HHS OIG Data Brief    July 2019    OEI-02-19-00390 
 
Opioid Use Decreased in Medicare Part D, While 
Medication-Assisted Treatment Increased 
Why OIG Did This Review 
The Nation has been grappling with an opioid crisis for several 
Key Takeaways 
years.  In 2017 alone, there were 47,600 opioid-related overdose 
  In 2018, the use of opioids in 
deaths in the United States.  It continues to be a public health 
Medicare Part D decreased from 
emergency.  The Office of Inspector General (OIG) has been 
the previous 2 years. 
tracking opioid use in Medicare during this crisis, particularly since 
2016.1  OIG has identified beneficiaries at serious risk of misuse or    At the same time, more 
Medicare beneficiaries received 
overdose and has identified prescribers with questionable 
drugs for medication-assisted 
prescribing for these beneficiaries.  These types of analyses are 
treatment for opioid use 
crucial to understanding and addressing the national opioid crisis.  
disorder. 
Building on past OIG work, this data brief details opioid use in 
Medicare Part D in 2018 and trends in drugs used to treat opioid    The number of beneficiaries at 
use disorder.  serious risk decreased. 
  The number of prescribers with 
What OIG Found 
questionable opioid prescribing 
Nearly 3 in 10 Medicare Part D beneficiaries (29 percent) received 
for beneficiaries at serious risk 
opioids in 2018, a significant decrease from the previous 2 years.  
also decreased. 
At the same time, the number of beneficiaries receiving drugs for 
medication-assisted treatment (MAT) for opioid use disorder has    While concerns remain, the 
steadily increased and reached 174,000 in 2018.  In addition, the  decreases in use attest to the 
number of beneficiaries receiving prescriptions through Part D for  value of awareness, drug 
treatment, and law enforcement 
naloxonea drug that can reverse the effects of an opioid 
efforts in addressing the crisis. 
overdosemore than doubled from 2017 to 2018.   
 
Nearly 354,000 beneficiaries received high amounts of opioids in 
2018, with about 49,000 of them at serious risk of opioid misuse or overdose.  About 200 prescribers 
ordered opioids for large numbers of beneficiaries at serious risk.    
What OIG Concludes 
Progress has been made in decreasing 
opioid use in Part D and increasing the use 
of MAT drugs and the availability of 
naloxone.  It is imperative for the 
Department of Health and Human 
Servicesincluding the Centers for 
Medicare & Medicaid Services (CMS) and 
OIGto continue to implement effective 
strategies and develop new ones to address 
this epidemic.     
  RESULTS 
Nearly 3 in 10  In 2018, nearly 3 in 10 beneficiaries received at least one prescription opioid 
through Medicare Part D.  Twenty-nine percent of beneficiaries
Medicare Part D 
13.4 million of the total of 46.8 million beneficiaries enrolled in Medicare 
beneficiaries  Part Dreceived opioids.  This is a significant decrease from 2017, when 
31 percent of beneficiaries received opioids through Part D, and from 2016, 
received opioids in 
when 33 percent did.  (See Appendix A for information about opioid use in 
2018, a decrease 
each State.) 
from the previous   
Part D paid for 71 million opioid prescriptionsan average of 
2 years  5.3 prescriptions per beneficiary receiving opioids in 2018.2  This too was 
a decrease from 2017 and 2016, when Part D paid for 76 million and 
 
79 million opioid prescriptions, respectively.  Tramadol was the most 
commonly dispensed opioid in each of the 3 years.3 
Overall Part D spending for opioids also went down; Part D paid $3.1 billion 
for opioids in 2018, compared to $3.4 billion in 2017 and $4.0 billion in 2016.  
See Exhibit 1. 
Exhibit 1:  Spending for opioids in Part D has continued to decrease, 
but remained at over $3 billion in 2018 
$4.2
$4.1 $4.0
$3.5 $3.4
$3.1 $3.1
$3.0
$2.9
$2.8
$2.5
$2.2
$1.7
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
*Spending in billions
 
