HHS OIG Data Brief    June 2018    OEI-02-18-00220 
 
Opioid Use in Medicare Part D Remains 
Concerning 
 
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 one in three  States115 deaths per day.  This is twice the number of opioid-related 
Part D beneficiaries  overdose deaths that occurred just 6 years earlier in 2010.2  Identifying 
received a prescription  patients who are at risk of overdose or abuse is key to addressing this 
opioid in 2017. 
national crisis.    
 Overall Part D spending 
Opioids include narcotics intended to manage pain from surgery, injury, or 
for opioids decreased, 
illness.  They can create a euphoric effect, which makes them vulnerable to 
due in part to declining 
abuse and misuse (i.e., taking opioids in a way other than prescribed).  
prices. 
Although opioids can be appropriate under certain circumstances, the 
 Almost 460,000  Office of Inspector General (OIG) and others are concerned about fraud, 
beneficiaries received 
abuse, and misuse of opioids, as well as drug diversionthe redirection of 
high amounts of 
prescription drugs for an illegal purpose, such as recreational use or resale.  
opioids in 2017, fewer 
These concerns about fraud, abuse, misuse, and diversion include opioids 
than in 2016. 
obtained under Medicare Part D, the optional prescription drug benefit for 
 About 71,000  Medicare beneficiaries.  In 2017, it covered 45 million beneficiaries.     
beneficiaries are at 
There is also growing concern about abuse of both prescription fentanyl 
serious risk of opioid 
misuse or overdose,  and illicitly manufactured fentanyl.  Fentanyl-related overdose deaths have 
also fewer than in 2016.  drastically increased in recent years.3  Fentanyl is 30 to 50 times more 
powerful than heroin and is sometimes mixed with other drugs, such as 
 Almost 300 prescribers 
cocaine or heroin, which increases the risk of overdose.4   
had questionable 
opioid prescribing for 
In addition to these concerns, opioid use carries a number of health risks.  
the 71,000 beneficiaries 
Side effects from using opioids may include respiratory depression, 
at serious risk.  
confusion, increased tolerance, and physical dependence.5  For seniors, 
 The high level of opioid  long-term use of prescription opioids also increases the likelihood of falls 
use continues to call  and fractures.6   
for the public and 
Prescribers play a crucial role in ensuring that beneficiaries receive 
private sectors to work 
together to address  appropriate amounts of opioids.  To help inform prescribers, the Centers for 
this crisis.    Disease Control and Prevention (CDC) published guidelines on prescribing 
opioids to patients with chronic pain.7  The guidelines recommend that 
prescribers use caution when ordering opioids at any dosage and avoid 
increasing dosages to the equivalent of 90 mg or more of morphine a day 
   
for chronic pain.8  In addition, because long-term opioid use often begins 
with the treatment of acute pain, the guidelines recommend that prescribers 
order opioids for the lowest effective dose and duration, noting that more 
than 7 days of opioids is rarely needed to address acute pain.9    
The Centers for Medicare & Medicaid Services (CMS) also initiated a number 
of actions to address opioid misuse and inappropriate prescribing.10  For 
instance, through its Overutilization Monitoring System, CMS routinely 
identifies Part D beneficiaries who are potentially overutilizing opioids and 
who may be in need of case management.11  It then provides each Part D 
sponsor with a list of these beneficiaries for follow up.   CMS also expects 
Part D sponsors to implement controls at the point of sale to prevent unsafe 
dosing.12  In addition, CMS is taking steps to implement the Comprehensive 
Addiction and Recovery Act of 2016 (CARA) for 2019.  CARA provides Part D 
sponsors the authority to restrict at-risk beneficiaries to selected pharmacies 
or prescribers (lock-in) for their opioid prescriptions.13   
This data brief is part of a larger strategy by OIG to fight the opioid crisis 
and protect beneficiaries from prescription drug misuse and abuse.  It 
provides 2017 data on the extent to which Medicare Part D beneficiaries 
receive extreme amounts of opioids or appear to be doctor shopping and 
compares these data to OIGs previous analysis of 2016.14  This data brief is 
being released with 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.15  OIG is also 
conducting a series of reviews on opioid utilization in Medicaid.16  In 
addition, OIG has ongoing reviews about key opioid initiatives at the 
Department of Health and Human Services (HHS or the Department), 
including access to buprenorphine for opioid use disorder; controls on 
opioid treatment programs, the Food and Drug Administrations oversight 
of programs to address opioid abuse, and a review of grants for 
prescription drug monitoring programs.17   
 
   
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RESULTS 
Nearly one in three  In 2017, nearly one in three beneficiaries received at least one prescription 
opioid through Medicare Part D.  Thirty-one percent of beneficiaries
Medicare Part D 
14.1 million of the total 45.2 million enrolled in Medicare Part Dreceived 
Beneficiaries 
opioids.  This is a slight decrease from 2016, when 33 percent of 
Received Opioids in  beneficiaries14.4 millionreceived opioids through Part D.   
2017 
Part D paid for 76 million opioid prescriptionsan average of 
5.4 prescriptions per beneficiary receiving opioids in 2017.  This was a 
decrease from 2016, when Part D paid for 79 million opioid prescriptions
an average of 5.5 per beneficiary receiving opioids.  Tramadol, 
hydrocodone-acetaminophen, and oxycodone-acetaminophen were the 
most commonly dispensed opioids in both years.18 
Exhibit 1: Opioid Utilization in Part D, 2017. 
 
