Data Brief    July 2018    OEI-05-18-00010 
 
Opioids in Ohio Medicaid: Review of Extreme 
Use and Prescribing 
The opioid crisis has been declared a public health emergency.1  In 2016, 
Key Takeaways 
more than 42,000 opioid-related overdose deaths occurred in the United 
  Nearly 5,000 beneficiaries 
States115 deaths per day.2  Identifying patients who are at risk of 
received high amounts of 
overdose or abuse is key to addressing this national crisis.   
opioids and did not have 
cancer or receive hospice 
Medicaid beneficiaries may be especially vulnerable to opioid misuse 
care. 
because they are more likely than nonbeneficiaries to have chronic 
 
conditions and comorbidities that require pain relief, especially those who 
  Among those receiving 
qualify because of a disability.  In 2016, Medicaid covered nearly 
high amounts, more than 
4 in 10 nonelderly adults with opioid addiction.3  
700 beneficiaries are at 
serious risk of 
Opioids include narcotics intended to manage pain from surgery, injury, or 
prescription opioid 
illness.  They can create a euphoric effect, which makes beneficiaries 
misuse or overdose; 
vulnerable to opioid abuse and misuse (i.e., taking opioids in a way other 
some received extreme 
amounts of opioids, while  than prescribed).  Although opioids can be appropriate under certain 
others appeared to be  circumstances, the Office of Inspector General (OIG) and others are 
doctor shopping.  concerned about fraud, abuse, and misuse of opioids obtained through 
  Medicaid and the Childrens Health Insurance Program (CHIP), including 
  Nearly 50 prescribers 
drug diversionthe redirection of prescription drugs for an illegal purpose, 
stood out by prescribing 
such as recreational use or resale.   
to more beneficiaries at 
serious risk than others  In addition to the risk of abuse and misuse, opioids carry a number of 
who prescribed opioids  health risks.  Side effects from using opioids may include respiratory 
to such beneficiaries. 
depression, confusion, tolerance to lower doses, and physical 
 
dependence.4, 5  Prescription opioid abuse can also lead to the use of illegal 
  Ohio has taken a number 
drugs such as heroin.6  For these reasons, it is essential that Medicaid and 
of steps to address the 
CHIP beneficiaries receive only medically necessary opioids in the 
opioid crisis and has 
appropriate amounts.   
reduced opioid use 
among its residents.  Our 
Prescribers play a crucial role in ensuring that beneficiaries receive 
results underscore the 
appropriate amounts of opioids.  To help inform prescribers, the Centers for 
tenacity of the opioid 
Disease Control and Prevention (CDC) published a guideline on prescribing 
crisis and the importance 
of Ohios ongoing  opioids to patients with chronic pain.7  The guideline recommends that 
commitment to  prescribers use caution when ordering opioids at any dosage and avoid 
addressing it.    increasing to dosages that are equivalent to 90 mg or more of morphine a   
day for chronic pain.8  In addition, because long-term opioid use often 
begins with the treatment of acute pain, the guideline recommends that 
prescribers order opioids for the lowest effective dose and duration.  The 
Centers for Medicare & Medicaid Services (CMS) has also initiated projects 
to address opioid misuse and inappropriate prescribing, including providing 
educational materials for States and prescribers.9, 10, 11     
States also play an important role in ensuring that beneficiaries receive 
appropriate amounts of opioids.  Ohio has a number of collaborative efforts 
underway to help address its opioid crisis that involve local and State 
partners, including law enforcement personnel, public health officials, 
addiction and treatment specialists, health care providers, educators, and 
parents.  Key initiatives include (1) educational initiatives designed to 
prevent drug use; (2) opioid prescribing guidelines and laws developed to 
address proper pain management practices; (3) prescription monitoring 
requirements via the States prescription drug monitoring program 
(PDMP);12 (4) a lock-in program that limits where certain beneficiaries can fill 
their prescriptions; (5) data analytics designed to identify fraudulent 
prescribers for administrative or legal actions; and (6) Ohios Pill Mill law, 
which helps to close illegal pain clinics.13  For more information about Ohios 
opioid initiatives, see Appendix A.  
This data brief is part of a larger OIG effort to fight the opioid crisis.  OIGs 
previous work highlighted beneficiaries who were at serious risk of opioid 
misuse or overdose and opioid prescribers who stood out when compared 
to their peers in Medicare Part D.14  Additionally, OIG is currently assessing 
multiple prevention and treatment efforts underway at State and national 
levels.15  OIG also released a toolkit that provides detailed steps for using 
prescription drug data to analyze patients opioid levels and identify 
patients who are at risk of opioid misuse or overdose.16 
This data brief extends previous Medicare Part D work to Medicaid claims in 
Ohio to identify beneficiaries at serious risk of opioid misuse or overdose 
and prescribers who ordered opioids for these beneficiaries at higher rates 
than their peers.  We selected Ohio to examine as the first State in a series 
of State Medicaid studies focusing on opioid use in the Medicaid program.  
Ohio is among the States most severely impacted by the opioid crisis, with 
nearly 3,500 overdose deaths in 2016.17, 18   
 
 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  2 
OEI-05-18-00010   
RESULTS 
One in six Ohio  Between June 2016 and May 2017, nearly one in six beneficiaries in Ohio 
received at least one opioid through Medicaid.  Sixteen percent of 
Medicaid 
beneficiaries539,810 of the nearly 3.5 million enrolled in Ohio Medicaid
beneficiaries  received opioids.19  This figure represents all opioid use among Medicaid 
beneficiaries in Ohio, regardless of the reason the opioids were prescribed 
received opioids 
or the amount that was prescribed.  It includes 21,146 beneficiaries who had 
between June 2016 
cancer or were in hospice care during our study period.  The number of 
and May 2017  beneficiaries receiving opioids and the amounts they received may be 
higher than reported in this data brief because this review analyzes only 
those opioids paid for by Ohio Medicaid.  Medicaid beneficiaries may opt to 
purchase opioids outside of the Medicaid benefit by paying cash.    
Notably, approximately 40,500 of the beneficiaries who received at least 
one opioid were children ages 18 and younger.20  Of these, 385 had cancer 
or were in hospice care during our study 
Exhibit 1: Hydrocodone-
period.  Most of the remaining children 
acetaminophen, 
who did not have cancer or were not in 
oxycodone-acetaminophen, 
hospice care received just 1 opioid 
and tramadol were the most 
prescription, although just over 6,600 
commonly prescribed 
received 2 or more prescriptions.  The 
opioids. 
opioid most commonly prescribed to 
children was hydrocodone-acetaminophen 
(brand name Vicodin).  Research shows 
that even using prescription opioids for 
legitimate purposes before high school 
graduation is associated with increased risk 
of future opioid misuse.21   
The majority of opioids prescribed to Ohio 
Medicaid beneficiaries (82 percent) were 
Schedule II or III controlled substances, 
meaning they have the highest potential 
for abuse among legally available drugs.22  
Schedule I drugs have the highest 
potential for abuse and Schedule V drugs 
have the lowest potential for abuse.  The 
most commonly prescribed opioids were 
hydrocodone-acetaminophen (including 
the brand-name version, Vicodin), 
oxycodone-acetaminophen (including the 
brand-name version, Percocet), and 
tramadol.23  See Exhibit 1 for the total  Source: OIG analysis of Ohio Medicaid 
data, 2018. 
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OEI-05-18-00010   
number of prescriptions written for each commonly prescribed opioid.  
The proportion of beneficiaries who received opioids during our study 
period varied across counties.  Seven counties in OhioAdams, Clark, 
Clinton, Jefferson, Madison, Meigs, and Miamihad the highest proportions 
of Medicaid beneficiaries who received opioids.  Adams County had the 
highest percentage of Medicaid beneficiaries who received opioids
20 percent.  In the remaining six counties, 19 percent of the Medicaid 
population received opioids.  See Exhibit 2 for additional details. 
Exhibit 2: Seven counties in Ohio had the highest proportions of 
Medicaid beneficiaries who received prescription opioids of any 
strength. 
Source: OIG analysis of Ohio Medicaid data, 2018. 
  