    Source:  OIG analysis of Medicare Part D data, 2019. 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  2 
OEI-02-19-00390  Beneficiaries use  Beneficiaries use of drugs for medication-assisted treatment (MAT) has 
steadily increased in Part D.  These drugs help treat opioid use disorder 
of drugs for 
(OUD)a problematic pattern of opioid use that leads to clinically 
medication-
significant impairment or distress.4  These medications should be prescribed 
assisted treatment  in combination with counseling and behavioral health therapies.  Research 
shows that this combination can successfully treat OUD and prevent 
has increased in 
relapse.5  Part D covers two drugs indicated for the treatment of OUD:  
Part D 
buprenorphine and naltrexone.6  We refer to these drugs as MAT drugs.  
In 2018, the number of Medicare beneficiaries receiving MAT drugs through 
Part D reached 174,000, an increase of 22 percent from 2017.  See Exhibit 2. 
Exhibit 2:  The number of beneficiaries receiving MAT drugs through 
Part D has increased each year 
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
2006 2007 20082009 2010 2011 2012 2013 2014 2015 2016 2017 2018
   Source:  OIG analysis of Medicare Part D data, 2019. 
The number of prescriptions for MAT drugs also has increased steadily in 
Part D.  From 2017 to 2018, this number rose from 1.3 million to 1.6 million 
prescriptions, an increase of 24 percent.  Previously, from 2016 to 2017, the 
number of prescriptions for these drugs also had increased by 24 percent.  
Congress and the Department have taken steps to increase access to MAT 
drugs, which may have contributed to these increases.7  (See Appendix B for 
more information on the use of MAT drugs in Part D.) 
 
Many more  The number of beneficiaries receiving naloxone prescriptions through 
Part D more than doubled from 2017 to 2018.  Naloxone is a drug that can 
beneficiaries are 
reverse the effects of an opioid overdose and prevent death.  Overdoses 
receiving opioid 
occur when high doses of opioidsalone or in combination with other 
overdose reversal  substancescause breathing to slow to dangerous levels or to stop 
drugs through  altogether.  When administered in a timely fashion, naloxone can save lives 
by blocking the effects of opioids and restoring normal breathing.  
Part D 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  3 
OEI-02-19-00390  The Department has made increasing the availability of naloxone a priority 
in its efforts to combat the opioid crisis.8  
Almost a quarter of a million beneficiaries (222,655) received a naloxone 
prescription in 2018, about two and a half times the number of beneficiaries 
in 2017.9  See Exhibit 3.   
Exhibit 3:  The number of beneficiaries receiving prescriptions for 
naloxonea drug that can reverse an opioid overdosemore than 
doubled from 2017 to 2018 
  225,000
200,000
 
175,000
 
150,000
  125,000
100,000
 
75,000
 
50,000
  25,000
0
 
2006200720082009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Source:  OIG analysis of Medicare Part D data, 2019. 
The total number of prescriptions for naloxone also more than doubled 
from 2016 to 2017 in Part D and more than doubled again the next year, 
reaching 239,210 prescriptions in 2018.  Congress and the Department have 
taken steps to increase the availability of naloxoneas they have done with 
MAT drugs which may be contributing to these increases.10  (See 
Appendix B for more information on the use of naloxone in Part D.)  
 
More than 350,000  In 2018, a total of 353,751 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.  This is a decrease of 23 percent from 2017, when 
received high 
458,935 beneficiaries received high amounts of opioids.  In 2016, a total of 
amounts of opioids  501,008 beneficiaries received high amounts of opioids.11   
in 2018 
Each of the 353,751 beneficiaries who received high amounts of opioids in 
  2018 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.   
Although beneficiaries may receive opioids for legitimate purposes, these 
amounts raise concern.  The Centers for Disease Control and Prevention 
(CDC) recommends that prescribers use caution when ordering opioids at 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  4 
OEI-02-19-00390  any dosage and avoid increasing dosages to the equivalent of 90 mg or 
more MED a day for chronic pain.12  
Opioids also carry health risks, including respiratory depression, 
constipation, drowsiness, and confusion.13  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.14 
 
Almost 49,000  Two groups of beneficiaries that are at serious risk of opioid misuse or 
overdose are (1) beneficiaries who receive extreme amounts of opioids and 
beneficiaries are at 
(2) beneficiaries who appear to be doctor shopping.  Other Part D 
serious risk of 
beneficiaries may also be at serious risk of opioid misuse or overdose but 
opioid misuse or  do not fall into either group.  
overdose, fewer 
A total of 48,558 beneficiaries were in these two groups in 2018.15  This does 
than in the previous  not include beneficiaries who have cancer or were in hospice care.  
2 years  Specifically, 40,374 beneficiaries received extreme amounts of opioids (i.e., 
an average daily MED greater than 240 mg for 12 months) and 
 