Source:  OIG analysis of Medicare Part D data, 2018. 
Raising concern, about 1 in 10 Part D beneficiaries received opioids on a 
regular basis.  Specifically, 4.9 million beneficiaries received opioids for a 
total of 3 or more months in 2017.  Opioids may have been necessary for 
many of these beneficiaries, but these high numbers raise questions as to 
whether opioids are being appropriately prescribed and used.19  Research 
shows that the risk of opioid dependence increases substantially for patients 
receiving opioids continually for 3 months.20  For this reason, it is essential 
that Medicare beneficiaries receive the lowest effective amount of opioids.   
Further, a number of States had higher proportions of beneficiaries 
receiving opioids than the Nation overall.  Alabama, Mississippi, Arkansas, 
and Oklahoma had the highest proportions, with more than 40 percent of 
each States Part D beneficiaries receiving at least one opioid.  These States 
also had the highest proportion of beneficiaries who received opioids in the 
Nation in 2016.  See Appendix A for more detailed information about each 
State. 
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Overall Part D  While overall opioid use decreased slightly, overall Part D spending for 
opioids went down more significantly.  Part D paid a total of $3.4 billion for 
spending for 
opioids in 2017, compared to $4.0 billion in 2016.  This difference represents 
opioids decreased, 
a 15 percent decrease.  See Exhibit 2. 
due in part to 
Exhibit 2:  Overall spending for opioids in Part D decreased in 2017, 
declining prices 
but remained more than $3 billion. 
$4.2
$4.1 $4.0
$3.5 $3.4
$3.1
$2.9 $3.0
$2.8
$2.5
$2.2
$1.7
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
*Spending in Billions
Source: OIG analysis of Medicare Part D data, 2018. 
A decrease in opioid prices appears to be a main driver of the drop in 
spending.  The average price of a months supply decreased for 18 of the 
20 most commonly prescribed opioids in 2017.  For example, decreases in 
the price per month of the top five opioids ranged from 11 percent to 
30 percent.  See Exhibit 3.  Notably, the price per month for hydrocodone-
acetaminophen 10-325 mg dropped 30 percent from 2016 to 2017, going 
from $37 to $26.  The prices of two other common strengths of 
hydrocodone-acetaminophen dropped 24 and 28 percent.  In total, 
Medicare Part D paid $220 million less in 2017 for these three commonly 
prescribed strengths of hydrocodone-acetaminophen than it did in 2016.21    
The slight decreases in the number of beneficiaries receiving opioids and 
the number of prescriptions per beneficiary discussed above also 
contributed to the overall decrease in spending. 
 
 
 
 
 
 
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Exhibit 3:  The prices of all of the most commonly prescribed opioids declined in 2017. 
Total Number of  Average Price  Average Price 
Prescriptions  per Month  per Month  Percent 
Drug Name*  in 2017  in 2016**  in 2017**  Change*** 
Tramadol 50 mg  14.7 million  $11  $9  -11% 
Hydrocodone-acetaminophen 10-325 mg  10.7 million  $37  $26  -30% 
Hydrocodone-acetaminophen 5-325 mg  10.6 million  $33  $24  -28% 
Hydrocodone-acetaminophen 7.5-325 mg  5.3 million  $34  $26  -24% 
Oxycodone-acetaminophen 10-325 mg  4.3 million  $78  $65  -16% 
*A drug is defined as on the active ingredient-strength-form level.  All numbers are for the tablet form of the drug. 
**Average price per month and percent change are rounded. 
***Percent change was calculated before the values were rounded. 
Source: OIG analysis of Medicare Part D data, 2018. 
 