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Nearly 91,000 Ohio Medicaid beneficiaries received opioids on a regular 
basis.  These beneficiaries received opioids for three or more months during 
our study period.  Opioids may have been necessary for many of these 
beneficiaries, but for others these opioids may have been inappropriately 
prescribed or used. 
Ohio has implemented multiple initiatives to help ensure appropriate opioid 
use among its residents, including Medicaid beneficiaries, and reports that 
opioid prescribing has declined.  Ohios initiatives include education 
campaigns to prevent opioid abuse, requirements for prescribers and 
pharmacies to routinely check the States PDMP when prescribing or 
dispensing opioids, and licensure of pain management clinics to reduce pill 
mills.  Ohio also issued guidelines that recommend that providers reassess 
opioid prescriptions for beneficiaries who receive opioids for 12 or more 
weeks.  Between 2012 and 2017, the total number of opioids dispensed in 
Ohio decreased by 28 percent.24  See Appendix A for more details on Ohios 
initiatives.  
 
Nearly 5,000 Ohio  Between June 2016 and May 2017, 4,754 Medicaid beneficiaries received 
high amounts of opioids.  This did not include beneficiaries who had cancer 
Medicaid 
or were in hospice care during our study period and does not include 
beneficiaries 
prescriptions used for medication-assisted treatment (MAT) of opioid use 
received high  disorder.   
amounts of opioids  
Each of the 4,754 Medicaid beneficiaries received high amounts of opioids, 
meaning an average morphine equivalent dose (MED) of more than 120 mg 
daily 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 16 tablets a day of Percocet 5 mg.  This dosage exceeds 
the amount that the manufacturer recommends.25  It also exceeds Ohio and 
CDC guidelines, which recommend caution or avoidance of dosages 
beyond daily MEDs of 80 mg and 90 mg, respectively.26, 27   
Beneficiaries who received high amounts of opioids were primarily between 
the ages of 45 and 64, and primarily female.  Fewer than 10 beneficiaries 
between the ages of 11 and 17 received high amounts.  For more 
information about beneficiaries who received high amounts, see 
Appendix B. 
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OEI-05-18-00010   
The most commonly prescribed  Exhibit 3: Oxycodone, 
opioid for beneficiaries with high  oxycodone-acetaminophen, and 
amounts was oxycodone 30 mg, with  methadone were the most 
one in four beneficiaries having at  commonly prescribed opioids to 
least one prescription for this drug.   beneficiaries with high amounts. 
Oxycodone is among the 
prescription opioids most commonly 
involved in law enforcement cases.28  
See Exhibit 3 for the total number of 
prescriptions written for commonly 
prescribed opioids. 
Although beneficiaries may receive 
opioids for legitimate purposes such 
as chronic pain management, these 
high amounts raise concern.  Opioids 
carry health risks, including 
respiratory depression, constipation, 
drowsiness, and confusion.  These 
beneficiaries may also be at an 
increased risk for prescription opioid 
misuse, which may lead to heroin 
use.29  
Recognizing the risks of prolonged 
use of high amounts of opioids, Ohio 
Source: OIG analysis of Ohio Medicaid data, 2018. 
has taken steps to reduce 
Note: The methadone prescriptions included in 
overutilization.  According to Ohio, 
this exhibit were not prescribed for use in MAT. 
the number of patients receiving a 
daily MED of more than 80 mg decreased by nearly 11 percent after the 
State recommended staying below that threshold.30  Also according to 
Ohio, prescribers checked its PDMP nearly 89 million times in 2017, which 
represents an increase from 24 million in 2016.31  However, the fact that 
some Medicaid beneficiaries continued to receive high amounts of opioids 
despite these protections suggest that some prescribers may not always 
adhere to these policies.  
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OEI-05-18-00010   
More than 700 Ohio  Ohio has taken numerous steps to address its opioid crisis, but two groups 
of beneficiaries that remain at serious risk of opioid misuse or overdose are 
Medicaid 
the focus of this review: (1) beneficiaries 
beneficiaries are at  Beneficiaries at serious risk of 
who received extreme amounts of 
serious risk of  opioids and (2) beneficiaries who  opioid misuse or overdose 
include: 
prescription opioid  appeared to be doctor shopping.  
There may be other Medicaid 
misuse or overdose  1.  Beneficiaries who received 
beneficiaries who are also at serious 
extreme amounts of 
 
