HHS OIG Data Brief    September 2019    OEI-02-19-00391 
 
Opioid Use in Medicare Part D in Missouri
  
 
The opioid crisis is a public health emergency.1  There were 
Key Takeaways 
47,600 opioid-related overdose deaths in the United States in 2017.2  
 Thirty-three percent of Medicare  As part of its efforts to address this crisis, the Office of Inspector 
Part D beneficiaries in Missouri  General (OIG) has assessed opioid use in Medicare Part D 
received a prescription opioid in  nationwide and in specific areas, such as the Appalachian 
2018.  This is higher than the  region.  This data brief focuses on Missouri and provides Statewide 
national rate.   data of opioid utilization in Medicare Part D.  These data are 
particularly important for Missouri, as it is the only State that does 
 Nearly 10,000 beneficiaries in 
not currently have a Statewide prescription drug monitoring 
Missouri received high amounts 
of opioids through Part D.  program.3 
 About 1,400 of these Medicare  Opioids include narcotics intended to manage pain from surgery, 
beneficiaries are at serious risk of  injury, or illness.  They can create a euphoric effect, which makes 
opioid misuse or overdose.   them vulnerable to abuse and misuse (i.e., taking opioids in a way 
other than prescribed).  Although opioids can be appropriate for 
  The severity of the national crisis 
some beneficiaries, OIG has had ongoing concerns related to the 
makes it imperative that States 
misuse, abuse, and diversion of these drugs.  These concerns extend 
take effective steps to address 
the epidemic.   to opioids obtained under Medicare Part D, the optional 
   prescription drug benefit for Medicare beneficiaries.  In 2018, Part D 
 OIG is committed to working  covered 45.8 million beneficiaries. 
with our Federal and State 
partners to fight the opioid crisis  In addition, opioid use carries a number of health risks.  Side effects 
and protect beneficiaries.   from using opioids may include respiratory depression, confusion, 
increased tolerance, and physical dependence.4  For seniors, long-
term use of prescription opioids also increases the likelihood of falls 
and fractures.5 
   
   
RESULTS 
One-third of  One out of every three beneficiaries in Missouri (33 percent) received at 
least one prescription opioid through Medicare Part D in 2018.  About 
beneficiaries in 
321,000 beneficiaries received opioids out of the approximately 973,000 
Missouri received 
who were enrolled in Medicare Part D in Missouri.  The proportion of 
an opioid through  beneficiaries receving opioids in Missouri was higher than in the Nation; 
nationwide, 29 percent of Part D beneficiaries received a prescription 
Part D in 2018, 
opioid.   
which is higher 
The proportion of beneficiaries in Missouri who received an opioid through 
than the national 
Medicare Part D decreased from 2016 and 2017; however, it was higher 
rate 
than the nationwide proportion each year.  See Exhibit 1.  
  Exhibit 1:  The proportion of beneficiaries in Missouri who received 
an opioid through Medicare Part D decreased from 2016 to 2018; 
however, Missouris rate was higher than the Nations each year.  
37%
36%
33% 33%
31%
29%
2016 2017 2018
Missouri Nation
Source: OIG analysis of Part D data, 2019. 
In addition, Missouri had a higher rate of opioid-related overdose deaths 
than did the Nation.6  Moreover, preliminary data for 2018 show that the 
number of drug overdose deaths in Missouri has increased, despite 
a decrease nationwide.7    
In total, Part D paid for 1.8 million opioid prescriptions for Missouri 
beneficiaries in 2018, an average of 5.6 prescriptions per beneficiary 
receiving opioids. 8  Part D paid a total of $86 million for these opioids.  
Tramadol, hydrocodone-acetaminophen, and oxycodone-acetaminophen 
were the most commonly prescribed opioids for beneficiaries in Missouri in 
2018.9   
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OEI-02-19-00391   
A number of counties stand out.  Pemiscot and Dunklinneighboring 
counties located in the southeastern corner of the Statehad the highest 
proportions of beneficiaries receiving opioids, each with more than 
45 percent of its Part D beneficiaries receiving at least one opioid.  In each 
of five additional countiesWashington, Ripley, Mississippi, New Madrid, 
and St. Francois41 percent or more of Part D beneficiaries received 
an opioid.  Perry County had the lowest proportion of beneficiaries 
receiving at least one opioid, at 27 percent.  See Exhibit 2 and Appendix A. 
Exhibit 2:  In seven counties in Missouri, 41 percent or more 
beneficiaries received at least one opioid through Medicare Part D in 
2018.  
* The stars indicate Pemiscot and Dunklin Counties.  
Source:  OIG analysis of Part D data, 2019. 
 