Almost 460,000  In 2017, a total of 458,935 beneficiaries received high amounts of opioids 
through Medicare Part D; these beneficiaries did not have cancer and were 
Part D beneficiaries 
not in hospice care.  The number of beneficiaries who received high 
received high 
amounts of opioids through Part D decreased from 501,008 beneficiaries in 
amounts of opioids  2016. 
in 2017, fewer than 
Each of the 458,935 beneficiaries received high amounts of opioids, 
in 2016  meaning they had an average morphine equivalent dose (MED) of greater 
than 120 mg a day for at least 3 months.  MED is a measure that converts all 
the various opioids and strengths into one standard value.  A daily MED of 
120 mg is equivalent to 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.22  They also exceed the 
90 mg MED level that CDC recommends avoiding for patients with chronic 
pain.23  
The most commonly prescribed opioid for beneficiaries with high 
amountsan average daily MED of greater than 120 mg for 3 monthswas 
oxycodone 30 mg.  Twenty percent of beneficiaries who received high 
amounts of opioids had at least one prescription for this opioid.  
Fourteen percent of beneficiaries who received high amounts of opioids 
received at least one prescription for fentanyl patch 50 mcg/hr.  Oxycodone 
and fentanyl are among the most common opioids involved in law 
enforcement cases.24 
Although beneficiaries may receive opioids for legitimate purposes, these 
amounts raise concern.  Many experts have noted that opioid dosages 
should not be increased to an MED of 90 mg a day or more without careful 
justification.25  Opioids carry health risks, including respiratory depression, 
constipation, drowsiness, and confusion.  Older adults may also be at an 
increased risk of injury, as research has shown that the risk of fracture may 
increase as drug dosage increases.26   
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About 71,000  Two groups of beneficiaries that are at 
Beneficiaries at serious risk of 
serious risk of opioid misuse or 
beneficiaries are at  opioid misuse or overdose 
overdose are the focus of this review.  
serious risk of  include:  
They include:  (1) beneficiaries who 
opioid misuse or  receive extreme amounts of opioids  1.  Beneficiaries who receive 
overdose, fewer  and (2) beneficiaries who appear to be  extreme amounts of 
doctor shopping.  Other Part D  opioidsi.e., an average 
than in 2016 
beneficiaries also may be at serious risk  daily MED greater than 
of opioid misuse or overdose but do  240 mg for 12 months. 
not meet these criteria.  
2. Beneficiaries who appear to 
A total of 71,260 beneficiaries were in  be doctor shoppingi.e., 
these two groups in 2017.  This does  receive a high amount of 
not include beneficiaries who have  opioids (an average daily 
cancer or were in hospice care.   MED greater than 120 mg 
Specifically, 57,611 beneficiaries  for 3 months) and have four 
received extreme amounts of opioids,  or more prescribers and four 
and 14,814 beneficiaries appeared to  or more pharmacies. 
be doctor shopping (i.e., received high 
amounts of opioids and had multiple 
prescribers and pharmacies).  A total of 1,165 beneficiaries were in both 
groups.  Most of the beneficiaries at serious risk were under the age of 65.  
Seventy-four percent of beneficiaries were under 65 years old, 22 percent 
were between 65 and 75, and 4 percent were over 75.  In addition to the 
elderly, individuals with disabilities may also be eligible for Medicare 
coverage.27  
Fewer beneficiaries were identified as being at serious risk of opioid misuse 
or overdose in 2017 compared to 2016, when OIG identified 
89,843 beneficiaries at serious risk.28  The numbers in each group declined, 
with the larger drop34 percentin the number of beneficiaries who 
appeared to be doctor shopping.  See Appendix B for more detailed 
information.  Despite the decrease, a high number of beneficiaries in these 
two groups is still at serious risk.   
About 58,000 beneficiaries received extreme amounts of 
opioids 
A total of 57,611 beneficiaries received extreme amounts of opioids, putting 
them at serious risk of opioid misuse or overdose.29  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.  Research has shown that 
patients who receive an MED at such a level are at increased risk of 
overdose death.30   
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Of note, 890 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.    
Receiving extreme amounts of opioids raises concerns.  It may signal that a 
beneficiarys care is not being monitored or coordinated properly or that 
the beneficiarys care needs to be reassessed.31  It may also indicate that the 
beneficiary is receiving medically unnecessary drugs, which could be 
diverted for resale.  It 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.   
 
Examples of Beneficiaries Receiving Extreme Amounts of Opioids 
A beneficiary in California received 48 prescriptions during the year
12 months each of 4 different powerful opioidsall ordered by one 
physician.  In total, the beneficiary had an average daily MED of 
3,460 mg for the entire year, which is 38 times the level that CDC 
recommends avoiding.   
A beneficiary in South Carolina received 60 opioid prescriptions during 
the yearan average of more than one a weekfrom one physician.  
His prescriptions included a years supply each of three different 
strengths of oxycodone.  This beneficiary had an average daily MED of 
3,068 mg for the entire year, which is 34 times the level that the CDC 
recommends avoiding.   
 
About 15,000 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 prescriptions from multiple 
prescribers and multiple pharmacies.  A total of 14,814 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 had four or more prescribers and four or more pharmacies 
in 2017.  It is uncommon for a beneficiary to have multiple prescribers or 
pharmacies.   Most beneficiaries who received opioids in 2017 had just one 
prescriber and one pharmacy.32  Although beneficiaries may receive opioids 
from multiple prescribers or pharmacies for legitimate reasons, these 
patterns raise concern. 
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Notably, 69 beneficiaries had particularly high numbers of prescribers and 
pharmacies.  Each received opioids from more than 10 prescribers and more 
than 10 pharmacies in 2017.   
Receiving high amounts of opioids and having multiple prescribers and 
pharmacies may signal that the beneficiarys care is not being monitored or 
coordinated properly.  It may also indicate that a beneficiary is seeking 
medically unnecessary drugs, perhaps to use them recreationally or to divert 
them.  It could also mean that the beneficiarys identification number was 
stolen, sold, or otherwise compromised. 
Furthermore, receiving high amounts of opioids and having multiple 
prescribers and pharmacies may indicate that prescribers are not checking 
the beneficiarys opioid history before prescribing.  All but one State 
maintain databases, called prescription drug monitoring programs, which 
track prescriptions for controlled substances.33  Prescribers can check these 
databases before ordering opioids to determine if the beneficiary is already 
receiving opioids ordered by other prescribers.34 
 
Examples of Beneficiaries Who Appear To Be Doctor Shopping 
A beneficiary in Washington, D.C. received 101 opioid prescriptions from 
26 prescribers and filled them at 28 pharmacies in 2017.  Many of these 
prescriptions were for various strengths of oxycodone.  Over the course 
of the year, this beneficiary received more than 10,000 pills containing 
oxycodone.  In 1 month alone, this beneficiary received 16 opioid 
prescriptions from 11 different prescribers and filled them at 
12 pharmacies. 
A beneficiary in Louisiana received 52 opioid prescriptions from 
30 prescribers and filled these prescriptions at 23 separate pharmacies 
located across New Jersey, New York, Louisiana, and Texas.  Over one-
half of these prescriptions were for fentanyl patches.  In total, this 
beneficiary received 165 fentanyl patches in 2017.  This beneficiary also 
received prescriptions for oxycodone, hydrocodone-acetaminophen, 
morphine, oxycodone-acetaminophen, and hydromorphone.  
 