risk of opioid misuse or overdose but 
opioidsi.e., an average 
do not meet these criteria. 
daily MED greater than 
240 mg for 12 months. 
In total, 708 beneficiaries were at 
serious risk of opioid misuse or  2.  Beneficiaries who appeared 
overdose from June 2016 to  to be doctor shoppingi.e., 
May 2017.32  Specifically,  received a high amount of 
481 beneficiaries received extreme  opioids (an average daily 
amounts of opioids, and  MED of greater than 120 mg 
231 beneficiaries appeared to be doctor  for 3 months) and had four 
shopping (i.e., received high amounts  or more prescribers and had 
of opioids from multiple prescribers  four or more pharmacies.  
and pharmacies).  Four beneficiaries 
were in both groups.   
Beneficiaries who were at serious risk of opioid misuse or overdose were 
primarily between the ages of 45 and 64 and nearly evenly divided between 
male and female.  For more information about beneficiaries who were at 
serious risk, see Appendix B. 
Although beneficiaries at serious risk may have legitimate reasons for 
receiving opioids, their dosage and usage patterns raise concerns and 
warrant further scrutiny.  These beneficiaries may be receiving poorly 
coordinated care.  They also may be seeking medically unnecessary drugs 
to sell or use recreationally.  Alternatively, these beneficiaries identification 
numbers may have been stolen or sold.   
Almost 500 beneficiaries received extreme amounts of opioids 
In total, 481 beneficiaries received extreme amounts of opioids for our entire 
study period, putting them at serious risk of opioid misuse or overdose.  
Each of these beneficiaries had an average daily MED that exceeded 240 mg 
for the entire study period.  This extreme amount is more than two and a 
half times the dose CDC recommends that chronic pain patients avoid.  
Research has shown that patients who receive an MED at such a level are at 
increased risk of overdose death.33 
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Twelve beneficiaries received even more extreme amounts of opioids.  
These beneficiaries each received an average daily MED greater than 
900 mg for the entire study period.   
Examples of Beneficiaries Receiving Extreme Amounts of Opioids 
A beneficiary received 59 prescriptions during the study periodall 
ordered from one internal medicine physician and filled at 
one pharmacy.  In total, the beneficiary had an average daily MED of 
1,147 mg, which is more than 12 times the level that CDC recommends 
avoiding. 
Another beneficiary received 46 prescriptions from 3 prescribers and 
1 pharmacy during our study period.  This beneficiarys prescriptions 
included prescriptions for long-acting oxycodone and short-acting 
oxycodone.  In total, the beneficiary had an average daily MED of 
1,080 mg for the study period, which is 12 times the level that CDC 
recommends avoiding. 
About 230 beneficiaries appeared to be doctor shopping 
A second group of beneficiariesthose who appeared to be doctor 
shopping (i.e., received high amounts of opioids from multiple prescribers 
and pharmacies)are also at serious risk of opioid misuse or overdose.   
Doctor shoppers are beneficiaries who seek prescriptions from multiple 
prescribers and multiple pharmacies.  In total, 231 beneficiaries appeared to 
be doctor shopping.  Each of these beneficiaries received a high amount of 
opioidsan average daily MED that exceeded 120 mg over at least 
3 monthsand had four or more prescribers and four or more pharmacies 
in our study period.  It is uncommon for a beneficiary to have multiple 
prescribers or pharmacies.  Most beneficiaries who received opioids in our 
study period had just one prescriber (59 percent) and one pharmacy 
(74 percent).34   
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Notably, several beneficiaries had particularly high numbers of prescribers 
and pharmacies during our study period.  Eleven beneficiaries had 15 or 
more prescribers or 10 or more pharmacies.   
Examples of Beneficiaries Who Appear To Be Doctor Shopping 
A beneficiary received 41 opioid prescriptions from 16 prescribers and 
filled them at 8 pharmacies during our study period.  This beneficiary 
received four opioidsoxycodone, hydrocodone, fentanyl, and 
tramadol.  In total, the beneficiary had an average daily MED of 196 mg. 
Another beneficiary received 22 opioid prescriptions from 15 prescribers 
and filled them at 10 pharmacies during our study period.  This 
beneficiary traveled more than 70 miles for oxycodone prescriptions 
from three different prescribers.  Six of this beneficiarys prescriptions 
were from a prescriber more than 145 miles away.   
 
Ohio has taken steps to help identify and stop doctor shopping.  For 
example, Ohio requires pharmacists to check a beneficiarys prescription 
history in the PDMP if they believe the beneficiary may be doctor shopping.  
Medicaid beneficiaries suspected of doctor shopping can be assigned to a 
lock-in program that requires them to fill all prescriptions at a preassigned 
pharmacy.  According to Ohio, from 2012 to 2016, the number of patients 
who appeared to be doctor shopping fell by 78 percent.35  Despite Ohios 
efforts, some beneficiaries still appeared to be doctor shopping, suggesting 
that they may not have been identified by pharmacists or targeted for 
inclusion in Ohios lock-in program. 
 
Nearly  In total, 1,646 prescribers ordered opioids for at least one beneficiary at 
serious risk of opioid misuse or overdose during our study period.  A vast 
50 prescribers stood 
majority of these prescribers81 percentordered opioids for just 
out by ordering 
one beneficiary.  
opioids for more 
Forty-seven of the prescribers who ordered opioids for beneficiaries at 
beneficiaries at 
serious risk of opioid misuse or overdose stand out as ordering opioids for 
serious risk than  more beneficiaries at serious risk than other prescribers in Ohio.  More than 
their peers  one-third of these prescribers are located in just two counties in Ohio: 
Franklin and Cuyahoga, which include Columbus and Cleveland, 
respectively.  Slightly more than half of these prescribers were physicians.  
For information about these prescribers specialties, see Appendix C.   
These 47 prescribers were outliers when compared to their peers who also 
ordered opioids for beneficiaries at serious risk.  These 47 prescribers 
ordered opioids for the greatest number of beneficiaries at serious risk.  
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OEI-05-18-00010   
Specifically, 26 prescribers ordered opioids for at least 5 beneficiaries who 
received extreme amounts, and 26 prescribers ordered opioids for at least 
4 beneficiaries who appeared to be doctor shopping.  These prescribers 
ordered opioids for an average of nine beneficiaries who received extreme 
amounts and six beneficiaries who appeared to be doctor shopping.  
Five prescribers ordered opioids for high numbers from both groups of 
beneficiaries at serious risk.  In total, prescribers that stood out wrote 
5,584 opioid prescriptions for beneficiaries at serious risk. 
Although prescribers may order opioids for legitimate reasons, those who 
stand out compared to their peers raise concerns and warrant further 
scrutiny.  These prescribers may be providing poorly coordinated care to 
Medicaid beneficiaries.  They may also be ordering medically unnecessary 
drugs, which could be sold or used recreationally.  Alternatively, the 
prescribers identification may have been sold or stolen and used for illegal 
purposes.   
Recognizing the role that prescribers play in ensuring that Ohio Medicaid 
beneficiaries do not receive dangerous amounts of opioids, Ohio has taken 
steps to reduce improper prescriptions.  Ohio expects prescribers to follow 
its opioid prescription guidelines and to check its PDMP at the required 
intervals.  To promote use of its PDMP, Ohio has worked to integrate the 
PDMP into electronic health record systems and pharmacy dispensing 
systems used across the State.  The 47 prescribers associated with 
beneficiaries at serious risk that stand out compared to their peers may not 
have followed all of Ohios guidelines and regulations.  
Ohio has reported taking action against prescribers that do not 
appropriately prescribe opioids.  From 2011 to 2017, the State Medical Board 
of Ohio took disciplinary actions against 273 prescribers for improper 
prescribing of prescription drugs, including opioids.36  From 2015 to 2016, 
inappropriate opioid prescribing remained one of the top reasons the Board 
took action on a prescribers license.37  
Nearly 30 prescribers each ordered opioids for numerous 
beneficiaries who received extreme amounts of opioids 
There were 26 prescribers that stand out compared to their peers because 
they ordered opioids for more beneficiaries who received extreme amounts.  
These prescribers ordered opioids for 5 to 18 beneficiaries who received 
extreme amounts of opioids.  These beneficiaries received an average daily 
MED of more than 240 mg for the entire study period and are at serious risk 
for opioid misuse or overdose.  See Appendix D for further information 
about these prescribers.   
Among these 26 prescribers, 5 stand out.  These prescribers ordered 
opioids for 12 or more beneficiaries with extreme amounts.  These 
prescribers include three nurse practitioners who specialize in family 
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practice, one internal medicine physician who specializes in hematology and 
oncology, and one physician who specializes in psychiatry and neurology.   
Examples of Prescribers Who Prescribed to Beneficiaries With 
Extreme Amounts 
A nurse practitioner ordered opioids for 18 beneficiaries who received 
extreme amounts during our study period.  For one of these 
beneficiaries, the nurse practitioner ordered 26 prescriptionsall of 
which were 30 days supply of either long-acting or short-acting 
oxycodone.  This beneficiary had an average daily MED of 265 mg, 
nearly three times the level that CDC recommends avoiding.  In total, 
this nurse practitioner ordered 260 prescriptions for beneficiaries who 
received extreme amounts of opioids. 
A physician specializing in psychiatry and neurology ordered opioids for 
12 beneficiaries who received extreme amounts during our study period.  
For one of these beneficiaries, the physician ordered 52 prescriptions, 
including 27 30-day prescriptions for oxycodone hydrochloride and 
25 15-day prescriptions for tramadol hydrochloride.  For another 
beneficiary, the physician ordered 39 prescriptions for oxycodone 
hydrochloride, tramadol hydrochloride, and fentanyl patches.  In total, 
this physician ordered 352 prescriptions for beneficiaries who received 
extreme amounts of opioids. 
 