   
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OEI-02-19-00391   
In 2018, a total of 9,981 beneficiaries in Missouri received high amounts of 
Almost 10,000 
opioids through Medicare Part D; these beneficiaries did not have cancer 
beneficiaries in 
and were not in hospice care.10  
Missouri received 
Each of the 9,981 beneficiaries received an average morphine equivalent 
high amounts of 
dose (MED) of greater than 120 mg a day for at least 3 months in 2018 
opioids through  through Medicare Part D.  MED is a measure that converts all the various 
Part D  types and strengths of opioids into one standard value.  This measure is 
also called morphine milligram equivalent (MME).  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.  See Appendix B.   
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 
any dosage and that they avoid increasing dosages to the equivalent of 
90 mg or more MED a day for chronic pain.11   
Opioids also carry health risks, including respiratory depression, 
constipation, drowsiness, and confusion.12  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.13 
The most commonly prescribed opioids for beneficiaries receiving high 
amounts were oxycodone-acetaminophen 10 mg and hydrocodone-
acetaminophen 10 mg.  Nearly 19 percent of all beneficiaries who received 
high amounts of opioids in Missouri had at least one prescription for 
oxycodone-acetaminophen 10 mg, while 16 percent had a prescription for 
hydrocodone-acetaminophen 10 mg.  Thirteen percent of beneficiaries who 
received high amounts of opioids had at least one prescription for fentanyl 
patch 50 mcg/hr.  Fentanyl and oxycodone are among the most common 
opioids involved in law enforcement cases.14   
 
About 1,400  Two groups of beneficiaries that are at serious risk of opioid misuse or 
overdose are (1) beneficiaries who receive extreme amounts of opioids and 
Medicare 
(2) beneficiaries who appear to be doctor shopping.  Other Part D 
beneficiaries in 
beneficiaries may also be at serious risk of opioid misuse or overdose but 
Missouri are at  do not fall into either group.   
serious risk of 
In Missouri, 1,411 beneficiaries in Medicare Part D were in one of these two 
opioid misuse or  groups in 2018 and were therefore at serious risk.  (This does not include 
overdose  beneficiaries who had cancer or were in hospice care.)  Specifically, 
1,182 beneficiaries received extreme amounts of opioids (i.e., an average 
 
