efforts to combat opioid misuse in Medicare.  These efforts include Part D 
sponsors program integrity activities to address prescription drug and pharmacy fraud.  We also 
9  specifically encourage Part D sponsors to effectively use CMSs Overutilization Monitoring 
System, which identifies beneficiaries who are potentially overutilizing opioids.  We further 
encourage sponsors to implement drug management programs for at-risk beneficiaries, following 
additional guidance from CMS.24  In addition, we continue to support our private and public 
sector partners as part of the Healthcare Fraud Prevention Partnership and our shared 
commitment to reducing the harms of opioids.25  By working together and expanding our efforts 
in Part D, we can help curb the opioid crisis in our Nation.   
   
   
10  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 received through Part D.  It does 
not include prescriptions received through other programs or through only paying cash.  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 Plan and Provider 
Enumeration System (NPPES), National Claims History File, and Part C Encounter Data file to 
obtain descriptive information about the drugs, prescribers, and beneficiaries.  First Databank 
contains information about each drug, such as the drug name, strength of the drug, therapeutic 
class (e.g., an opioid), and controlled substance schedule (e.g., Schedule II or III).  NPPES 
contains information about prescribers, such as their name, address, and taxonomy (i.e., 
specialty).  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 for beneficiaries 
enrolled in Medicare Advantage plans.  For the purposes of this study, we use the term 
prescription to mean one PDE record. 
Analysis of Opioid Utilization 
We identified PDE records for opioids that beneficiaries received in 2016.26  We calculated total 
Part D spending, the total number of beneficiaries, and the total number of prescriptions for all 
opioids and all Schedule II and III opioids.  To determine total spending, we summed four fields 
on the PDE records that represent the total gross drug costs: ingredient cost, dispensing fee, 
vaccine administration fee, and sales tax.  Next, using PDE data and Medicare enrollment data, 
we determined the proportion of Part D beneficiaries who received opioids in the Nation and in 
each State.  We then identified the most commonly prescribed opioids by calculating the total 
number of prescriptions for each generic drug name (delineated by strength and form).  Lastly, 
we counted the total number of days during the year that each beneficiary received opioids. 
Beneficiary Analysis 
Next, we determined the amount of opioids that each beneficiary received.  To do this, we 
calculated each beneficiarys average daily morphine equivalent dose (MED).27  The MED 
converts opioids of different ingredients, strengths, and forms into equivalent 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).28  To do this, we used the following equation: 
(strength per unit)(quantity dispensed)(MED conversion factor)
 MED =  
(Days supply)
 
11  We then 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 in 
2016.29     
Next, we determined the extent to which beneficiaries received high amounts of opioids.  
We calculated each beneficiarys average daily MED over each 90-day period in 2016.  
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 
current criteria used by CMS for its Overutilization Monitoring System.30  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.    
Lastly, 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 2016.  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.  
Prescriber Analysis  
For this analysis, we identified prescribers who ordered opioids for a high number of 
beneficiaries at serious risk: beneficiaries who received extreme amounts of opioids and 
beneficiaries who appeared to be doctor shopping.  We considered these prescribers to have 
questionable prescribing patterns that warrant further scrutiny. 
In total, 60,742 prescribers ordered opioids for beneficiaries who received extreme amounts and 
79,175 prescribers ordered opioids for beneficiaries who appeared to be doctor shopping.  For 
each of these prescribers, we calculated the number of beneficiaries in each group for whom  the 
prescriber ordered opioids.  We then identified the prescribers who ordered opioids for the 
highest number of beneficiaries in each group.31    
Lastly, we calculated the average number of prescriptions that each prescriber ordered for 
beneficiaries in each group.  We also calculated the average daily MED for beneficiaries for each 
prescriber for each group. 
Standards 
This study was conducted in accordance with the  Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
   
12   ACKNOWLEDGMENTS
 
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.  
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 Nadia Chait and Meghan Kearns.  We would also like to acknowledge 
the contributions of other Office of Inspector General staff, including Robert Gibbons,  
Lauren McNulty, and Jessica Swanstrom. 
   