Nearly 30 prescribers each ordered opioids for several beneficiaries 
who appeared to be doctor shopping 
There were 26 prescribers that stand out compared to their peers because 
they ordered opioids for more beneficiaries who appeared to be doctor 
shopping.  These prescribers ordered opioids for 4 to 11 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.  Like beneficiaries who receive extreme amounts, beneficiaries 
who appeared to be doctor shopping are at serious risk of opioid misuse or 
overdose.  See Appendix D for further information about these prescribers.   
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Among these 26 prescribers, two stand out.  These prescribers ordered 
opioids for 10 or more beneficiaries who exhibited doctor-shopping 
behavior.  These prescribers include a physician who specializes in 
interventional pain management and a physician assistant.   
Examples of Prescribers Who Prescribed to Beneficiaries Who 
Appeared To Be Doctor Shopping 
A pain management physician ordered opioids for 11 beneficiaries who 
appeared to be doctor shopping.  Nearly two-thirds of these 
prescriptions were for oxycodone.  In total, this physician ordered 
120 prescriptions for beneficiaries who appeared to be doctor shopping. 
Additionally, this physician shared a beneficiary with a clinical nurse 
specialist who ordered opioids for a high number of beneficiaries who 
appeared to be doctor shopping.  They ordered a combined 
21 prescriptions for this beneficiary, including 5 oxycodone and 
oxymorphone prescriptions in just 1 month. 
   
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CONCLUSION 
Ohio has taken multiple steps to address its opioid crisis and reports that its 
efforts have resulted in successes.  For example, Ohio has developed opioid 
prescribing guidelines and requires that prescribers and pharmacists 
routinely check its PDMP.  Ohios prescription opioid overdose death rate 
has fallen in recent years.   
However, despite these efforts, nearly 3,500 people died of opioid 
overdoses in Ohio in 2016, including 564 who died from prescription opioid 
overdoses.  In addition, we found that some Medicaid beneficiaries and 
prescribers have opioid use or prescribing patterns that may warrant further 
scrutiny.  We found that 708 Medicaid beneficiaries are at serious risk of 
opioid misuse or overdose, and we identified 47 prescribers associated with 
these beneficiaries who stood out compared to their peers.   
We also identified children who may be at increased risk for future opioid 
misuse.  Just over 40,000 children who did not have cancer and were not in 
hospice care received at least one opioid prescription during our study 
period.  Although we found that very few children were receiving high 
amounts of opioids, any opioids for children are concerning because 
research shows that even opioids used for legitimate purposes before high 
school graduationsuch as an opioid prescribed by a dentist after 
extracting a wisdom toothare associated with increased risk of future 
opioid misuse.38   
Our results suggest that some prescribers and pharmacies may not be 
following Ohios opioid prescribing policies, potentially putting Medicaid 
beneficiaries at risk.  For example, some prescribers may not be screening 
beneficiaries for substance abuse issues as frequently as suggested in Ohios 
prescribing guidelines for patients with chronic pain, resulting in 
beneficiaries with undetected problems.  Additionally, some prescribers and 
pharmacists may not be checking the PDMP as frequently as required, 
resulting in beneficiaries being able to obtain dangerously high amounts of 
opioids from several prescribers or pharmacies.    
Our results also underscore both the tenacity of the opioid crisis and the 
importance of Ohios ongoing commitment to addressing it.  Ohio 
continues to explore new strategies to protect Ohio residents from opioid 
misuse.  Subsequent to our study period, Ohio further strengthened its 
prescribing controls by limiting the length of acute care opioid prescriptions 
to 7 days for adults and 5 days for minors.  Ohio has also mandated that by 
July 2018 Medicaid managed care beneficiaries who meet certain criteria be 
enrolled in its lock-in program.  We encourage Ohio to continue to explore 
new strategies to address its opioid crisis and look for ways to improve 
existing strategies.  For example, Ohio could consider providing targeted 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  13 
OEI-05-18-00010   
education to prescribers who prescribe opioids to children with the goal of 
reducing the number of children who receive any opioid prescriptions.  
Additionally, Ohio could further evaluate whether additional actions are 
needed for this vulnerable group.   
OIG is also working to increase its efforts to fight the opioid crisis.  We are 
working with our law enforcement partners and with the Ohio Department 
of Medicaid to follow up on identified prescribers.  We are also working in 
new ways to conduct investigations and reviews that address the ongoing 
problems of opioid misuse.  This includes working closely with the Ohio 
Medicaid Fraud Control Unit and the Department of Justices new Opioid 
Fraud and Abuse Detection Units.  In addition to enforcement, we continue 
to identify other approaches to support prevention and treatment efforts 
and to improve the effectiveness of the broader Department efforts.  For 
example, we will conduct additional analyses of opioid use and payment for 
treatment in other State Medicaid programs.39  We are also in the process 
of assessing oversight of strategies designed to address prescription opioid 
abuse, including State PDMP programs, as well as access to and oversight of 
opioid use disorder treatment, including buprenorphine.40 
OIG is also committed to continuing to forge relationships with States and 
with private sector partners to address this crisis.  OIG continues to support 
our State and private sector partners through the Healthcare Fraud 
Prevention Partnership and our shared commitment to reducing the harms 
of opioids.41 
 
  
 