daily MED greater than 240 mg for 12 months) and 240 beneficiaries 
appeared to be doctor shopping (i.e., received high amounts of opioids 
and had 4 or more prescribers and 4 or more pharmacies).  Eleven 
Data Brief:  Opioid Use in Medicare Part D in Missouri     4 
OEI-02-19-00391   
beneficiaries were in both groups.  Most beneficiaries who received opioids 
in Missouri through Medicare Part D had just one prescriber and 
one pharmacy.   
A beneficiarys receiving extreme amounts of opioids or receiving high 
amounts of opioids from multiple prescribers and pharmacies raises 
concern.  It may signal that the beneficiarys care is not being monitored or 
coordinated properly or that the beneficiarys care needs to be 
reassessed.15  It may also indicate that the beneficiary is seeking medically 
unnecessary drugs, perhaps to use them recreationally or to divert them or 
that the beneficiary is addicted to opioids and at risk of overdose.   
Furthermore, when a beneficiary receives high amounts of opioids from 
multiple prescribers and pharmacies, it may indicate that prescribers and 
pharmacies are not checking information about the beneficiarys opioid 
history, or that they do not have access to this information.  All States but 
Missouri have Statewide prescription drug monitoring programs, which are 
databases that track prescriptions for controlled substances.16  Prescribers 
and pharmacies can check these databases before ordering or dispensing 
opioids to determine whether a beneficiary is already receiving opioids.   
In Missouri, St. Louis County began operating a prescription drug 
monitoring program in 2017, and about half of Missouris counties and 
some additional localities in the State participate in this program.17  
Prescribers and pharmacies may check the St. Louis County database 
before ordering or dispensing opioids, but they are not required to do so.  
Further, the database contains information only about opioids dispensed in 
counties and localities that participate in the St. Louis program.  
Most of the beneficiaries at serious risk in Missouri were under the age of 
65.  These individuals may have qualified for Medicare because they have 
disabilities or end-stage renal disease. 18  Seventy-six percent of 
beneficiaries at serious risk were under 65 years old; 20 percent were 
between 65 and 75; and 3 percent were over 75.  
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Examples of Medicare Part D Beneficiaries in Missouri at Serious Risk of  
Opioid Misuse or Abuse 
One beneficiarys average daily MED for the year was 2,017 mg22 times the level of opioids 
that CDC recommends avoiding.  The beneficiary received 50 opioid prescriptions during the 
year, which included prescriptions for morphine and methadone.  All but one of these 
prescriptions were ordered by a single physician. 
_______________________________________________________ 
A beneficiary received a 13-month supply of oxycodone 80 mg, a 12-month supply of fentanyl 
100 mcg/hr patches, and a 12-month supply of oxycodone-acetaminophen 7.5 mg/325 mg.  
Over the course of the year, the beneficiary received 37 opioid prescriptions, resulting in 
an average daily MED of 2,065 mg.  All of these prescriptions were ordered by one physician. 
_______________________________________________________ 
Another beneficiary received 42 opioid prescriptions from 18 prescribers and filled these 
prescriptions at 9 pharmacies in 2018.  In a single month, this beneficiary received eight 
opioid prescriptions from six different prescribers and filled them at three different 
pharmacies.  These included prescriptions for oxycodone and hydrocodone-acetaminophen. 
_______________________________________________________ 
A fourth beneficiary received 47 opioid prescriptions from 14 prescribers and filled these 
prescriptions at 6 pharmacies during the year.  All of these prescriptions were for oxycodone.  
In one instance, the beneficiary received prescriptions on 2 consecutive days for different 
strengths of oxycodone.  Shortly after, the patient received a third prescription, for a 30-day 
supply of a high strength of oxycodone (80 mg extended-release).  This prescription, which 
was ordered by dentist, increased the patients daily MED to 375 mg. 
 
 
 
 
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CONCLUSION 
Opioid abuse and overdose deaths are at epidemic levels.  In Missouri, 
33 percent of Part D beneficiaries received a prescription opioid in 2018.  
Although this is a decrease from 2016 and 2017, the percentage of 
beneficiaries receiving opioids in Missouri remains higher than the 
percentage in the Nation as a whole.  Furthermore, almost 10,000 Medicare 
beneficiaries in Missouri received high amounts of opioids in 2018 and 
about 1,400 of them were at serious risk of opioid misuse or overdose 
because they received extreme amounts of opioids or appeared to be 
doctor shopping.     
Although opioids may be necessary for some patients, the extreme use of 
opioids and indications of doctor shopping described in this study raise 
concern.  These patterns may indicate that opioids are being prescribed for 
medically unnecessary purposes and then diverted for resale or 
recreational use.  It may also indicate that a beneficiary is receiving poorly 
coordinated care or that a beneficiarys care may need to be reassessed.  In 
addition, it raises concern that prescribers and pharmacies are not checking 
patients histories of opioid prescriptions, or that they lack access to this 
information. 
The lack of available data is of particular concern in Missouri, as Missouri 
does not have a Statewide prescription drug monitoring program.  St. Louis 
County operates a program in which about half of Missouris counties and 
some additional locations participate.  However, prescribers and 
pharmacists are not required to check the programs database to 
determine whether a patient is already receiving opioids before they order 
or dispense an opioid.  Also, the St. Louis database does not include data 
from the many parts of the State that do not participate.   
The severity of the national crisis makes it imperative that States, including 
Missouri, take effective steps to address the epidemic.  In 2018, Missouri 
began limiting certain initial prescriptions of opioids.19  Starting in 2021, 
Missouri will require electronic prescribing of opioids, in most cases.20  
In addition, Missouri is coordinating with its partners to increase 
prevention, treatment, and recovery services.21  
CMS has also implemented a number of new initiatives to address opioid 
overutilization in Part D.22  For instance, Part D sponsors may limit certain 
at-risk beneficiaries to selected pharmacies or prescribers for their opioid 
prescriptions.23  Also, 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 expected to limit initial opioid prescriptions to no more 
than 7 days for the treatment of acute pain.   
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OIG supports State and Federal efforts to combat the opioid crisis.  
Notably, OIG supports States efforts to implement and enforce strong 
prescription drug monitoring programs that require prescribers and 
pharmacies to check a database before prescribing and dispensing 
opioids.  Prescription drug monitoring programs can provide valuable 
information to prescribers and pharmacies about a patients opioid 
prescription history.   
OIG also remains committed to fighting the opioid crisis and protecting 
beneficiaries from prescription drug abuse and misuse.  We will continue 
to work with State and Federal partners to follow up on beneficiaries and 
prescribers, as appropriate.  In addition, OIG recently released an opioid 
analysis toolkit to assist our partners.24  The toolkit provides detailed 
step-by-step instructions for using prescription drug data to identify 
patients who are at risk of opioid misuse or overdose.  OIG also has reviews 
in progress regarding key opioid initiatives, including access to 
medication-assisted treatment for opioid use disorder and grants for 
prescription drug monitoring programs.25   
 