13  ENDNOTES
 
 
1 CDC, Increases in Drug and Opioid-Involved Overdose Deaths: United States, 20102015.  MMWR Morb 
Mortal Wkly Rep, December 30, 2016, pp. 144552.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm on May 4, 2017. 
2 OIG, High Part D Spending on Opioids and Substantial Growth in Compounded Drugs Raise Concerns, OEI-02-
16-00290, June 2016.  Also see OIG, Questionable Billing and Geographic Hotspots Point to Potential Fraud and 
Abuse in Medicare Part D, OEI-02-15-00190, June 2015. 
3 Maxwell, Ann, Assistant Inspector General for Evaluations and Inspections, Office of Inspector General, U.S. 
Department of Health and Human Services, Opioid Use Among Seniors: Issues and Emerging Trends 
(Congressional testimony), February 24, 2016.  Also see Cantrell, Gary, Deputy Inspector General for 
Investigations, Office of Inspector General, U.S. Department of Health and Human Services, Fraud in Medicare 
(Congressional testimony), March 24, 2015.    
4 Chau, Diane L. et al. Opiates and Elderly: Use and Side Effects. Clinical Interventions in Aging, 2008, p. 276. 
Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/ on April 17, 2017.  Also see CDC, CDC 
Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. MMWR Recomm Rep, March 18, 2016.   
5 Saunders, Kathleen W. et al. Relationship of Opioid Use and Dosage Levels to Fractures in Older Chronic Pain 
Patients. Journal of General Internal Medicine, 2010, pp. 31015. Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842546/ on April 17, 2017. 
6 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. MMWR Recomm Rep, 
March 18, 2016, pp. 149.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on May 4, 2017. 
7 Ibid, p. 16.  The CDC guidelines recommend that prescribers avoid increasing opioids to morphine equivalent 
dosages of 90 mg a day or more or carefully justify the decision to increase to this level.   
8 CMS identifies beneficiaries who are at high risk for opioid overutilization.  On a quarterly basis, CMS provides 
each Part D sponsor with a list of these beneficiaries through its Overutilization Monitoring System.  For more 
information about CMSs complete efforts to address opioids misuse, see CMS, CMS Opioid Misuse Strategy 2016.  
Accessed at https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/CMS-Opioid-Misuse-
Strategy-2016.pdf on April 20, 2017.   
9 OIG, Ensuring the Integrity of Medicare Part D, OEI-03-15-00180, June 2015.  Also see OIG, High Part D 
Spending on Opioids and Substantial Growth in Compounded Drugs Raise Concerns, OEI-02-16-00290, June 2016. 
10 Controlled substances are drugs regulated by the Controlled Substances Act, which established five schedules 
based on the medical use and the potential for abuse.  Schedule I drugs, such as heroin, have no currently accepted 
medical use.  Schedule II drugs, such as oxycodone, hydrocodone, and fentanyl, have a high potential for abuse and 
may lead to severe psychological or physical dependence.  Schedule V have the lowest potential for abuse among 
controlled substances. See 21 U.S.C.  812.  In total, Part D paid $3.9 billion for Schedule II and III opioids in 2016. 
11 Although tramadol is a Schedule IV drug, which means it has low potential for abuse and low risk of dependence, 
recent research raised concern about a link between tramadol and long-term use of opioids.  The research found that 
initial treatment with tramadol increases the probability of long-term use.  In addition, the Substance Abuse and 
Mental Health Services Administration reports that emergency department visits associated with tramadol increased 
145 percent from 2005 to 2011.  See CDC, Characteristics of Initial Prescription Episodes and Likelihood of Long-
Term Opioid Use: United States, 20062015.  MMWR Morb Mortal Wkly Rep, March 17, 2017, pp. 265-69. 
Accessed at https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm  on May 4, 2017. 
12 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. MMWR Recomm Rep, 
March 18, 2016, p. 25. 
13 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 page 2 at 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/040330s015,040341s013,040434s003lbl.pdf and for 
Vicodin see page 20 at http://www.rxabbvie.com/pdf/vicodin_apap_300mg_hydrocodone_5mg-7_5mg-
10mg_PI.pdf. 
14 In addition, CMS uses a daily MED of 120 mg for 90 daysas well as beneficiaries having four or more 
prescribers and four or more pharmaciesto identify beneficiaries who are potentially overutilizing opioids for its 
14   