 
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METHODOLOGY 
We based this data brief on an analysis of Ohios Transformed Medicaid 
Statistical Information System (T-MSIS) prescription drug records.  This data 
brief includes prescriptions that beneficiaries received through Medicaid.  It 
does not include prescriptions paid through other programs or those paid 
in cash.42  It also does not include prescriptions for medication-assisted 
treatment of opioid use disorders, such as buprenorphine, naltrexone, and 
methadone.43  Pharmacists submit prescription drug records to the State, or 
a States Medicaid managed care organization, for every drug dispensed to 
a beneficiary enrolled in Medicaid.  Medicaid managed care organizations 
submit records to the State.  Each record contains information about the 
drug and the beneficiary as well as the identification numbers for the 
pharmacy and the prescriber.   
We matched T-MSIS prescription records to CDCs morphine milligram 
equivalent (MME) conversion file and other T-MSIS files to obtain 
descriptive information about drugs, prescribers, and beneficiaries.  CDCs 
MME conversion file 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) as well as information 
about each opioids drug morphine milligram equivalence.44  In addition to 
prescription records, T-MSIS includes provider, eligibility, and claims files.  
Provider and eligibility files contain information about prescribers and 
beneficiaries, such as their names, addresses, provider specialties, and 
eligibility categories (e.g., the various ways in which individuals can be 
eligible for Medicaid).  Claims files contain data, including diagnosis codes, 
from inpatient hospital, long-term care, and other types of health care 
episodes.  For the purposes of this study, we use the term prescription to 
mean one T-MSIS prescription record. 
Testing Quality of T-MSIS Data 
T-MSIS is a new data source, and OIG has previously identified concerns 
about its quality.  Before using Ohios T-MSIS data, we assessed the quality 
by reviewing whether required variables were populated, whether variables 
that were populated met format standards, and that a sample of data 
matched Ohios source data.  On the basis of the results of our quality 
checking, we determined that Ohios T-MSIS data were of sufficient quality 
to use for our analysis.  Our quality checking did not evaluate the accuracy 
of information submitted to Ohio by Medicaid providers and managed care 
plans.   
T-MSIS files contained the claims data necessary for our analysis for most 
beneficiaries in our review.  However, in some cases we identified missing 
elements in Ohios T-MSIS data.  As a result, we had to remove a small 
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OEI-05-18-00010   
number of claims for some beneficiaries that were missing information 
needed for one part of our analysis.  Excluded claims did not change the 
outcome of our analysis for most beneficiaries.  For some of the remaining 
beneficiaries, the excluded claims may have caused us to under-represent 
beneficiaries at serious risk or providers who stood out compared to their 
peers.  Specifically, we excluded a portion of claims from our doctor-
shopping analysis that were missing prescriber or dispenser identification.  
The excluded claims would not have changed our results in the vast majority 
of cases, but they could have caused us to report overly conservative 
numbers for up to 230 beneficiaries. 
When possible, we addressed data quality concerns identified by our quality 
assessment.  We assigned unique patient identifiers to Medicaid 
beneficiaries who had more than one Medicaid ID.  We also used the 
T-MSIS provider file to identify prescribers National Provider Identifiers in 
cases where they were missing from prescription claims. 
Analysis of Opioid Utilization 
We identified T-MSIS prescription claims for opioids that beneficiaries 
received over the 12-month period of June 2016 to May 2017.  We 
calculated the number of beneficiaries and total number of prescription 
claims for all opioids and for all Schedule II and III opioids.  Using T-MSIS 
prescription drug records and T-MSIS eligibility files, we determined the 
proportion of Medicaid beneficiaries with claims for opioids in Ohio and in 
each of its counties.  We then identified the most commonly prescribed 
opioids by calculating the total number of prescriptions for each active 
pharmaceutical ingredient (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 MED.45  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., each T-MSIS prescription record).46  To do 
this, we used the following equation: 
 
We then summed each beneficiarys MED for each day of the year based on 
the dates of service and days supply on each T-MSIS prescription record.  
We refer to this as the daily MED.  We excluded from this analysis 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  16 
OEI-05-18-00010   
beneficiaries with a diagnosis of cancer or a hospice stay at any point during 
our study period.47   
Next we determined the extent to which beneficiaries received high or 
extreme amounts of opioids or appeared to be doctor shopping.  For each 
group of beneficiaries, we used the same definitions as previous OIG work.48    
High amounts of opioids.  To determine the extent to which beneficiaries 
received high amounts of opioids, we calculated each beneficiarys average 
daily MED over each 90-day period during our study period.  We 
considered a beneficiary to have 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 (not necessarily 
consecutive).  The MED of 120 mg exceeds the level CDC recommends that 
patients with chronic pain avoid, which is an MED of 90 mg.  
Extreme amounts of opioids.  To determine the extent to which beneficiaries 
received extreme amounts of opioids, we calculated each beneficiarys 
average daily MED over our entire study period.  We considered a 
beneficiary who exceeded an average daily MED of 240 mg for our entire 
study period and had received opioids for 360 days or more to have 
received an extreme amount of opioids.   
Doctor shopping.  To determine the extent to which beneficiaries appeared 
to be doctor shopping, we calculated the total number of prescribers and 
pharmacies from which each beneficiary received opioids during our study 
period.  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 during our study period, and 
received opioids from four or more prescribers and four or more 
pharmacies. 
Demographics.  Lastly, we calculated frequencies for select demographic 
information including age, sex, and whether a beneficiary was ever eligible 
for Medicaid due to a disability in our study period.  We did this for 
beneficiaries who received any opioids, received high or extreme amounts 
of opioids, and who appeared to be doctor shopping.   
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 stand out in comparison to their peers 
and warrant further scrutiny. 
In total, 564 prescribers ordered opioids for beneficiaries who received 
extreme amounts, and 1,235 prescribers ordered opioids for beneficiaries 
who appeared to be doctor shopping.  For each of these prescribers, we 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  17 
OEI-05-18-00010   
calculated the number of beneficiaries in each group for whom the 
prescriber ordered opioids.  We then identified the prescribers who ordered 
opioids for the greatest number of beneficiaries in each group.49  
Prescribers who ordered opioids for five or more beneficiaries who received 
extreme amounts are considered outliers.50  Prescribers who ordered 
opioids for four or more beneficiaries who appeared to be doctor shopping 
are considered outliers.51  See Appendix D for how frequently prescribers 
ordered opioids for beneficiaries at serious risk.  
Limitations 
We did not determine whether the high or extreme amounts of opioids that 
beneficiaries received were medically justified, as we did not conduct a 
medical record review.   
Our review may underestimate opioid use for some beneficiaries.  As 
previously stated, we removed some claims from a small number of 
beneficiaries that could have caused us to report overly conservative 
numbers for up to 230 beneficiaries.  In addition, we did not report on 
opioids obtained outside of the Medicaid program, such as through private 
insurance or cash payments. 
We did not compare our results to national trends because timely, nation-
wide information about opioid use in the Medicaid program is not 
available.52 
 
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. 
   
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APPENDIX A: OVERVIEW OF OHIOS OPIOID 
INITIATIVES  
Ohio has taken a number of steps to address its opioid crisis.  In this appendix, we provide specific 
information about Ohios opioid prescribing guidelines for prescribers and Ohios requirements for when 
prescribers and pharmacists are required to check the States PDMP.  We also summarize many of Ohios 
other efforts and provide links to Ohio resources for more detail.   
Opioid prescribing guidelines for providers 
 
Emergency department  Prescribers should consider: 
and acute care facilities    not writing prescriptions of more than 3 days,  
(released April 2012)    not prescribing long-acting opioids,  
  checking Ohio PDMP prior to prescribing, and 
  referring to primary care. 
 
Chronic, nonterminal pain   Prescribers must:* 
(released October 2013)    check Ohio PDMP for every patient with a prescription for more 
than 12 weeks. 
 
Prescribers should consider: 
  pressing pause at prescribing 80 mg MED or more, 
  using caution when co-prescribing benzodiazepines,  
  checking Ohio PDMP for every patient with a prescription at 80 mg 
MED or more, and 
  reevaluating patient for pain, function, medication effectiveness, 
and screen for substance abuse at 12 weeks. 
 
Acute pain outside of  Prescribers must:* 
emergency department    check Ohio PDMP for prescriptions of 7 days or more (in most 
(released January 2016)  cases). 
 