 
 
 
   
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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 in Missouri received through Part D.  It does not include 
prescriptions paid for through other programs such as Medicaid; 
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 
pharmacies, 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) database.  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 dataincluding diagnosis codesfrom Medicare Parts A 
and B.  Part C Encounter Data contain medical claims dataincluding 
diagnosis codesfor beneficiaries enrolled in Medicare Advantage plans.  
CDCs MME conversion file contains information about each opioids drug 
morphine milligram equivalence.26  The NPPES contains information about 
prescribers, such as names and addresses.  For the purposes of this study, 
we use the term prescription to mean one PDE record. 
Analysis of Part D Opioid Utilization and Spending 
We identified all PDE records for opioids that beneficiaries received in 
2018.27  We calculated the total number of Part D beneficiaries in Missouri 
who received opioids in 2018.28  For these beneficiaries, 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 receiving opioids.  
We also calculated the proportion of beneficiaries in the State who 
received opioids in 2018, and the proportion of beneficiaries in each county 
who received opioids in 2018.29   We based this analysis on the PDE records 
and Medicare enrollment data.  We compared these data to data from our 
previous data briefs, which calculated the proportion of beneficiaries who 
received opioids in each State and in the Nation as a whole in 2016, 2017, 
and 2018.  We then calculated the most commonly prescribed opioids by 
calculating the total number of prescriptions for each drug name 
(delineated by strength and form).  
   
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Beneficiary Analysis  
We determined the amount of opioids that each beneficiary in Missouri 
received in 2018.  To do this, we calculated each beneficiarys average daily 
morphine equivalent dose (MED).30  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).31  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 2018.32   
We analyzed the MED data using the same criteria that we used in our 
previous national analyses of Part D data from 2016, 2017, and 2018.33  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.   
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 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; received 
opioids for 90 or more days in the year; and received opioids from four or 
more prescribers and four or more pharmacies.   
   
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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, such as 
Medicaid. 
 
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. 
   
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APPENDIX A:  BENEFICIARIES RECEIVING 
OPIOIDS THROUGH PART D, BY COUNTY 
Exhibit A-1:  In seven counties in Missouri, 41 percent or more beneficiaries received at 
least one opioid through Part D in 2018. 
Proportion of Beneficiaries in Each County in Missouri Who Received an Opioid 
Through Medicare Part D in 2018 
Pemiscot  48%  Taney  35%  Dallas  32% 
Dunklin  46%  Douglas  35%  Miller  32% 
Washington  42%  Henry  35%  Daviess  32% 
Ripley  42%  Lawrence  35%  Polk  32% 
Mississippi  41%  Lewis  35%  Holt  32% 
New Madrid  41%  Benton  35%  Chariton  32% 
St. Francois  41%  Wright  35%  DeKalb  32% 
Butler  40%  Christian  35%  Jackson  32% 
Stoddard  39%  Vernon  35%  Audrain  32% 
Madison  39%  Greene  35%  Andrew  32% 
Howell  39%  Pike  35%  Callaway  32% 
Shannon  39%  Randolph  34%  Camden  32% 
Scott  39%  Texas  34%  Caldwell  31% 
McDonald  38%  Stone  34%  Adair  31% 
Iron  38%  Maries  34%  Montgomery  31% 
Bollinger  38%  Clinton  34%  St. Charles  31% 
Barton  38%  Gasconade  34%  Monroe  31% 
Bates  38%  Macon  34%  Pettis  31% 
Oregon  37%  Buchanan  34%  Shelby  31% 
Wayne  37%  Schuyler  34%  Carroll  31% 
Carter  37%  Warren  34%  Howard  31% 
Dent  37%  Worth  34%  Ste. Genevieve  31% 
Reynolds  37%  Harrison  34%  Ralls  31% 
Barry  37%  Putnam  34%  Platte  31% 
Crawford  37%  Cass  34%  Atchison  30% 
Scotland  37%  Lafayette  33%  Linn  30% 
Cedar  37%  Franklin  33%  Moniteau  30% 
Ray  37%  Gentry  33%  Mercer  29% 
Newton  36%  Marion  33%  Nodaway  29% 
Lincoln  36%  Cape Girardeau  33%  Cooper  29% 
St. Clair  36%  Laclede  33%  Cole  29% 
Pulaski  36%  Hickory  33%  St. Louis  29% 
Ozark  36%  Saline  33%  Knox  29% 
Jasper  36%  Grundy  33%  St. Louis City  29% 
Phelps  36%  Johnson  33%  Osage  28% 
Jefferson  36%  Livingston  33%  Boone  28% 
Dade  36%  Morgan  33%  Perry  27% 
Clark  35%  Sullivan  32%     
Webster  35%  Clay  32%     
Source: OIG analysis of Medicare Part D data, 2019. 
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APPENDIX B:  BENEFICIARIES RECEIVING HIGH 
AMOUNTS OF OPIOIDS AND BENEFICIARIES 
AT SERIOUS RISK  
 