   
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Almost 300  Almost 90,000 prescribers ordered opioids for at least one beneficiary at 
serious risk of opioid misuse or overdose (i.e., a beneficiary who has 
prescribers had 
received extreme amounts or appeared to be doctor shopping) in 2017.35  
questionable opioid 
The vast majority of these prescribers each ordered opioids for only one or 
prescribing  for the  two of these beneficiaries.  Some prescribers ordered for many more.   
71,000 beneficiaries 
A total of 282 prescribers stand out as having questionable prescribing; 
at serious risk   these prescribers ordered opioids for the highest numbers of beneficiaries 
at serious risk.  This total is lower than the 401 prescribers identified in 2016, 
as there were fewer beneficiaries identified as being at serious risk in 2017.36  
Like the prescribers identified in 2016, the patterns of the 282 prescribers 
are far outside the norm and warrant further scrutiny.   
Specifically, 145 prescribers ordered opioids for a high number of 
beneficiaries who received extreme amounts in 2017.  These prescribers 
each ordered opioids for at least 45 beneficiaries who received an average 
daily MED of more than 240 mg for the entire year, did not have cancer or 
were not in hospice care.  Beneficiaries who receive these extreme amounts 
of opioids are at serious risk.  CDC recommends that prescribers avoid 
increasing dosages to 90 mg or more MED a day for chronic pain, yet these 
beneficiaries are receiving more than two and a half times that amount.   
Further, 169 prescribers ordered opioids for a high number of beneficiaries 
who appeared to be doctor shopping.37  Each prescriber ordered opioids for 
at least 18 beneficiaries who appeared to be doctor shopping.  These 
beneficiaries received high amounts of opioids, had four or more 
prescribers and four or more pharmacies, did not have cancer and were not 
in hospice care.  Like beneficiaries who receive extreme amounts, 
beneficiaries who appear to be doctor shopping are at serious risk of opioid 
misuse or overdose. 
Although these opioids may be necessary for some patients, prescribing to 
an unusually high number of beneficiaries at serious risk raises concerns.  It 
may indicate that beneficiaries are receiving poorly coordinated care and 
could be in danger of overdose or dependence.  It may also signal that 
prescribers are not checking State prescription drug monitoring databases, 
or that these databases do not have current data.   
Prescribing to an unusually high number of beneficiaries at serious risk 
could also indicate that the prescriber is ordering medically unnecessary 
drugs, which could be diverted for resale or recreational use.  The 
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.  Another possibility is that the prescribers 
identification was sold or stolen and is being used for illegal purposes.  
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In total, these 282 prescribers with questionable ordered 178,091 opioid 
prescriptions for beneficiaries at serious risk, costing Part D a total of $47 
million.  A little more than one-third of these prescribers were nurse 
practitioners or physician assistants. In total, 64 were nurse practitioners and 
37 were physician assistants.  
Examples of Prescribers With Questionable Prescribing  
A physician in Florida ordered opioids for 192 beneficiaries who 
received extreme amounts during the year.  For one of these 
beneficiaries, the physician ordered 33 prescriptions, including 
11 months each of fentanyl patches and oxycodone.  This beneficiary 
had an average daily MED of 535 mg over the entire year, about  
6 times the level CDC recommends avoiding.  In total, this physician 
ordered 2,692 opioid prescriptions for beneficiaries who received 
extreme amounts of opioids, costing Part D $570,000. 
In the first 7 months of 2017, a physician in Texas ordered opioids for 
53 different beneficiaries who appeared to be doctor shopping.  Most 
of these prescriptions were for hydrocodone, oxycodone, or morphine.  
In total, this prescriber ordered more than 600 opioid prescriptions for 
these beneficiaries.  
     
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CONCLUSION 
Opioid use among Medicare Part D beneficiaries has decreased slightly but 
remains concerning.  Nearly one in three beneficiaries received a 
prescription opioid through Part D in 2017.  Despite this decrease, the high 
level of opioid use in Part D continues to raise concerns.   
During the year, close to 460,000 beneficiaries received high amounts of 
opioidsan average daily MED of greater than 120 mg for at least 3 months 
of the yearthrough Part D.  About 71,000 of these beneficiaries are at 
serious risk of misuse or overdose.  Beneficiaries at serious risk include those 
who received extreme amounts of opioidsmore than an average daily 
MED of 240 mg 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).  Although the number decreased 
from 2016, a high number of beneficiaries are at serious risk in 2017.  In 
addition, almost 300 prescribers had questionable prescribing for the 
71,000 beneficiaries at serious risk.  This prescribing is far outside the norm 
and warrants 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.  These patterns may indicate that a 
beneficiary is receiving poorly coordinated care or that the beneficiarys care 
may need to be reassessed.  They may also indicate that opioids are being 
prescribed for medically unnecessary purposes and could be diverted for 
resale or recreational use. 
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.  However, focusing 
on prescribers alone is not enough.   
The severity of the opioid crisis makes it imperative that HHS, including CMS 
and OIG, continues to work together to develop new strategies to address 
this epidemic.  A multifaceted approach is necessary.  As the Department 
has highlighted, strengthening 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 research all need to be part of the strategy to 
fight the opioid crisis.38   
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As part of these efforts, CMS is implementing a number of new initiatives in 
2019 to address opioid overutilization in Part D.39  For instance, Part D 
sponsors will be able to restrict certain at-risk beneficiaries to selected 
pharmacies or prescribers for their opioid prescriptions (a practice known as 
lock in).40  Also, Part D sponsors will be expected to implement care 
coordination alerts at the point of sale when a beneficiarys total daily MED 
reaches or exceeds 90 mg.  Further, for beneficiaries starting opioids, Part D 
sponsors will be expected to limit initial opioid prescriptions to no more 
than 7 days for the treatment of acute pain.  These policies aim to increase 
patient safety in Part D by addressing multiple facets of the issue.  
OIG is also working to increase its efforts to fight the opioid crisis.  We are 
working with our law enforcement partners and with CMS 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 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 broader Department efforts.  For 
example, as noted earlier, OIG is conducting a series of reviews on opioid 
use in Medicaid and has ongoing reviews about key opioid initiatives in the 
Department.41   
OIG is also committed to continue forging 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.42   
In addition, we encourage Part D sponsors to work with OIG and CMS to 
improve efforts to combat opioid misuse in Medicare.  Sponsors are on the 
front lines of fighting the opioid crisis in Medicare Part D.  More specifically, 
we call on Part D sponsors to implement their new lock-in authority, as 
appropriate.  We also call on Part D sponsors to work with pharmacies to 
ensure that the new point-of-sale care coordination alerts are implemented 
and effective.  Specifically, sponsors should ensure that when these controls 
are triggered, the pharmacists consult with the prescribers before 
dispensing additional opioids.   
We also support States efforts to implement and enforce strong 
prescription drug monitoring programs that require prescribers and 
pharmacies to check the State database before prescribing and dispensing 
opioids.  Further, we encourage States to provide greater access to these 
data, including sharing these data with entities such as State Medicaid 
agencies.  We also encourage States to analyze these data to help identify 
patients who may be at risk and to promote appropriate opioid prescribing 
practices.  For example, States could provide reports to prescribers about 
Opioid Use in Medicare Part D Remains Concerning    12 
OEI-02-18-00220   
their opioid prescribing patterns.  By working together and expanding our 
efforts in Part D, we can help curb the opioid crisis in our Nation. 
   