8,796 beneficiaries appeared to be doctor shopping (i.e., received high 
amounts of opioids and had 4 or more prescribers and 4 or more 
pharmacies).  A total of 612 beneficiaries were in both groups.   
The number of beneficiaries at serious risk (48,558) was lower in 2018 than 
in previous years.  OIG identified 71,260 beneficiaries at serious risk of 
opioid misuse or overdose in 2017 and 89,843 in 2016.16  The numbers of 
beneficiaries in each of the two groups has decreased, with the larger drop 
occurring with beneficiaries who appear to be doctor shopping.  (See 
Appendix C for more detailed information.)  Despite the decrease, tens of 
thousands of beneficiaries in these two groups are still at serious risk.   
Receiving extreme amounts of opioids or high amounts of opioids from 
multiple prescribers and pharmacies raises concern.  It may signal that 
a beneficiarys care is not being monitored or coordinated properly or that 
a beneficiarys care needs to be reassessed.17  It may also indicate that 
a beneficiary is seeking medically unnecessary drugs, perhaps to use them 
recreationally or to divert them or that a beneficiary is addicted to opioids 
and at risk of overdose.   
Furthermore, a beneficiarys 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 States but 
Missouri maintain databasescalled prescription drug monitoring 
programsthat track prescriptions for controlled substances.18  Prescribers 
can check these databases before ordering opioids to determine whether 
a beneficiary is already receiving opioids ordered by other prescribers.19 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  5 
OEI-02-19-00390   
Examples of Beneficiaries at Serious Risk of Misuse or Overdose 
A Pennsylvania beneficiary received 10,728 oxycodone tablets and 
570 fentanyl patches in 2018.  Her average daily MED was nearly 
2,900 mg for the year32 times the level that CDC recommends 
avoiding.  She received all of her opioid prescriptions from a single 
physician.   
A New York beneficiary received 38 opioid prescriptions during the year, 
including 14 1-month supplies of one strength of extended release 
morphine tablets and an additional 13 1-month supplies of another 
strength of morphine.  In total, this beneficiarys average daily MED for 
the year was 2,173 mg.  All of her prescriptions were ordered by a single 
physician. 
Over the course of a year, an Alabama beneficiary received 56 opioid 
prescriptions ordered by 25 prescribers and filled at 5 pharmacies.  These 
included prescriptions for morphine, oxycodone, and oxycodone-
acetaminophen.  In 1 month alone, this beneficiary received 
seven prescriptions from five different prescribers. 
   
Almost 200  About 58,000 prescribers ordered opioids for at least 1 beneficiary at serious 
risk of opioid misuse or overdose (i.e., a beneficiary who has received 
prescribers had 
extreme amounts or appeared to be doctor shopping) in 2018.20  The vast 
questionable opioid 
majority of these prescribers each ordered opioids for only one or two of 
prescribing for  these beneficiaries.  Some prescribers ordered for many more.   
beneficiaries at 
A total of 198 prescribers stand out as having questionable prescribing; they 
serious risk  
were far outside the norm with their prescribing and warrant further 
scrutiny.  They ordered opioids for the highest numbers of beneficiaries at 
serious risk.  Specifically, 106 prescribers each ordered opioids for at least 
39 beneficiaries who received extreme amounts of opioids in 2018.  Further, 
98 prescribers each ordered opioids for at least 16 beneficiaries who 
appeared to be doctor shopping.21 
The number of prescribers with questionable prescribing for beneficiaries at 
serious risk decreased in 2018.  There were 198 of these prescribers in 2018, 
down from 282 in 2017 and 401 in 2016.22 
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.   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  6 
OEI-02-19-00390  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.  
In total, these 198 prescribers with questionable prescribing ordered 
112,028 opioid prescriptions in 2018 for beneficiaries at serious risk, costing 
Part D a total of $32.4 million.  As in previous years, a little more than 
one-third of these prescribers were nurse practitioners or physician 
assistants.  In total, 41 were nurse practitioners and 34 were physician 
assistants.   
 
  Examples of Prescribers with Questionable Prescribing Patterns 
  One physician in Florida ordered opioids for 104 beneficiaries who 
received extreme amounts of opioids during 2018.  In total, this physician 
 
ordered 2,619 opioids for these beneficiaries, costing Part D almost 
$1.2 million.  In one instance, this physician ordered 37 opioid 
 
prescriptions for a single beneficiary, all of which were for oxycodone.  
  The beneficiary had an average daily MED that was over 10 times the 
level that CDC recommends avoiding.   
 
A physician in West Virginia ordered 1,419 opioids in 2018 for 
 
99 beneficiaries who received extreme amounts of opioids.  Part D paid 
  nearly $303,000 for these opioids, the majority of which were oxycodone, 
morphine, and oxymorphone. 
 
A physician in South Carolina ordered 237 opioids in 2018 for 
 
46 beneficiaries who appeared to be doctor shopping.  About half of 
these opioid prescriptions were for oxycodone.   
 