Exhibit B-1: Almost 10,000 beneficiaries in Missouri received high amounts of opioids  
in 2018. 
  Number of  
Beneficiaries 
  in 2018   
Beneficiaries who received high amounts of opioids    9,981   
Source: OIG analyses of Medicare Part D data, 2019. 
 
 
 
Exhibit B-2: About 1,400 beneficiaries in Missouri are at serious risk of opioid misuse or  
overdose in 2018. 
  Number of  
Beneficiaries 
  in 2018   
Beneficiaries who received an extreme amount of opioids    1,182   
Beneficiaries who appear to be doctor shopping    240   
Total beneficiaries at serious risk    1,411*   
Source: OIG analyses of Medicare Part D data, 2019. 
* A total of 11 beneficiaries were in both groups in 2018. 
   
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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 
Adam Freeman, Althea Hosein, and Christine Moritz.  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 Alex M. Azar II, Secretary of Health and Human Services, Renewal of Determination that a Public Health Emergency 
Exists, July 16, 2019.   
2 CDC, Drug and Opioid-Involved Overdose DeathsUnited States, 2013-2017, Morbidity and Mortality Weekly 
Report (MMWR) 67, nos. 51 and 52, January 4, 2019.  Accessed at https://www.cdc.gov/mmwr/volumes/67/ 
wr/pdfs/mm675152e1-H.pdf  on July 18, 2019. 
3 For more information about State 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.   
4 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 July 18, 2019. 
Also see CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR 65, no. 1, 
March 18, 2016.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on July 18, 2019.   
5 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 July 18, 2019.   
6 In 2017, the age-adjusted opioid-related overdose death rate was 16.5 per 100,000 persons in Missouri and 14.6 per 
100,000 persons in the Nation in 2018.  See National Institute on Drug Abuse, Missouri Opioid Summary, March 2019.  
Accessed at https://www.drugabuse.gov/node/pdf/21971/missouri-opioid-summary on July 19, 2019.  
7 Data on opioid-related overdose deaths in Missouri for 2018 are not yet available.  CDC, Provisional Drug Overdose 
Death Counts, Figure 1b: Percent Change in 12 Month-ending County of Drug Overdose Deaths, by Jurisdiction, 
July 2019.  Accessed at https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#dashboard on July 23, 2019. 
8 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. 
9 The five most commonly dispensed opioids were tramadol 50 mg, hydrocodone-acetaminophen 5-325 mg, 
hydrocodone-acetaminophen 10-325 mg, hydrocodone-acetaminophen 7.5-325 mg, and oxycodone-acetaminophen 
10-325 mg. 
10 In total, 3.1 percent of the beneficiaries who received an opioid in Missouri received a high amount of opioids. This 
is higher than the national rate, which was 2.6 percent.   
11 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.  Patients 
who are already taking high dosages of opioids should be offered the opportunity to re-evaluate their continued use 
of these dosages, and prescribers should offer to work with them to taper their opioids to safer dosages.  This may 
be challenging because of physical or psychological dependence.  CDC, CDC Guideline for Prescribing Opioids for 
Chronic Pain: United States, 2016. MMWR 65, no. 1, March 18, 2016, pp. 149.  Accessed at 
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on May 28, 2019.  
12 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 July 18, 2019. 
Also see CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR 65, no. 1, 
March 18, 2016.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf  on July 18, 2019.   
 
