U.S. Department of Health and Human Services
Office of Inspector General
Data Snapshot
December 2020, OEI-05-19-00410
Opioids in Medicaid: Concerns About Opioid Use Among 
Beneficiaries in Six Appalachian States in 2018
Background
Key Takeaways
Opioid abuse and overdose deaths remain at crisis levels in the United 
Across 6 Appalachian States in 2018, 
States generally and the Appalachian region under review in this data 
nearly 6,000 beneficiaries received 
snapshot. In 2018, an estimated 9.9 million Americans misused 
potentially harmful amounts of 
prescription opioids,1and nearly 47,000 Americans died from opioid 
opioids.  More than 450 of these 
overdoses.2 In 2017, Appalachian counties had an opioid overdose death 
beneficiaries were at serious risk of 
rate that was 72 percent higher than in non-Appalachian counties 
opioid misuse or overdose. throughout the country.3
Opioids include narcotics intended to manage pain.  They can create a 
OH euphoric effect, which makes them vulnerable to abuse and misuse (i.e., 
being taken in a way other than prescribed).  Although opioids can be 
WV
appropriate under certain circumstances, the Office of Inspector General 
KY VA
(OIG) is concerned about the abuse and misuse of opioids and fraud 
TN
associated with opioids, including drug diversionthe redirection of 
Of the 10 million 
prescription drugs for an illegal purpose, such as recreational use or 
Medicaid 
AL resale. 
beneficiaries in 
6Appalachian States  Multiple reports from across the six Appalachian States show dramatic 
in 2018, increases in opioid-related overdoses and deaths since the start of the 
COVID-19 pandemic,4and challenges posed by the pandemic may be 
1,044,558
contributing to these increases. Some Medicaid programs have relaxed 
beneficiaries (about   rules related to telehealth and opioid prescribing, suspending 
1 in 10) received at  safeguardslike face-to-face visits with prescribersthat are intended to 
least 1 prescription  help ensure the safety of beneficiaries receiving prescription opioids.  
Additionally, shelter-in-place and social distancing orders intended to 
opioid. 
slow the pandemics spread may have reduced access to in-person 
5,897 screenings for opioid misuse and addiction treatment facilities. These 
of these 
orders may also contribute to a sense of isolation that can trigger opioid 
beneficiaries received 
misuse. 
high amounts of 
opioids. This data snapshot is part of a larger strategy by OIG to fight the opioid 
crisis and protect beneficiaries from prescription drug misuse and 
463 abuse. As part of this strategy, OIG is partnering with other law 
of these 
enforcement agencies and the Centers for Medicare & Medicaid Services 
beneficiaries are at 
(CMS) in the Appalachian Regional Prescription Opioid Strike Force, 
serious risk of 
bringing together resources and expertise to fight the opioid crisis in six 
opioid misuse or 
States. This data snapshot focuses on opioid use in 2018 in those six 
overdose.
States: Alabama, Kentucky, Ohio, Tennessee, Virginia, and West 
Virginia. Other OIG work that is part of this strategy includes data briefs 
19 on opioid use in Medicare Part D both nationally5and in the Appalachian 
prescribers had 
region6as well as in the Ohio Medicaid program;7factsheets that describe 
questionable opioid 
the oversight of opioid prescribing and monitoring of opioid use in five of 
prescribing practices. 
the six Appalachian States included in this review;8and reviews of access 
to medication-assisted treatment for opioid use disorder.9
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 1 Results
Medicaid beneficiaries in 6 Appalachian
1 in 10
States received a prescription opioid in 2018.
In 2018, just over 1 million beneficiaries in the 6 Appalachian States received at least 
1 prescription opioid through Medicaid.
 Most of these beneficiaries appeared to use opioids for a short period of time, likely to address an acute issue 
like recovering from surgery.  Approximately 595,000 beneficiariesnearly 60 percent of the beneficiaries who 
received opioids in 2018received just 1 opioid prescription through Medicaid, almost always for a weeks 
worth of medication or less.  Another 146,000 beneficiariesapproximately 14 percent of beneficiaries who 
received opioids in 2018received 2 opioid prescriptions through Medicaid during the year.
 Beneficiaries may have also received opioids for other legitimate purposes, including the management of 
certain conditions.  For example, approximately 57,000 beneficiariesabout 5 percent of the beneficiaries who 
received at least one opioid prescriptionhad cancer or sickle cell disease or were in hospice care in 2018.  