Prescribers should consider: 
  using nonpharmacologic/nonopioid therapies,  
  limiting pills per prescription, 
  not prescribing long-acting opioids,  
  checking Ohio PDMP prior to prescribing, and 
  reevaluating patient at 2 weeks. 
 
Source: OIG review of Ohios prescribing guidelines, 2018. 
*Note: Although included in Ohios guideline documents, the prescriber requirements to check the PDMP became law in April 2015. 
   
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Ohio requirements for checking PDMP (effective January 2015) 
 
Prescribers  Must check PDMP before initially prescribing or personally furnishing an 
opioid analgesic or benzodiazepine and follow up with periodic checks for 
any treatment continuing for more than 90 days. 
 
Pharmacists  Must check PDMP for 1-year period when: 
  patient adds new or different controlled substance to their therapy, 
  no PDMP reported reviewed during preceding 12 months, 
  prescriber located outside usual pharmacy geographic area, 
  pharmacist has reason to believe patient has received prescriptions 
for controlled substances from more than one prescriber in 
preceding 3 months (unless from a group practice), or 
  patient exhibits signs of potential abuse or diversion. 
 
Source: OIG review of Ohios PDMP requirements, 2018. 
 
Ohio actions geared toward prevention 
  Passed Pill Mill bill in 2011 requiring licensure of pain management clinics, authorized regulatory 
boards to establish standards for Ohios PDMP, and restricted in-office dispensing of controlled 
substances (May 2011) 
  Published the opioid prescribing guidelines described above 
  Opioid prescriptions for acute pain limited to 7 days for adults and 5 days for minors (August 2017) 
  State-wide youth drug-prevention initiative 
  School districts required to provide education on opioid abuse  
  Lock-in program for beneficiaries who demonstrate patterns of use beyond medical necessity 
 
Ohio actions geared toward detection 
  The Ohio Medicaid Prescription Drug Program Integrity Group brings together representatives 
from multiple State agencies to analyze data to identify fraudulent Medicaid prescribers for 
potential administrative or legal actions.  
  Ohio agencies are collaborating with the Department of Justices Opioid Fraud and Abuse 
Detection Unit to identify fraudulent Medicaid prescribers for potential administrative or legal 
actions.  
 
Ohio actions geared toward enforcement 
  The State of Ohio Board of Pharmacy trained local law enforcement partners on how to use its 
PDMP to assist with drug overdose investigations and linked data from its PDMP to overdose 
death data to help identify prescribers linked to overdose deaths (2015). 
  Ohios 2016-2018 Drug Interdiction, Disruption, and Reduction Plan provides the framework for 
greater collaboration between law enforcement and treatment providers. 
  The Ohio State Highway Patrol seized more than 32,000 opioid pills and 165 pounds of heroin; 
State troopers made more than 16,000 illegal drug arrests (2017). 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  20 
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Ohio actions geared toward treatment 
 
  MAT and alternative pain solutions (i.e., acupuncture) are now covered under Medicaid. 
  Naloxone, an overdose antidote, is widely available, and the Ohio Department of Health 
encourages use for any suspected overdose. 
  The State has funded an addiction treatment program that connects court-involved individuals to 
MAT.   
  Court systems are using specialized approaches to direct people to treatment. 
  Expanded treatment within State prisons and upon release is available. 
 
Additional Ohio actions 
  Released a toolkit for communities to address opioid abuse 
 
Resources for more details about Ohios actions related to combating the opioid crisis 
 
  Combating the opiate crisis in Ohio: 
http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/Combatting-the-Opiate-Crisis.pdf  
  Timeline of initiatives: http://fightingopiateabuse.ohio.gov/timeline/index.htm   
  Ohios opioid prescribing guidelines: 
http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/20160112-GCOAT-Prescribing-Guidelines-
Summary.pdf  
   
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APPENDIX B: SELECT DEMOGRAPHIC DATA 
Exhibit B-1: Most beneficiaries who received opioids in Ohio Medicaid were adults. 
% of beneficiaries  % of beneficiaries  % of beneficiaries  % of beneficiaries 
  who received any  who received high  who received  who appeared to be 
opioid   amounts of opioids  extreme amounts of  doctor shopping 
(N=539,810)  (N=4,754)  opioids (N=481)  (N=231) 
0-18  7.5%  0.1%  0%  0% 
19-44  57.2%  33.2%  29.7%  54.6% 
45-64  33.4%  63.2%  68.8%  44.2% 
65+  1.9%  3.5%  1.5%  1.3% 
Total  100%  100%  100%  100% 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
 
Exhibit B-2: Most beneficiaries who received opioids in Ohio Medicaid were female. 
       
  
Any opioid  High amounts  Extreme amounts  Doctor shopping 
Female  63.8%  53.7%  51.4%  51.1% 
Male  36.1%  46.1%  48.4%  48.9% 
Unknown  0.1%  0.2%  0.2%  0% 
Total  100%  100%  100%  100% 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
 
Exhibit B-3: Most beneficiaries who received opioids in Ohio Medicaid were eligible for reasons 
other than a disability. 
       
  
Any opioid   High amounts  Extreme amounts  Doctor shopping 
No disability*  83.8%  57.7%  52%  53.2% 
Disability**  13.1%  40.2%  46.8%  45.5% 
Unknown  3.1%  2.1%  1.2%  1.3% 
Total  100%  100%  100%  100% 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
* Eligible for reasons other than disability. 
** Eligible due to a disability. 
   
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Exhibit B-4: Cuyahoga, Franklin, and Lucas Counties had the largest numbers of beneficiaries 
with high amounts of opioids.  
 
Source: OIG analysis of Ohio Medicaid data, 2018. 
Note: Franklin County had the most beneficiaries with high amounts of opioids579 beneficiaries.  Cuyahoga County had 313 beneficiaries with 
high amounts of opioids, and Lucas County had 315.  Major cities are located in each of these counties: Columbus in Franklin County, Cleveland in 
Cuyahoga County, and Toledo in Lucas County. 
   
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Exhibit B-5: Cuyahoga, Franklin, Hamilton, Mahoning, Summit, and Trumbull Counties had the 
largest numbers of beneficiaries with extreme amounts of opioids. 
 
Source: OIG analysis of Ohio Medicaid data, 2018. 
Note: Franklin County had the most beneficiaries with extreme amounts of opioids56 beneficiaries.  Cuyahoga County had 42 beneficiaries with 
extreme amounts of opioids, Mahoning County had 30, Summit County had 27, Trumbull County has 26, and Hamilton had 25.  Major cities are 
located in most of these counties: Columbus in Franklin County, Cleveland in Cuyahoga County, Cincinnati in Hamilton County, Youngstown in 
Mahoning County, and Akron in Summit County.  
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  24 
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Exhibit B-6: Franklin and Lucas Counties had the largest numbers of beneficiaries who appeared 
to be doctor shopping. 
 
Source: OIG analysis of Ohio Medicaid data, 2018. 
Note: Lucas County had the most beneficiaries who appeared to be doctor shopping26 beneficiaries.  Franklin County had 25 beneficiaries who 
appeared to be doctor shopping.  Major cities are located in each of the counties highlighted above: Columbus in Franklin County and Toledo in 
Lucas County. 
    