 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  7 
OEI-02-19-00390  CONCLUSION 
Opioid use in Medicare Part D has decreased in 2018, while the use of drugs 
for medication-assisted treatment has increased.  The number of 
beneficiaries receiving prescriptions through Part D for naloxonea drug 
that can reverse the effects of an opioid overdosehas also increased.  In 
addition, in 2018 there were fewer Part D beneficiaries receiving high 
amounts of opioids and fewer beneficiaries at serious risk of opioid misuse 
or overdose than in the previous 2 years.  The number of prescribers with 
questionable opioid prescribing for beneficiaries at serious risk has also 
decreased.  Despite this apparent progress, concerns remain.   
Almost 3 in 10 Part D beneficiaries received an opioid in 2018.  About 
354,000 beneficiaries received high amounts of opioids during the year, 
with about 49,000 of them at serious risk of opioid misuse or overdose.  
Although opioids may be necessary for some patients, the extreme use of 
opioids and apparent doctor shopping described in this study raise concern.  
These patterns may indicate that a beneficiary is receiving poorly 
coordinated care or that the beneficiarys care may need to be reassessed.  
They also may indicate that opioids are being prescribed for medically 
unnecessary purposes and could be diverted for resale or recreational use.  
Although progress has been made in decreasing opioid use in Part D and 
increasing the use of MAT drugs and the availability of naloxone, it is 
imperative for the Department to continue to implement effective strategies 
and develop new ones to address this epidemic.  While concerns remain, 
the decreases in use attest to the value of awareness, drug treatment, and 
law enforcement efforts in addressing the opioid crisis.  
The Department has a five-point strategy to combat opioid misuse and 
overdose that emphasizes increasing access to treatment and better 
targeting the availability of opioid-reversal drugs.23  The Department has 
also begun implementing the SUPPORT for Patients and Communities Act, 
which was signed into law in October 2018.24  The law takes a multifaceted 
approach to addressing the opioid crisis and contains many provisions 
related to Medicare and Medicaid.  It aims to expand access to prevention, 
treatment, and recovery services and, at the same time, to reduce access to 
the supply of inappropriate opioids.  Key aspects include requiring CMS to 
notify outlier prescribers of opioids on an annual basis and requiring 
Part D plan sponsors to implement drug management programs beginning 
in 2022.  Under these drug management programswhich are currently 
voluntarysponsors may restrict certain at-risk beneficiaries to selected 
pharmacies or prescribers for their opioid prescriptions.   
 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  8 
OEI-02-19-00390  In addition, CMS implemented a number of changes in 2019.25  For example, 
Part D sponsors are now 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 are now 
expected to limit initial opioid prescriptions to no more than 7 days for the 
treatment of acute pain.  
OIG remains committed to fighting the opioid crisis.  In June 2018, OIG 
released an opioid analysis toolkit that provides step-by-step instructions 
for using prescription drug data to identify patients who are at risk of opioid 
misuse or overdose.26  We are also working with our law enforcement 
partners and with CMS to follow up on the prescribers we identified in our 
reviews as having questionable opioid prescribing.  This includes working 
closely with the Department of Justices Appalachian Regional Prescription 
Opioid Strike Force.27  In addition to continuing our enforcement efforts, we 
continue to identify other approaches to support prevention and treatment 
efforts and to improve the effectiveness of broader Department efforts.  For 
example, OIG is conducting a series of reviews on key State and 
Departmental initiatives to address the opioid crisis, including access to 
MAT drugs.28  
Looking forward, we encourage Part D sponsors to work with OIG and CMS 
to bolster their efforts to combat the opioid crisis in Medicare Part D on the 
front lines.  As part of their efforts, we call on Part D sponsors to implement 
drug management programs for at-risk beneficiaries.  We also support CMS 
and the Department as a whole in their efforts to fully implement the 
SUPPORT for Patients and Communities Act and to provide improved 
access to prevention, treatment, and recovery services. 
Lastly, we 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.  We also encourage States to provide greater access to these data, 
including sharing the data with entities such as State Medicaid agencies. 
 