The Centers for Disease Control and Prevention (CDC) excludes patients with these conditions from its opioid 
prescribing guidelines for chronic pain.10
Beneficiaries may have also received opioids outside of Medicaid. 
 Because Medicaid beneficiaries may opt to purchase opioids outside of the Medicaid benefit by using other 
types of health insurance or by paying in cash, it is possible that more than 1 million Medicaid beneficiaries in 
these States received opioids or that the amounts these beneficiaries received may have been higher than 
those presented in this review.  For example, Medicaid beneficiaries may also qualify for Medicare.  In 
2017,OIG found that just over one in three Medicare beneficiaries enrolled in Part D received at least one 
opioid prescription in five states in the Appalachian region.11 
The proportion of Medicaid beneficiaries who received at least one prescription opioid 
5%
varied across States, from 5 percent in Virginiato 13 percent in Kentucky.  See Appendix B 
for details.
13%
Nearly 12 percent of beneficiaries who received at least 1 prescription opioid through 
Medicaidapproximately 120,000 beneficiarieswere children ages 18 and younger.
 Of these instances, approximately 12,600 were particularly concerning.  These 
Studies show that even 
children received more than one opioid prescription, did not have cancer or 
legitimate opioid use 
sickle cell disease, and were not in hospice care.
in adolescents is 
associated with an  One child received 27 opioid prescriptions and had an average daily MED* of 
increased risk of  just over 200 mg for the entire year.  In total, this child received nearly 
future misuse of  2,300tablets of morphine and oxycodone in 2018.  
opioids.12
*See page 3 for the definition of MED.
7%
The percentage of beneficiaries with at least one opioid prescription who were childrenvaried 
considerably by State, from 7 percent in Ohioto 27 percent in Alabama.  See Appendix B for 
details.
27%
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018  2 5,897
beneficiaries in the 6 Appalachian States received high
amounts of opioids, exceeding levels that CDC encourages providers to avoid.
In 2018, a total of 5,897 beneficiaries in the 6 Appalachian States received high amounts of 
opioids through Medicaid. 
 OIG considers beneficiaries to have received high amounts of opioids if their average morphine 
equivalent dose (MEDsee textbox below) is greater than 120 mg a day for at least 3 months. 
 These amounts of opioids are potentially dangerous and raise concerns regardless of the reasons why 
beneficiaries may receive them.  Opioids carry health risks, including respiratory depression, 
constipation, drowsiness, and confusion.13 These beneficiaries may be at an increased risk for 
prescription opioid misuse, which is associated with increased use of illegal opioid drugs such as heroin 
and in some cases may lead to death.14 Further, the COVID-19 pandemic may amplify the risks posed 
by opioid use, as COVID-19 is a disease that attacks the lungs,15 and respiratory disease is known to 
increase the risk of fatal overdose among people taking opioids. 
 The CDC recommends that 
Morphine Equivalent Dose (MED)
prescribers avoid increasing 
opioids to MEDs of greater than or  MED is a measure that converts all the various types 
equal to 90 mg a day or carefully  and strengths of opioids into one standard value.  A 
justify the decision to increase to  daily MED of 120 mg is equivalent to taking 16 tablets 
this level.16 a day of Percocet 5 mg. 
We excluded beneficiaries who had cancer or sickle cell disease (SCD) or were in hospice care in 2018 from all analyses 
on this page.
One beneficiary had a daily average MED 
Nearly 20 percent of beneficiaries who received  of more than 1,000 mg for 3 months, more 
high amounts of opioids had at least one  than 11 times the amount that CDC 
prescription for fentanyl, ranging from a low of  recommends avoiding.  Overall, this 
10 percent in Tennessee to a high of 30 percent  beneficiary received 33 prescriptions that 
in West Virginia.  Fentanyl is 80 to 100 times  covered nearly all of 2018.  Nearly 
more powerful than morphine.  Fentanyl is  one-third of these prescriptions were for a 
among the most common types of opioids  total of 132 fentanyl extended-release 
involved in law enforcement cases.17 patches.
32 per 100k
Across these 6 Appalachian States, nearly 60 of every 100,000 Medicaid beneficiaries 
received high amounts of opioids, ranging from 32 of 100,000beneficiaries in Tennessee
88 per 
to 88 of 100,000 beneficiaries in Ohio.  See Appendix B for details.
100k
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 3 463 beneficiaries in the 6 Appalachian States
were at serious risk of opioid misuse or overdose.