  
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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 paid 
through other programs, prescriptions paid for in cash, or illicitly purchased 
drugs.  Part D sponsors submit a PDE record to CMS each time a drug is 
dispensed to a beneficiary enrolled in their plans.  Each record contains 
information about the drug and beneficiary as well as the identification 
numbers for the pharmacy and the prescriber.   
We matched PDE records to data from the First Databank, National Claims 
History File, Part C Encounter Data, CDCs morphine milligram equivalent 
(MME) conversion file, National Plan and Provider Enumeration System 
(NPPES), and the National Council for Prescription Drug Programs (NCPDP) 
database to obtain descriptive information about the drugs, beneficiaries, 
and pharmacies.  First Databank contains information about each drug, such 
as the drug name, strength of the drug, and therapeutic class (e.g., an 
opioid).  The National Claims History File contains claims data from 
Medicare Parts A and B, including diagnoses codes.  Part C Encounter Data 
contains medical claims data, including diagnosis codes, for beneficiaries 
enrolled in Medicare Advantage plans.  CDCs MME conversion file contains 
information about each opioids drug morphine milligram equivalence.43  
NPPES contains information about prescribers, such as their name, address, 
and taxonomy (i.e., specialty).  The NCPDP database contains information 
about pharmacies, such as their name and address.  For the purposes of this 
study, we use the term prescription to mean one PDE record. 
Analysis of Part D Opioid Utilization and Spending 
We identified all PDE records for opioids that beneficiaries received in 
2017.44  We calculated the total number of Part D beneficiaries who received 
opioids in 2017.  We then calculated the total number of opioid 
prescriptions paid for by Part D in 2017 and the average number of opioid 
prescriptions per beneficiary.  We compared the 2017 data to the data from 
2016 in our prior data brief.  Next we calculated total Part D spending for 
opioids from 2006 to 2017.  To do this, 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 we calculated the proportion of beneficiaries who received opioids in 
the Nation and in each State in 2017.  We based this analysis on the PDE 
records and the Medicare Enrollment Database.  We then identified the 
most commonly prescribed opioids by calculating the total number of 
prescriptions for each drug name (delineated by strength and form) and 
determined that average price per 30-day supply for each of these drugs in 
Opioid Use in Medicare Part D Remains Concerning    14 
OEI-02-18-00220   
2016 and 2017.  (When calculating these drug prices, we analyzed brand-
name and generic drugs separately.)  We use the term month to refer to a 
30-day supply.  Lastly, we counted the total number of days during the year 
that each beneficiary received opioids and determined the proportion that 
received opioids for at least 3 months. 
Beneficiary Analysis  
Next we determined the amount of opioids that each beneficiary received in 
2017.  To do this, we calculated each beneficiarys average daily morphine 
equivalent dose (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., PDE record).46  To do this, we used the 
following equation: 
(Strength per unit)(Quantity dispensed)(MME conversion factor)
MED=  
(Days supply)
Next we summed each beneficiarys MED for each day of the year based on 
the dates of service and days supply on each PDE record.  We refer to this 
as the daily MED.  We excluded from this analysis beneficiaries with a 
diagnosis of cancer or a hospice stay at any point in 2017.47   
We analyzed the MED data using the same criteria that we used in our 
previous analysis of the 2016 data.  We began by determining the extent to 
which beneficiaries received high amounts of opioids.  To do this, we 
calculated each beneficiarys average daily MED over each 90-day period in 
2017.  We determined that a beneficiary received high amounts of opioids if 
he or she exceeded an average daily MED of 120 mg for any 90-day period 
and had received opioids for 90 or more days in the year.  We used these 
criteria because they closely align with the criteria used by CMS in 2016 and 
2017 for its Overutilization Monitoring System.48  The MED of 120 mg also 
exceeds the level CDC recommends avoiding for patients with chronic 
painan MED of 90 mg.    
We then determined the extent to which beneficiaries received extreme 
amounts of opioids.  We calculated each beneficiarys average daily MED 
over the entire year.  We considered a beneficiary who exceeded an 
average daily MED of 240 mg for the entire year and had received opioids 
for 360 days or more to have received an extreme amount of opioids.    
Next we determined the extent to which beneficiaries appeared to be 
doctor shopping.  To do this, we calculated the total number of prescribers 
and pharmacies from which each beneficiary received opioids in 2017.  We 
considered beneficiaries to have appeared to be doctor shopping if they 
Opioid Use in Medicare Part D Remains Concerning    15 
OEI-02-18-00220   
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.   
Lastly, we compared the number of beneficiaries who received high 
amounts of opioids and who were at serious risk of opioid misuse or 
overdose to the number of beneficiaries we identified in our previous 
analysis of the 2016 data.  
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 that 
warrants further scrutiny. 
In total, 47,985 prescribers ordered opioids for beneficiaries who received 
extreme amounts, and 53,933 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.  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. 
Limitations 
This analysis is based on Part D PDE records; it is not based on a review of 
medical records.  The analysis does not include data on opioids that 
beneficiaries may have received from sources other than Part D.  
 