 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  9 
OEI-02-19-00390  METHODOLOGY 
We based this data brief on an analysis of prescription drug event (PDE) 
records for Part D drugs.  These PDE records are for prescriptions that 
beneficiaries received through Part D.  They do not include prescriptions 
paid for 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.   
To obtain descriptive information about the drugs, beneficiaries, and 
prescribers, we matched PDE records to data from the First DataBank, the 
National Claims History File, Part C Encounter Data, CDCs Morphine 
Milligram Equivalent (MME) conversion file, and the National Plan and 
Provider Enumeration System (NPPES).  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 diagnosis 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 opioid drugs morphine milligram 
equivalence.29  The NPPES contains information about prescribers, such as 
their name, address, and taxonomy (i.e., specialty).  For the purposes of this 
study, we use the term prescription to mean one PDE record. 
Analysis of Part D Utilization of Opioids, Drugs for MAT, and 
Naloxone 
We identified all PDE records for opioids that beneficiaries received in 
2018.30  We calculated the total number of Part D beneficiaries who received 
opioids in 2018.  We then calculated the total number of opioid 
prescriptions paid for by Part D in 2018 and the average number of opioid 
prescriptions per beneficiary.  We compared the 2018 data to the data from 
2016 and 2017 in our previous data briefs, which used the same 
methodology.  Next, we calculated total Part D spending for opioids from 
2006 (the first year of Part D) to 2018.  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 2018.  We based this analysis on the PDE 
records and Medicare enrollment data.  We then identified the most 
commonly prescribed opioids by calculating the total number of 
prescriptions for each drug name (delineated by strength and form).  
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  10 
OEI-02-19-00390  We then identified all PDE records for (1) MAT drugs indicated for the 
treatment of OUD and (2) naloxone (the opioid overdose reversal drug).  
We first calculated the total number of beneficiaries who received MAT 
drugs and the number of prescriptions for these drugs from 2006 through 
2018. 31  Next, we calculated the total number of beneficiaries who received 
naloxone and the number of prescriptions for naloxone from 2006 through 
2018.32 
Beneficiary Analysis  
We determined the amount of opioids that each beneficiary received in 
2018.  To do this, we calculated each beneficiarys average daily morphine 
equivalent dose (MED). 33  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., for each PDE record).34  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 who had 
a diagnosis of cancer or a hospice stay at any point in 2018.35   
We analyzed the MED data using the same criteria that we used in our 
previous analysis of the 2016 and 2017 data. 36  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 2018.  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.  
The MED of 120 mg exceeds the 90-mg MED level that CDC recommends 
avoiding for patients with chronic pain.    
We then determined the extent to which these 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 2018.  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, 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  11 
OEI-02-19-00390  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 numbers of beneficiaries that we had previously identified 
in our analyses of the 2016 and 2017 data.  
Prescriber Analysis  
For this analysis, we identified prescribers who ordered opioids for a high 
number of beneficiaries at serious riski.e., beneficiaries who received 
extreme amounts of opioids and beneficiaries who appeared to be doctor 
shopping.  We considered these prescribers to have questionable 
prescribing patterns that warrant further scrutiny. 
In total, 34,930 prescribers ordered opioids for beneficiaries who received 
extreme amounts of opioids and 32,317 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 he or she 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, MAT drugs, 
or naloxone that beneficiaries may have received from sources other than 
Part D.  
 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  12 
OEI-02-19-00390  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 in Each State Who Received Opioids Through 
Medicare Part D in 2018 
Alabama  42%  Nebraska  28% 
Arkansas  40%  Virginia  28% 
Mississippi  39%  Ohio  27% 
Oklahoma  38%  Nevada  27% 
Louisiana  37%  Iowa  27% 
Tennessee  36%  New Mexico  27% 
Georgia  36%  Illinois  27% 
Kentucky  35%  Wisconsin  26% 
South Carolina  34%  Maryland  26% 
Missouri  33%  South Dakota  26% 
Texas  33%  California  26% 
North Carolina  33%  Delaware  25% 
Indiana  32%  Pennsylvania  25% 
Kansas  32%  North Dakota  25% 
Utah  32%  Minnesota  24% 
Idaho  31%  District of Columbia  24% 
West Virginia  31%  Maine  22% 
Michigan  30%  Connecticut  22% 
Oregon  30%  New Jersey  21% 
Wyoming  29%  Massachusetts  21% 
Washington  29%  Rhode Island  21% 
Alaska  29%  New Hampshire  21% 
Colorado  29%  Vermont  19% 
Florida  28%  New York  19% 
Arizona  28%  Hawaii  18% 
Montana  28%       
Source:  OIG analysis of Medicare Part D data, 2019. 
 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  13 
OEI-02-19-00390  APPENDIX B:  USE OF MEDICATION-ASSISTED 
TREATMENT DRUGS AND NALOXONE IN 
PART D 
Exhibit B-1:  Both the number of beneficiaries and the number of prescriptions for 
medication-assisted treatment (MAT) drugs for opioid use disorder increased between 2016 and 
2018. 
  Percent  Percent 
Change  Change 
from 2016   from 2017 
2016  2017  2018  to 2017  to 2018 
Beneficiaries who received a MAT drug  113,964  142,204  174,000  25%  22% 
through Part D 
Part D prescriptions for drugs for MAT  1,030,730  1,278,161  1,591,112  24%  24% 
Source:  OIG analysis of Medicare Part D data, 2019. 
 