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13 CDC, CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016, MMWR 65, no. 1, March 18, 
2016, pp. 13, 44. 
14 U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information 
System, NFLIS-Drug 2018 Midyear Report, 2019.  Accessed at 
https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLISDrug2018MY.pdf  on 
July 22, 2019.  
15 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 10.  
16 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.  
17 According to St. Louis County, a total of 72 jurisdictionsincluding 60 counties and 12 localitiesparticipate in the 
program, which covers 84 percent of the population of Missouri.  For more information, see Saint Louis County 
Prescription Drug Monitoring Program.  Accessed at https://www.stlouisco.com/PDMP on July 18, 2019.  
18 In addition to being available 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 July 18, 2019.  Because of rounding, the percentages on page 4 do not sum to 100.   
19 Mo. Rev. Stat.  195.080.  The prescriber may order more than a 7-day supply if, in the prescribers medical 
judgement, the quantity is needed.  In these cases, the prescriber must note in the patients medical record the 
reason for the additional quantity and that a nonopioid was not appropriate.   
20 Mo. Rev. Stat.  195.550.  Prescribers will be required to prescribe Schedule 2, 3 and 4 controlled substances 
electronically, with some exceptions.  For example, prescribers may issue a paper prescription when a patient 
specifically requests one.  
21 These efforts were goals of Missouris Opioid State Targeted Response, for which it received a grant from the 
Substance Abuse and Mental Health Services Administration.  For more information, see Opioid Crisis Response.  
Accessed at https://dmh.mo.gov/OpioidCrisisResponse.htm on July 22, 2019.  
22 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 July 26, 2019.  
23 Under the Comprehensive Addiction and Recovery Act of 2016, 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 P.L. No. 114-198  704 (July 22, 2016).  Accessed at 
https://www.congress.gov/114/plaws/publ198/PLAW-114publ198.pdf on July 26, 2019.  For the 2019 plan year, at-risk 
beneficiaries are, at minimum, defined as those who are considered high risk in the Overutilization Monitoring 
System, and most opioids and benzodiazepines are designated as frequently abused drugs.  See 83 Fed. Reg. 16452 
(April 16, 2018).  Accessed at https://www.gpo.gov/fdsys/pkg/FR-2018-04-16/pdf/2018-07179.pdf on July 26, 2019. 
24 For more information on the toolkit, 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.  
 
Data Brief:  Opioid Use in Medicare Part D in Missouri     16 
OEI-02-19-00391   
 
25 For example, OIG is releasing a series of factsheets on States oversight of opioid prescribing and monitoring of 
opioid use.  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.  Also see OIG, Overview of Ongoing 
and Completed Opioid Related OIG StudiesAs of September 2019 at https://oig.hhs.gov/reports-and-
publications/featured-topics/opioids/OIG-Opioid-Related-Studies-Breakdown.pdf. 
26 These files contain MME conversion factors for each National Drug Code.  MED and MME are interchangeable 
terms.   
27 To identify PDE records for opioids, we matched the National Drug Codes on the PDE records with two files: 
First DataBank and CDCs MME conversion file.   
28 We used the beneficiarys address on the PDE record to identify the State.   
29 For beneficiaries who resided in more than one county during the year, we included the beneficiary in the analysis 
for each of those counties. 
30 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 July 18, 2019. 
31 To ensure that we included all the opioids received by each beneficiary in 2018, we included opioids dispensed in 
2017 with days of use in 2018.  Note that we did not include PDE records for injection, intravenous, or intrathecal 
opioids because CDC does not publish MME conversion factors for these opioids.  We also did not include opioids 
indicated for medication-assisted treatment. 
32 We identified beneficiaries with a cancer diagnosis or hospice stay using CMSs National Claims History File and 
Part C Encounter data.   
33 OIG, Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased, OEI-02-19-00390, 
July 2019.  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. 
Data Brief:  Opioid Use in Medicare Part D in Missouri     17 
OEI-02-19-00391