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:  STATE DATA 
Exhibit A-1: Alabama had the highest proportion of beneficiaries receiving 
opioids through Medicare Part D, while Hawaii had the lowest proportion. 
Proportion of Beneficiaries per State That Received Opioids Through 
Medicare Part D in 2017  
Alabama  44%  Colorado  31% 
Mississippi  43%  Ohio  30% 
Arkansas  42%  Nebraska  30% 
Oklahoma  41%  Montana  30% 
Louisiana  40%  Iowa  29% 
Tennessee  40%  New Mexico  29% 
Georgia  39%  Illinois  29% 
South Carolina  38%  Maryland  28% 
Kentucky  37%  Wisconsin  28% 
North Carolina  36%  Delaware  28% 
Missouri  36%  South Dakota  28% 
Indiana  35%  California  28% 
Texas  35%  Pennsylvania  27% 
West Virginia  35%  North Dakota  26% 
Kansas  34%  District of Columbia  26% 
Utah  34%  Minnesota  26% 
Idaho  34%  Maine  25% 
Michigan  34%  Connecticut  24% 
Nevada  33%  Rhode Island  24% 
Alaska  32%  New Jersey  24% 
Oregon  32%  Massachusetts  23% 
Arizona  32%  New Hampshire  23% 
Washington  31%  Vermont  22% 
Virginia  31%  New York  21% 
Florida  31%  Hawaii  20% 
Wyoming  31%     
Source: OIG analysis of Medicare Part D data, 2018. 
 
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APPENDIX B:  DATA ON BENEFICIARIES 
RECEIVING OPIOIDS THROUGH PART D 
Exhibit B-1: Almost 460,000 beneficiaries received high amounts of opioids through Part D in 
2017, fewer than in 2016. 
  Number of  Number of  
Beneficiaries  Beneficiaries  Percent 
in 2016  in 2017  Change 
Beneficiaries who received high amounts of opioids  501,008  458,935  -8% 
Source: OIG analyses of Medicare Part D data, 2017 and 2018. 
 
 
Exhibit B-2: About 71,000 beneficiaries are at serious risk of opioid misuse or overdose, fewer 
than in 2016. 
  Number of  Number of  
Beneficiaries  Beneficiaries  Percent 
in 2016  in 2017  Change 
Beneficiaries who received an extreme amount of opioids  69,563  57,611  -17% 
Beneficiaries who appear to be doctor shopping  22,308  14,814  -34% 
Total beneficiaries at serious risk  89,843*  71,260**  -21% 
Source:  OIG analyses of Medicare Part D data, 2017 and 2018. 
* A total of 2,028 beneficiaries were in both groups in 2016. 
** A total of 1,165 beneficiaries were in both groups in 2017. 
 
   
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ACKNOWLEDGMENTS 
Miriam Anderson served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Margaret Himmelright and Jason Kwong.  
Office of Evaluation and Inspections staff who provided support include 
Meghan Riggs.  We would also like to acknowledge the contributions of 
other Office of Inspector General staff, including Robert Gibbons and Lauren 
McNulty. 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 
General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. 
 