 
Exhibit B-2:  The number of beneficiaries and the number of prescriptions for naloxone more 
than doubled each year, between 2016 and 2018. 
  Percent  Percent 
Change  Change 
from 2016   from 2017 
2016  2017  2018  to 2017  to 2018 
Beneficiaries who received naloxone  37,041  89,906  222,655  143%  148% 
through Part D 
Part D prescriptions for naloxone  39,904  96,345  239,210  141%  148% 
Source:  OIG analysis of Medicare Part D data, 2019. 
 
 
 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  14 
OEI-02-19-00390  APPENDIX C:  BENEFICIARIES RECEIVING 
OPIOIDS THROUGH PART D 
Exhibit C-1:  Almost 354,000 beneficiaries received high amounts of opioids through Part D in 
2018, a decrease from the previous 2 years. 
  Percent  Percent 
Change  Change 
from 2016   from 2017 
2016  2017  2018  to 2017  to 2018 
Beneficiaries who received high  501,008  458,935  353,751  -8%  -23% 
amounts of opioids   
Source:  OIG analyses of Medicare Part D data, 2017, 2018, and 2019. 
 
 
Exhibit C-2:  About 49,000 beneficiaries are at serious risk of opioid misuse or overdose in 2018, 
a decrease from the previous 2 years. 
  Percent  Percent 
Change  Change 
from 2016  from 2017 
2016  2017  2018  to 2017  to 2018 
Beneficiaries who received an  69,563  57,611  40,374  -17%   -30% 
extreme amount of opioids   
Beneficiaries who appear to be  22,308  14,814  8,796  -34%   -41% 
doctor shopping   
Total beneficiaries at serious risk  89,843*  71,260**  48,558***  -21%   -32% 
Source:  OIG analyses of Medicare Part D data, 2017, 2018, and 2019. 
* A total of 2,028 beneficiaries were in both groups in 2016. 
** A total of 1,165 beneficiaries were in both groups in 2017. 
*** A total of 612 beneficiaries were in both groups in 2018. 
 
 
   
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  15 
OEI-02-19-00390  ACKNOWLEDGMENTS 
Miriam Anderson served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Margaret Himmelright and Jason Kwong.  
Office of Evaluation and Inspections staff who provided support include 
Adam Freeman and Christine Moritz.  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 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. 
 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  16 
OEI-02-19-00390  ENDNOTES 
 