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APPENDIX C: PROVIDER SPECIALTIES 
Exhibit C-1: Physicians comprised more than half of the prescribers who ordered opioids for 
more beneficiaries than their peers. 
Classification  Number of providers  Percentage of providersrs 
Physician  24  51.1%% 
  Pain medicine  5   
  Family medicine  3   
  Internal medicine  2   
  Internal medicine, hematology, and oncology  2   
  Anesthesiology, pain medicine  1   
  Family medicine, addiction medicine  1   
  Family medicine, geriatric medicine  1   
  Internal medicine, geriatric medicine  1   
  Internal medicine, hematology  1   
  Internal medicine, hospice and palliative medicine  1   
  Internal medicine, medical oncology  1   
  Pain medicine, interventional medicine  1   
  Physical medicine and rehabilitation, pain medicine  1   
  Psychiatry and neurology, neurology  1   
  Psychiatry and neurology, pain medicine  1   
  Specialist  1   
Nurse practitioner  16  34%% 
  Family  7   
  Adult health  5   
  No specialty  4   
Physician assistant  5  10.6%% 
  No specialty  4   
  Medical  1   
Certified clinical nurse specialist  2  4.3%% 
  Adult health  2   
Total  47  100%% 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
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APPENDIX D: PRESCRIBERS ASSOCIATED 
WITH BENEFICIARIES AT SERIOUS RISK  
Exhibit D-1: Of the prescribers who ordered opioids for beneficiaries with extreme amounts, 
most were associated with just one or two of these beneficiaries. 
450
400 These prescribers were 
outliers compared to 
350
their peers 
300
250
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Number of beneficiaries with extreme amounts of opioids 
 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
Note: Of the 35,102 prescribers who ordered opioids for Ohio Medicaid beneficiaries in our study period, 34,538 did not order opioids for any 
beneficiaries with extreme amounts. 
   
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Exhibit D-2: Of the prescribers who ordered opioids for beneficiaries who appeared to be doctor 
shopping, most were associated with just one or two of these beneficiaries. 
1100
1000 These prescribers were 
outliers compared to 
900
their peers 
800
700
600
500
400
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11
Number of beneficiaries who appeared to be doctor shopping 
Source: OIG analysis of Ohio T-MSIS data, 2018. 
Note: Of the 35,102 prescribers who ordered opioids for Ohio Medicaid beneficiaries in our study period, 33,867 did not order opioids for any 
beneficiaries who appeared to be doctor shopping. 
 
 
 
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ACKNOWLEDGMENTS 
Lisa Minich served as the team leader for this study, and Hilary Slover served 
as the lead analyst.  Others in the Office of Evaluation and Inspections who 
conducted the study include Lauren Anderson and Nicole Hrycyk.  Office of 
Evaluation and Inspections staff who provided support include Melissa 
Baker, Adam Freeman, Dave Graf, Althea Hosein, Kevin Manley, Kayla 
Phelps, Meghan Riggs, and Megan Shade.   
We would also like to acknowledge the contributions of other Office of 
Inspector General staff, including Robert Gibbons, Lauren McNulty, and 
Jessica Swanstrom. 
This report was prepared under the direction of Thomas Komaniecki, 
Regional Inspector General for Evaluation and Inspections in the Chicago 
regional office, and Laura Kordish and Kelly Waldhoff, 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. 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  29 
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ENDNOTES 
 
1 Eric D. Hargan, Acting Secretary, U.S. Department of Health and Human Services, HHS Acting Secretary Declares 
Public Health Emergency to Address National Opioid Crisis, press release, October 26, 2017.  Accessed at 
https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-
national-opioid-crisis.html on April 13, 2018.  Acting Secretary Hargan and Secretary Alex M. Azar II renewed the 
public health emergency in January 2018 and April 2018, respectively.  See 
https://www.phe.gov/emergency/news/healthactions/phe/Pages/opioid-24Jan2018.aspx and 
https://www.phe.gov/emergency/news/healthactions/phe/Pages/opioid-20Apr2018.aspx.  
2 CDC, Data Brief 294: Drug Overdose Deaths in the United States, 19992016 and supplement tables. 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 23, 2018. 
3 Kaiser Family Foundation, Medicaids Role in Addressing the Opioid Epidemic.  Accessed at 
https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/ on March 26, 2018. 
4 CDC, Opioid Overdose: Prescription Opioids.  Accessed at 
https://www.cdc.gov/drugoverdose/opioids/prescribed.html on January 18, 2018. 
5 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016, MMWR Recomm Rep, March 18, 
2016, p. 13.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on January 11, 2018. 
6 National Institutes of Health, Prescription Opioids and Heroin.  Accessed at 
https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-
abuse/prescription-opioid-use-risk-factor-heroin-use on February 26, 2018. 
7 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016, MMWR Recomm Rep, March 18, 
2016, pp. 11-49.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on January 11, 2018. 
8 The CDC guidelines recommend that prescribers avoid increasing opioids to morphine equivalent dosages of 90 mg 
a day or more and to justify carefully the decision to increase this level.  Ibid., p. 16. 
9 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 January 11, 2018. 
10 CMS, CMCS Informational Bulletin: Best Practices for Addressing Prescription Opioid Overdoses, Misuse, and 
Addiction, January 28, 2016.  Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/cib-02-02-
16.pdf on March 20, 2018. 
11 CMS, State Medicaid Director Letter #18-006: Leveraging Medicaid Technology to Address the Opioid Crisis, 
June 11, 2018.  Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/smd18006.pdf on 
July 3, 2018.   
12 Department of Justice, Drug Enforcement Administration, State Prescription Drug Monitoring Programs: Questions & 
Answers, Question 1.  A PDMP is a statewide electronic database that collects designated data on substances 
dispensed in the State.  Accessed at https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#1 on February 9, 2018. 
13 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. 
14 OIG, Opioid Use in Medicare Part D Remains Concerning, OEI-02-18-00220, June 2018; OIG, Opioids in Medicare Part 
D: Concerns about Extreme Use and Questionable Prescribing, OEI-02-17-00250, July 2017; OIG, High Part D Spending 
on Opioids and Substantial Growth in Compounded Drugs Raise Concern, OEI-02-16-00290, June 2016. 
15 See the OIG Work Plan at https://oig.hhs.gov/reports-and-publications/workplan/index.asp. 
16 OIG, Analysis Toolkit: Using Data Analysis to Calculate Opioid Levels and Identify Patients At Risk of Misuse or 
Overdose, OEI-02-17-00560, June 2018. 
17 Kaiser Family Foundation, Opioid Overdose Deaths and Opioid Overdose Deaths as a Percent of All Drug Overdose 
Deaths, 2015.  Accessed at https://www.kff.org/other/state-indicator/opioid-overdose-
deaths/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Opioid%20Overdose%20Deaths%22,%22sort%22:%
22asc%22%7D on April 18, 2018. 
 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  30 
OEI-05-18-00010   
 