 
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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, 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. 
2 In 2016, there were 42,249 opioid-related overdose deaths; in 2010, there were 21,089.  See Holly Hedegaard, 
Margaret Warner, and Arialdi M. Minino, CDC, National Center for Health Statistics (NCHS), NCHS Data Brief 294, 
Drug Overdose Deaths in the United States, 19992016 and supplement tables, December 2017.  Accessed at 
https://www.cdc.gov/nchs/data/databriefs/db294.pdf and 
https://www.cdc.gov/nchs/data/databriefs/db294_table.pdf#page=1 on February 23, 2018. 
3 Wilson M. Compton, Deputy Director, National Institute on Drug Abuse, National Institutes of Health, U.S. 
Department of Health and Human Services, Research on the Use and Misuse of Fentanyl and Other Synthetic 
Opioids Congressional testimony, June 30, 2017.  Accessed at https://www.drugabuse.gov/about-nida/legislative-
activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids on March 26, 2018.  In 
addition, according to CDC, between 2015 and 2016 overdose deaths related to the category of opioids that includes 
fentanyl increased from 9,580 to 19,413 raising significant concern about diversion of fentanyl.  CDC, NCHS Data Brief 
294.  Drug Overdose Deaths in the United States, 19992016, December 2017.  Accessed at 
https://www.cdc.gov/nchs/data/databriefs/db294_table.pdf#page=1 on February 23, 2018.     
4 U.S. Drug Enforcement Administration, FAQs  Fentanyl and Fentanyl-Related Substances. Accessed at 
https://www.dea.gov/druginfo/fentanyl-faq.shtml on April 19, 2018. 
5 Diane L. Chau, Vanessa Walker, Latha Pai, et al., Opiates and Elderly: Use and Side Effects, Clinical Interventions in 
Aging 3, no. 2 (2008): 276.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/ on March 29, 2018.  
Also see CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, Morbidity and Mortality 
Weekly Report (MMWR): Recommendations and Reports 65, no. 1, March 18, 2016.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on March 27, 2018. 
6 Kathleen W. Saunders, Kate M. Dunn, Joseph O. Merrill, et al., Relationship of Opioid Use and Dosage Levels to 
Fractures in Older Chronic Pain Patients, Journal of General Internal Medicine 25, no. 4 (2010): 310315.  Accessed at 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842546/ on March 27, 2018. 
7 These guidelines provide recommendations for prescribing opioids for chronic pain outside of cancer treatment, 
palliative care, and end-of-life care.  See CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 
2016. MMWR Recommendations and Reports 65, no. 1, March 18, 2016, 149.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on March 27, 2018. 
8 Ibid. 16.  The CDC guidelines recommend that prescribers avoid increasing opioids to morphine equivalent dosages 
of greater than or equal to 90 mg a day or carefully justify the decision to increase to this level.   
9 Ibid. 24. 
10 CMS, CMS Opioid Misuse Strategy 2016, Strategy Paper, January 2017.  Accessed at https://www.cms.gov/Outreach-
and-Education/Outreach/Partnerships/Downloads/CMS-Opioid-Misuse-Strategy-2016.pdf on March 27, 2018.  
11 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.  CMS, Announcement 
of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment 
Policies and Final Call Letter, April 2018.  Accessed at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf on April 3, 2018.  Also see CMS, Analysis of 
Proposed Opioid Overutilization Criteria Modifications in Medicare Part D, April 2017.  Accessed at 
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Revised-OMS-
Criteria-Modification-Analysis.pdf on March 29, 2018.    
 
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12 Beginning in 2017, CMS expects Part D sponsors to implement controls at the point of sale that alert pharmacists 
when a beneficiarys opioid level (across all Part D prescriptions) exceeds certain levels.  For more information, see 
CMS, Announcement of Calendar Year (CY) 2017 Medicare Advantage Capitation Rates and Medicare Advantage and 
Part D Payment Policies and Final Call Letter, April 2016.  Accessed at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf on May 8, 2018. 
13 Federal Register, 83 F.R. 16440 (April 16, 2018).  Accessed at https://www.gpo.gov/fdsys/pkg/FR-2018-04-
16/pdf/2018-07179.pdf on April 18, 2018.   
14 OIG, Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing, OEI-02-17-00250, 
July 2017.   
15 The toolkit is based on the methodology OIG developed in its extensive work on opioids.  It provides technical 
information and is intended to assist our public and private sector partners with analyzing prescription drug claims 
data to help combat the opioid crisis.  See OIG, Toolkit: Using Data Analysis to Calculate Opioid Levels and Identify 
Patients At Risk of Misuse or Overdose, OEI-02-17-00560, June 2018. 
16 OIG, Opioids in Medicaid:  Concerns about Extreme Use and Questionable Prescribing in Selected States, OEI-05-18-
00010, forthcoming. 
17 OIG, Work Plan, 2018 at https://oig.hhs.gov/reports-and-publications/workplan/index.asp. 
18 In both years, the five most commonly dispensed opioids included tramadol 50mg, hydrocodone-acetaminophen  
10-325 mg, hydrocodone-acetaminophen 5-325 mg, hydrocodone-acetaminophen 7.5-325 mg, and oxycodone-
acetaminophen 10-325 mg.  
19 In total, 2.7 million of the 14.1 million beneficiaries who received at least one opioid had a cancer diagnosis or 
hospice care in 2017.  
20 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR Recommendations and 
Reports 65, no. 1, March 18, 2016, 25. 
21 In 2017, Part D paid a total of $481 million for these three strengths of hydrocodone-acetaminophen tablets.  
22 According to the manufacturer labels, the maximal daily dose for Percocet 5 mg is 12 tablets and the daily dosage 
for Vicodin 10 mg should not exceed 6 tablets.  For more information about Percocet, see Endo Pharmaceuticals, 
PERCOCET (Oxycodone and Acetaminophen Tablets, USP), 2.  Accessed at 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/040330s015,040341s013,040434s003lbl.pdf; for Vicodin, 
see page 20 at http://www.rxabbvie.com/pdf/vicodin_apap_300mg_hydrocodone_5mg-7_5mg-10mg_PI.pdf. 
23 An additional 180,160 beneficiaries had an average daily MED that exceeded 90 mgbut did not exceed 120 mg
for 3 months.  These levels also exceed the MED levels that CDC recommends avoiding for patients with chronic pain.  
See CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR Recommendations 
and Reports 65, no. 1, March 18, 2016, 25. 
24 U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information System, 
2016 Annual Report, 2017.  Accessed at 
https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS2016AR.pdf on 
March 28, 2018. 
25 This is based on a summary of the research CDC reviewed to develop its prescribing guidelines.  CDC, CDC 
Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR Recommendations and Reports 65, 
no. 1, March 18, 2016, 23.     
26 Ibid. 13, 44. 
27In addition to people over the age of 65, Medicare is available to younger people with disabilities and those with 
end-stage renal disease. U.S. Department of Health and Human Services, Who Is Eligible for Medicare?  Accessed at 
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html on April 12, 2018. 
28 A total of 38,994 of the same beneficiaries were identified as being at serious risk in both 2016 and 2017. 
29 This does not include beneficiaries who had cancer or were in hospice care. 
 