1 OIG first began tracking opioid use in  Part D in  2014.   In 2016  and 2017,  OIG conducted more  in-depth  reviews  that  
determined the number of beneficiaries who were  receiving high  amounts of opioids,  as well as the number  of 
beneficiaries who were at serious risk for opioid misuse or overdose and the number of prescribers  with questionable 
opioid prescribing for these beneficiaries.   See  OIG, Questionable Billing and Geographic Hotspots Point to Potential 
Fraud and Abuse in Medicare Part D, OEI-02-15-00190, June 2015; OIG, High Part D Spending on Opioids and 
Substantial Growth in Compounded Drugs Raise Concerns, OEI-02-16-00290, June 2016; OIG, Opioids in Medicare  
Part  D: Concerns About Extreme Use and Questionable Prescribing,  OEI-02-17-00250, July  2017; OIG, Opioid Use in 
Medicare Part D Remains Concerning, OEI-02-18-00220, June 2018. 
2 This represents the total number of opioid prescriptions paid for under Part D, including those in the deductible 
stage of the benefit when  some beneficiaries pay the full cost.  
3 In 2016, 2017, and  2018, the  most commonly dispensed opioids  included tramadol 50 mg, hydrocodone 
acetaminophen 10-325 mg, hydrocodone-acetaminophen 5-325 mg, and hydrocodone-acetaminophen 7.5-325 mg.   
4  Diagnostic and Statistical Manual of Mental Disorders:  DSM-5. Arlington, VA: American Psychiatric Publishing, 2013.  
5 SAMHSA,  Medication and Counseling Treatment.  Accessed  at  https://www.samhsa.gov/medication-assisted-
treatment/treatment on May 28, 2019. 
6 Methadone is  another drug used for MAT.   However, methadone used for MAT is not covered by Part  D.   See  
Medicare Prescription Drug Benefit Manual,  ch. 6,  10.8.  Accessed at https://www.cms.gov/Medicare/Prescription-
Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf on May 28, 2019.   
7 For  example, Section 303 of the Comprehensive Addiction and Recovery Act of 2016 (CARA), P.L. No. 114-198 
(enacted July 22, 2016), and  Section 3201 of the Substance UseDisorder Prevention that Promotes Opioid Recovery 
and Treatment for Patients and Communities Act (SUPPORT for Patients and Communities Act), P.L. No. 115-271 
(enacted October 24, 2018), expanded prescribing authority for MAT drugs.   The Departments five-point  strategy to 
combat opioid misuse and overdose  also emphasizes increasing access to medication-assisted treatment.  See HHS,  
Strategy to Combat Opioid Abuse, Misuse, and Overdose, September 2018.  Accessed at 
https://www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-508compliant.pdf on 
May 28, 2019. 
8 HHS, Better Availability  of Overdose-Reversing Drugs.  Accessed at https://www.hhs.gov/opioids/about-the-
epidemic/hhs-response/better-overdose-response/index.html on May  28, 2019. 
9 The total number of beneficiaries who  received naloxone may be underestimated.  This number includes  only 
naloxone prescriptions that  were paid for by Part D. 
10 For  example, Section 107 of CARA, P.L.  No. 114-198  (enacted July 22,  2016) authorized the Department to award 
grants to expand access to  opioid-overdose reversal  drugs,  e.g. naloxone.  The Departments  five-point strategy to 
combat opioid misuse and overdose  also emphasizes increasing availability of opioid-reversal drugs.  See HHS, 
Strategy to Combat Opioid Abuse, Misuse, and Overdose.  Accessed at 
https://www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-508compliant.pdf on 
May 28, 2019.  
11 In addition, a smaller percentage of  beneficiaries  who received an opioid received  high amounts  of opioids.  
In 2018, 2.6 percent of beneficiaries who  received an opioid received high amounts, down from 3.3 percent in 2017 
and  3.5 percent  in  2016. 
12 The CDC Guideline provides recommendations for prescribing opioids for  chronic pain  outside of cancer treatment, 
palliative care, and end-of-life care.  It recommends 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.  CDC, CDC 
Guideline for Prescribing Opioids for Chronic Pain:  United States, 2016. MMWR [Morbidity and Mortality Weekly  
Report] Recommendations and Reports, Vol. 65,  No.  1, March 18,  2016, pp. 149.   Accessed at 
 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  17 
OEI-02-19-00390   
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on May  28, 2019.  
13 Diane  L. Chau, Vanessa  Walker,  Latha Pai, et  al., Opiates and Elderly: Use and Side Effects, Clinical Interventions in  
Aging, Vol. 3, No. 2 (2008), p. 276.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/ on May 28, 
2019.  Also see CDC, CDC  Guideline for Prescribing Opioids for Chronic Pain:  United States, 2016, details above in 
endnote 12.  
14 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, Vol. 25, No. 4  (2010), pp.  310315.   
Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842546/ on May 28, 2019.  
15 This group of beneficiaries is a subset of the 353,751 beneficiaries who received  high amounts of opioids.   
16 A total of 19,192 of the beneficiaries identified as being  at serious risk in 2018 were also identified  as such in both 
2016 and 2017.  This  represents 40 percent of the  beneficiaries at serious  risk  in 2018.  
17 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 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, details above in  endnote 12. 
18 Missouri is the only  State that lacks a Statewide prescription  drug monitoring program.   Currently, St. Louis County, 
Missouri, operates  a program.  For more information about prescription drug monitoring  programs, see Prescription 
Drug Monitoring Program Training and Technical Assistance Center, Brandeis University, untitled webpage.  Accessed  
at http://www.pdmpassist.org/ on May 28. 2019.   
19 State requirements for checking this  information  vary.  For more information about these programs, see 
Prescription Drug Monitoring Program Training and  Technical Assistance  Center, Brandeis University, Tracking PDMP 
Enhancement: The Best Practice  Checklist, 2017.  Accessed at  
http://www.pdmpassist.org/pdf/2016_Best_Practice_Checklist_Report_20170228.pdf  on March 29, 2018.   See  also  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  
May 28, 2019.   
20 A total of 58,144 prescribers ordered opioids for at least 1 beneficiary at serious risk of opioid misuse or overdose in 
2018.    
21 Six prescribers ordered opioids for high numbers of beneficiaries  in both  groups  at serious  risk.    
22 In total, we identified 73  prescribers as having  questionable  opioid prescribing in  2016, 2017, and 2018.  OIG 
identified 282 prescribers with questionable opioid prescribing in 2017.  These prescribers each ordered  opioids for at 
least 45 beneficiaries who  received extreme amounts  of opioids  or  18 beneficiaries who appeared to be doctor 
shopping.  See OIG, Opioid  Use in  Medicare Part  D Remains Concerning,  OEI-02-18-00220, June 2018.   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.   We are working  with our law enforcement partners and with CMS to  follow up  on the prescribers we 
identified in  our reviews  as  having  questionable opioid  prescribing.  
23 HHS, Strategy  to Combat Opioid Abuse, Misuse, and Overdose, September 2018.   Accessed at 
https://www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-508compliant.pdf on 
May 28, 2019. 
24 SUPPORT for Patients and Communities  Act, P.L. No. 115-271. 
25 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.  
 