18 Ohio Department of Health, 2016 Ohio Drug Overdose Data: General Findings.  Accessed at 
http://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health/injury-prevention/2016-Ohio-Drug-Overdose-Report-
FINAL.pdf?la=en on April 24, 2018. 
19 OIG analysis of Ohio Medicaid data, June 2016-May 2017.  This number includes beneficiaries covered by CHIP.  
This does not include prescriptions used for medication-assisted treatment of opioid use disorder. 
20 In August 2017, subsequent to our study period, new rules went into effect limiting the amount of opiates that can 
be prescribed for acute pain.  The rules limit prescriptions to 7 days for adults and 5 days for minors.  Ohios initial 
data suggest that these rules led to decreases in the average (1) days supply for acute opioid prescriptions, 
(2) number of opioid doses per prescription, and (3) MED per acute opioid prescription.  See State of Ohio Board of 
Pharmacy, Ohio Automated Rx Reporting System Annual Report 2017.  Accessed at 
https://www.ohiopmp.gov/documents/Annual%20Report%20(2017).pdf on March 22, 2018.    
21 Richard Miech, Lloyd Johnston, Patrick M. OMalley, et al., Prescription Opioids in Adolescence and Future Opioid 
Misuse, Pediatrics, Volume 136, Number 5, August 2015.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834210/pdf/peds.2015-1364.pdf on March 1, 2018. 
22 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 drugs have the lowest potential for abuse 
among controlled substances.  See 21 U.S.C.  812. 
23 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, 2006-2015, MMWR Morb Mortal Wkly Rep, March 17, 2017, pp. 265-69.  Accessed at 
https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm on March 5, 2018. 
24 State of Ohio Board of Pharmacy, Ohio Automated Rx Reporting System Annual Report 2017.  Accessed at 
https://www.ohiopmp.gov/documents/Annual%20Report%20(2017).pdf on March 22, 2018. 
25 According to the manufacturer labels, the maximum daily dose for Percocet 5 mg is 12 tablets.  For more 
information about Percocet, see page 2 at 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/040330s015,040341s013,040434s003lbl.pdf. 
26 Ohio Department of Mental Health and Addiction Services, Ohio Guidelines for Prescribing Opioids for the 
Treatment of Chronic, Non-Terminal Pain, October 2013.  Accessed at 
http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/Guidelines-Chronic-Pain.pdf on March 23, 2018. 
27 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016.  MMWR Recomm Rep, March 18, 
2016, p. 16.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on January 11, 2018. 
28 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 January 
11, 2018.  
29 Christopher M. Jones, Joseph Logan, R. Matthew Gladden, et al., Vital Signs: Demographic and Substance Use 
Trends Among Heroin UsersUnited States, 2002-2013, MMWR Weekly Report, Volume 64, Number 26, July 10, 
2015, pp. 719-25.  Accessed at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm?s_cid=mm6426a3_w 
on March 8, 2018.  
30 Governors Cabinet Opiate Action Team, Combating the Opiate Crisis in Ohio, February 2018.  Accessed at 
http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/Combating-the-Opiate-Crisis_Feb2018.pdf on May 8, 2018. 
31 State of Ohio Board of Pharmacy, Ohio Automated RX Reporting System 2017 Annual Report.  Accessed at 
https://www.ohiopmp.gov/documents/Annual%20Report%20(2017).pdf on April 6, 2018. 
32 This does not include beneficiaries who had cancer or were in hospice care.  This also excludes all methadone 
prescriptions that may have been used to treat opioid use disorder. 
 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  31 
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33 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain  United States, 2016, MMWR Recomm Rep, March 18, 
2016, p. 10.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm on January 11, 2018. 
34 This analysis does not include beneficiaries who had cancer or hospice care.  For this analysis, one pharmacy 
refers to just one pharmacy locationwe considered multiple locations of the same retail pharmacy to be multiple 
pharmacies. 
35 Ohio defines doctor shopping as an individual receiving a prescription for a controlled substance from five or 
more prescribers at five or more pharmacies in one calendar month.  See State of Ohio Board of Pharmacy, Ohio 
Automated Rx Reporting System Annual Report 2017, p. 9.  Accessed at 
https://www.ohiopmp.gov/documents/Annual%20Report%20(2017).pdf on March 22, 2018. 
36 Governors Cabinet Opiate Action Team, Combating the Opiate Crisis in Ohio, February 2018.  Accessed at 
http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/Combating-the-Opiate-Crisis_Feb2018.pdf on May 8, 2018. 
37 Ibid. 
38 Richard Miech, Lloyd Johnston, Patrick M. OMalley, et al., Prescription Opioids in Adolescence and Future Opioid 
Misuse, Pediatrics, Volume 136, Number 5, August 2015.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834210/pdf/peds.2015-1364.pdf on March 1, 2018. 
39 See the OIG Work Plan at https://oig.hhs.gov/reports-and-publications/workplan/index.asp. 
40 Ibid. 
41 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 29, 2018. 
42 Approximately 7,010 beneficiaries (1.3 percent) who received any opioid were dually eligible for Medicare Part D at 
some point during our study period.  Each of these beneficiaries had at least one opioid claim that was paid, in part 
or in full, by Medicaid.  Of the beneficiaries who received high amounts of opioids, 119 were dually eligible.  
Two beneficiaries who received extreme amounts of opioids were dually eligible, as were six beneficiaries who 
appeared to be doctor shopping. 
43 We identified methadone that may have been used to treat opioid use disorder by excluding all methadone claims 
for beneficiaries who had a diagnosed opioid use disorder or who received treatment from a methadone clinic or 
other addiction treatment clinics at any point during our study period.  We included methadone claims for 
beneficiaries who did not meet these criteria, as methadone may also be used to treat pain. 
44 These files contain MME conversion factors for each National Drug Code.  MED and MME are interchangeable 
terms.  In 2017, CDC stopped including an MME conversion factor for buprenorphine products because those 
products are not expected to be associated with overdose risk in the same way as other opioids.  See CDC, SAS 
Merging Program.  Accessed at https://www.cdc.gov/drugoverdose/data-
files/SAScodetouseMMEconvsnfileSept2017.sas on April 10, 2018.     
45 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 March 5, 2018. 
46 We included prescription drug records with days of use between June 2016 and May 2017.  We excluded records 
for injection, intravenous, and intrathecal opioids from this analysis.  
47 We identified beneficiaries with a cancer diagnosis or hospice stay using the T-MSIS claims files.  In total, we 
identified 21,146 beneficiaries with cancer or hospice who received at least one opioid. 
48 OIG, Opioids Use in Medicare Part D Remains Concerning, OEI-02-18-00220, June 2018; OIG, Opioids in Medicare 
Part D: Concerns about Extreme Use and Questionable Prescribing, OEI-02-17-00250, July 2017. 
49 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 three standard deviations above the 
mean and in the top 1.5 percent.  Our thresholds differ from those used in similar OIG work because the number and 
distribution of beneficiaries at serious risk across prescribers varies across Federal programs and geographic 
locations. 
50 Outlier prescribers ordered opioids for 5 to 18 beneficiaries who received extreme amounts. 
51 Outlier prescribers ordered opioids for 4 to 11 beneficiaries who appeared to be doctor shopping. 
 
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  32 
OEI-05-18-00010   
 
52 OIG, Status Update: T-MSIS Data Not Yet Available for Overseeing Medicaid, OEI-05-15-00050, June 2017; OIG, Early 
Outcomes Show Limited Progress for the Transformed Medicaid Statistical Information System, OEI-05-12-00610, 
September 2013.  
Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing  33 
OEI-05-18-00010