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OEI-02-18-00220   
 
30 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR Recommendations and 
Reports 65, no. 1, March 18, 2016, 10. 
31 CDC recommends that clinicians evaluate opioid use at least every 3 months for patients with chronic pain.  If the 
benefits of continued use do not outweigh the harm, clinicians should work with the patients to taper the opioids to a 
lower dosage or to discontinue use.  CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 
2016, MMWR Recommendations and Reports 65, no. 1, March 18, 2016, 16. 
32 Specifically, in 2017, 60 percent of Medicare Part D beneficiaries who received opioids have one prescriber and 
79 percent have one pharmacy.  This does not include beneficiaries who had cancer or hospice care. 
33 Although a statewide prescription drug management program for Missouri was authorized in 2017, it is not yet 
operational.  Currently, St. Louis County, Missouri, operates a program.  For more information, see Prescription Drug 
Monitoring Program, Training and Technical Assistance Center, Brandeis University.  Accessed at 
http://www.pdmpassist.org/ on March 20, 2018.  Also see Mo. Exec. Order 17-18.  Accessed at 
https://www.sos.mo.gov/library/reference/orders/2017/eo18 on June 7, 2018.  
34  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, Brandeis University, 2017.  Accessed at 
http://www.pdmpassist.org/pdf/2016_Best_Practice_Checklist_Report_20170228.pdf on March 29, 2018.  Also see The 
PEW Charitable Trusts, 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 
March 29, 2018. 
35 A total of 86,461 prescribers ordered opioids for at least one beneficiary at serious risk of opioid misuse or 
overdose in 2017.   
36 In total, 166 of the same prescribers were identified as having questionable opioid prescribing in both 2016 and 
2017.  OIG identified 401 prescribers with questionable opioid prescribing in 2016.  These prescribers each ordered 
opioids for at least 44 beneficiaries who received extreme amounts of opioids or 21 beneficiaries who appeared to be 
doctor shopping.  See OIG, Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing, 
OEI-02-17-00250, July 2017. 
37 Thirty-two prescribers ordered opioids for high numbers of beneficiaries in both groups at serious risk.   
38 Thomas E. Price, Secretary Price Announces HHS Strategy for Fighting Opioid Crisis, speech at the National Rx 
Drug Abuse and Heroin Summit, April 19, 2017, Atlanta, Georgia.  Accessed at 
https://www.hhs.gov/about/leadership/secretary/speeches/2017-speeches/secretary-price-announces-hhs-strategy-
for-fighting-opioid-crisis/index.html on March 30, 2018. 
39 CMS, Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and 
Part D Payment Policies and Final Call Letter, April 2018.  Accessed at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf on April 3, 2018.  
40 Under CARA, the Secretary of Health and Human Services has the authority to develop the guidelines under which 
beneficiaries are determined to be at-risk as well as which drugs are considered frequently abused.  See Pub. L. No. 
114-198,  704 (July 22, 2016).  Accessed at https://www.congress.gov/114/plaws/publ198/PLAW-114publ198.pdf on 
June 7, 2018.  For the 2019 plan year, at-risk beneficiaries will be, at minimum, defined as those who are considered 
high risk in the Overutilization Monitoring System, and most opioids and benzodiazepines will be designated as 
frequently abused drugs.  See Federal Register, 83 F.R. 16452 (April 16, 2018). Accessed at 
https://www.gpo.gov/fdsys/pkg/FR-2018-04-16/pdf/2018-07179.pdf on April 18, 2018. 
41 OIG, Opioids in Medicaid:  Concerns about Extreme Use and Questionable Prescribing in Selected States, OEI-05-18-
00010, forthcoming.  Also, see OIG, Work Plan, 2018 at https://oig.hhs.gov/reports-and-
publications/workplan/index.asp. 
42 Healthcare Fraud Prevention Partnership, Health Payer Strategies to Reduce the Harms of Opioids, White Paper, 
January 2017.  Accessed at https://downloads.cms.gov/files/hfpp/hfpp-opioid-white-paper.pdf on March 29, 2018. 
 
Opioid Use in Medicare Part D Remains Concerning    22 
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43 These files contain MME conversion factors for each National Drug Code (NDC).  MED and MME are 
interchangeable terms.   
44 Using CMSs Integrated Data Repository, we reviewed 75,976,074 PDE records for opioids with dates of service in 
2017.  To identify PDE records for opioids, we matched the NDCs on the PDE records with two filesFirst Databank 
and CDCs MME conversion file.   
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 28, 2018. 
46 We included opioids dispensed in 2016 with days of use in 2017.  This analysis excludes PDE records for injection, 
intravenous, and intrathecal opioids, as well as opioids indicated for medication-assisted treatment. 
47 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 2,667,678 beneficiaries with cancer or in hospice care who received at 
least one opioid.  
48 Through 2017, CMSs Overutilization Monitoring System identified beneficiaries who had a daily MED of 120 mg for 
90 days plus 4 or more prescribers and 4 or more pharmacies.   Note that the guidance uses the phrase more than 
3 prescribers and more than 3 pharmacies which is equivalent to 4 or more prescribers and 4 or more pharmacies.  
The criteria for the Overutilization Monitoring System changed in 2018.  See CMS, Announcement of Calendar Year 
(CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call 
Letter and Request for Information, April 2017.  Accessed at https://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2018.pdf on March 29, 2018.  
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