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  18 
OEI-02-19-00390   
26 OIG, Toolkit:  Using Data Analysis To Calculate Opioid  Levels and Identify Patients At Risk of Misuse or Overdose, 
OEI-02-17-00560, June 2018. 
27 In October 2018, the  Department of Justice (DOJ)  announced the  creation of the Appalachian Regional Prescription 
Opioid (ARPO) Strike Force to address illegal opioid prescriptions.  The ARPO Strike Force originally consisted of 
jurisdictions in five States: Alabama, Kentucky, Ohio, Tennessee, and West Virginia.  See  DOJ, Justice Departments 
Criminal Division Creates Appalachian Regional Prescription Opioid  Strike Force to Focus on Illegal Opioid Prescriptions.  
Accessed at  https://www.justice.gov/opa/pr/justice-department-s-criminal-division-creates-appalachian-regional-
prescription-opioid on June  10, 2019.  To support the efforts of the ARPO Strike Force, OIG released the data brief 
Concerns about Opioid Use in Medicare Part D in the Appalachian Region, OEI-02-18-00224.  The ARPO Strike Force 
has since expanded into Virginia.  See DOJ, Appalachian Regional Prescription Opioid (ARPO) Strike Force  Takedown  
Results in Charges Against 60 Individuals, Including 53 Medical Professionals.  Accessed at 
https://www.justice.gov/opa/pr/appalachian-regional-prescription-opioid-arpo-strike-force-takedown-results-
charges-against on  May 28, 2019.   
28 For  example, OIG is releasing a series of factsheets on States oversight opioid prescribing  and monitoring.  See 
OIG,  States' Oversight of Opioid  Prescribing and Monitoring of Opioid Use.  Accessed at  
https://oig.hhs.gov/oas/opioid-oversight-map/oversight.asp on May  28, 2019.  OIG is also  assessing access to  certain  
MAT drugs,  see OIG, Access to Buprenorphine-Waivered Providers for Treatment of Opioid Use  Disorder, 
OEI-12-17-00240, forthcoming.   For more information about other planned  opioid-related  OIG work, see  OIG,  Work 
Plan, 2019 at https://oig.hhs.gov/reports-and-publications/workplan/index.asp. 
29 These files contain MME  conversion  factors for each National Drug Code.  MED  and MME are interchangeable  
terms.   
30 Using CMSs  Integrated  Data Repository, we reviewed 70,587,887  PDE  records  for opioids with dates of service in 
2018.  To  identify PDE records for  opioids,  we matched the NDCs  on the PDE records with two files: First DataBank 
and CDCs MME conversion file.   
31 Part  D  covers two MAT drugs indicated for OUD:  buprenorphine  and naltrexone.  Some buprenorphine products 
indicated for OUD also contain naloxone,  e.g. Suboxone.  To identify PDE records for MAT drugs  containing 
buprenorphine or naltrexone, we matched the NDCs to First  Databank.   We reviewed  each  drug and  included all 
formulations indicated for the treatment of OUD.  Note that some of these formulations  are also indicated for alcohol 
use disorder.  We based  this on PDE records from CMSs Integrated Data Repository. 
32 To identify PDE records for naloxone, we matched the NDCs to First Databank.  We included formulations indicated 
for the emergency  treatment of a  known or suspected opioid overdose in this analysis.  We based this on PDE 
records from CMSs Integrated Data Repository.  
33 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 May 23, 2019. 
34 We  included  opioids dispensed in 2017 with days of use in 2018.  This analysis excludes  PDE  records for injection, 
intravenous, and intrathecal  opioids, as well as opioids indicated for medication-assisted treatment. 
35 We  identified beneficiaries  with a cancer diagnosis or hospice stay by using CMSs  National Claims History File and 
Part C Encounter data.   In  total,  we  identified  2,982,945 beneficiaries with cancer or in hospice care who received at 
least 1 opioid.    
36 We  selected these criteria because  they closely align with the criteria that CMS used  in 2016 and  2017 for its 
Overutilization Monitoring System.  Through 2017, CMSs Overutilization Monitoring System identified beneficiaries 
who had a  daily MED of  120  mg for 90 days plus  four  or more prescribers and four or more pharmacies.  Note that 
the guidance uses the term more  than 3 prescribers  and  more  than 3 pharmacies, which  is the equivalent of 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  
May 23, 2019.  
Data Brief:  Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased  19 
OEI-02-19-00390