Overutilization Monitoring System.  Beginning in 2018, CMS is changing its criteria to an average daily MED of 90 
mg plus four or more prescribers and four or more pharmacies or six or more prescribers, regardless of the number 
of pharmacies.  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.  Accessed at 
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2018.pdf on 
April 25, 2017.  Note that the guidance uses the term more than 3 prescribers and more than 3 pharmacies, which 
is which equivalent to 4 or more prescribers and 4 or more pharmacies. 
15 U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information 
System: Year 2015 Annual Report, 2016.  Accessed at 
https://www.deadiversion.usdoj.gov/nflis/2015_annual_rpt.pdf on April 24, 2017. 
16 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016.  MMWR Recomm Rep, 
March 18, 2016, p. 23.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on May 4, 2017. 
17 Ibid, p. 13, 44. 
18 This does not include beneficiaries who had cancer or were in hospice care. 
19 Ibid, p. 10.   
20 As mentioned above, CMS uses a daily MED of 120 mg for 90 daysin addition to beneficiaries having four or 
more prescribers and four or more pharmaciesto identify beneficiaries who are potentially overutilizing opioids 
for its Overutilization Monitoring System.  
21 Specifically, 58 percent of beneficiaries who received opioids have one prescriber and 78 percent have one 
pharmacy.  This does not include beneficiaries who had cancer or hospice care. 
22  State requirements for checking this information vary.  For more information about these programs, see 
Prescription Drug Monitoring Program Training and Technical Assistance Center, Tracking PDMP Enhancement: 
The Best Practice Checklist, 2017.  Accessed at 
http://www.pdmpassist.org/pdf/2016_Best_Practice_Checklist_Report_20170228.pdf on April 26, 2017.  Also see 
PEW, Prescription Drug Monitoring Programs: Evidence-based practices to optimize prescriber use, 2016. 
Accessed at http://www.pewtrusts.org/~/media/assets/2016/12/prescription_drug_monitoring_programs.pdf on April 
21, 2017. 
23 Price, Tom, Secretary, U.S. Department of Health and Human Services, Secretary Price Announces HHS 
Strategy for Fighting Opioid Crisis.  Speech to the National Rx Drug Abuse and Heroin Summit, April 19, 2017.  
Accessed at https://www.hhs.gov/about/leadership/secretary/speeches/2017-speeches/secretary-price-announces-
hhs-strategy-for-fighting-opioid-crisis/index.html on May 3, 2017. 
24 The Comprehensive Addiction Recovery Act of 2016 allows Part D sponsors to establish drug management 
programs for beneficiaries who are at risk for prescription drug abuse.  Under these programs, sponsors may limit at-
risk beneficiaries coverage of frequently abused drugs to one or more selected prescribers and one or more selected 
pharmacies.  Comprehensive Addiction and Recovery Act of 2016, Pub. L. No. 114-198,  704 (July 22, 2016).  
25 Healthcare Fraud Prevention Partnership, Health Payer Strategies to Reduce the Harms of Opioids, January 2017. 
Accessed at https://downloads.cms.gov/files/hfpp/hfpp-opioid-white-paper.pdf on March 7, 2017. 
26 Using CMSs Integrated Data Repository, we identified a total of 79,425,530 PDE records for opioids with dates 
of service in 2016.   
27 To calculate MED, we used CDCs Morphine Milligram Equivalent (MME) file, which is available at 
https://www.cdc.gov/drugoverdose/media/index.html.  It contains MED conversion factors for each National Drug 
Code.  MED and MME are interchangeable terms.  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 June 26, 2017. 
28 We included PDE records dispensed in 2015 with days of use in 2016.  We excluded PDE records for injection, 
intravenous, and intrathecal opioids from this analysis. 
29 We identified beneficiaries with a cancer diagnosis or hospice stay using CMSs National Claims History File and 
Part C Encounter data.  In total, we identified 2,658,350 beneficiaries with cancer or hospice who received at least 
one opioid.  
30 As stated above, CMS currently uses a daily MED of 120 mg for 90 daysin addition to beneficiaries having four 
or more prescribers and four or more pharmaciesto identify beneficiaries who are potentially overutilizing opioids 
for its Overutilization Monitoring System. 
15   
31 Each of these prescribers is an extreme outlier in terms of the number of beneficiaries to whom they prescribed 
opioids in one of the groups at serious risk.  These prescribers were more than 3 standard deviations above the mean 
and in the top 0.3 percent. 
  
 
16