Of the beneficiaries who received high amounts of opioids, two groups stood out as being at 
serious risk of opioid misuse or overdose:
1 Beneficiaries who received extreme  2 Beneficiaries who appeared to be doctor shoppingi.e., they 
amounts of opioidsan average daily  received high amounts of opioids (an average daily MED of 
MED greater than 240 mg for 12 months.    greater than 120 mg for 3 months) and had four or more 
These beneficiaries were receiving more  prescribers AND had four or more pharmacies.  These 
than two and a half times the amount that  beneficiaries may be trying to obtain higher amounts than 
CDC recommends avoiding. any one prescriber or pharmacy would allow them.
362 beneficiariesapproximately  104 beneficiariesapproximately 22 percent of 
78percent of beneficiaries at serious  beneficiaries at serious riskappeared to be doctor 
riskreceived extreme amountsof  shopping.  These beneficiaries received opioid prescriptions 
opioids in these States.  Thirteen of  from as many as 12 prescribers and filled them at as many as 
these beneficiaries had a daily average  10 pharmacies.  In comparison,71 percent of beneficiaries 
MED greater than 720 mg for  who received any opioid in 2018 had oneprescriber, and 
12monthsmore than three times our  82 percent had one pharmacy.
threshold for extreme amounts.
One beneficiary received 34 prescriptions from 8 different 
One beneficiary received 14 prescriptions  prescribers and filled them at 5 pharmacies during our study 
and had an average daily MED of  period.  Ten of the prescriptions were for fentanyl and were 
1151mg, which is more than 12 times the  prescribed concurrently with oxycodone and methadone.  The 
level that CDC recommends avoiding.  beneficiary had an average daily MED of 590 mg. 
Three beneficiaries were in both of these groups.18
We excludedbeneficiaries who had canceror SCD or were in hospice care in 2018 from all analyses on this page.
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;
 a beneficiarys care needs to be reassessed;  Approximately 
 a beneficiary is seeking medically unnecessary drugsperhaps to use them  27percent of 
recreationally or divert them; beneficiaries at serious 
 a beneficiary is addicted to opioids and at risk of overdose;  risk received at least 
 a beneficiarys Medicaid ID has been stolen and is being used by others to obtain  1 fentanyl prescription
opioids; or in 2018, including 
 prescribers are not checking the beneficiarys opioid history before prescribing. 16beneficiaries who 
received at least 
Some beneficiaries at serious risk of opioid misuse or overdose experience 
200fentanyl 
negative outcomes related to their opioid use.  
extended-release 
In prior work, OIG found that of the Medicare Part D beneficiaries at serious risk of opioid patches, far more than a 
misuse or overdose in 2017, typical 1-year supply.  
 about half were diagnosed with opioid use disorder or a related condition in the  These patches are 
following year; and  typically worn for 3 days 
 11 percent experienced an overdose or other adverse event in the following year.19 each.
Across these States, nearly 5 of every 100,000 Medicaid beneficiaries were at serious risk  1 per 100k
for opioid misuse or overdose, ranging from approximately 1 of every 100,000beneficiaries 
inTennessee to approximately 9 of every 100,000 beneficiaries in Ohio.  See Appendix B  9 per 
100k
for details.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018
4 19
prescribers had questionable prescribing practices.
These 19 prescribers stand out from their peers because they ordered opioids for the highest 
numbers of beneficiaries at serious risk. 
 These prescribers each ordered opioids for at least four beneficiaries at serious risk (i.e., beneficiaries who 
received extreme amounts or appeared to be doctor shopping) in 2018.  
 These 19 prescribers represent only 2 percent of the 890 prescribers who ordered opioids for 
beneficiaries at serious risk in 2018, but they ordered opioids for 20 percent of beneficiaries at serious 
risk.  Exhibit 1 shows the disproportionate impact these prescribers had on beneficiaries at serious risk. 
Although these opioids may be necessary for some beneficiaries, 
prescribing to more beneficiaries at serious risk than ones peers raises 
concerns and warrants further scrutiny.  Prescribing to more beneficiaries 
One nurse practitioner ordered 
at serious risk than ones peers could indicate that:
opioids for nine beneficiaries 
(1) The prescriber is not appropriately coordinating care. 
who received extreme amounts 
 These prescribers may not be checking State prescription drug 
of opioids during 2018 and 
monitoring databases, or these databases may not have current data 
three beneficiaries who 
necessary for appropriate care coordination.
appeared to be doctor shopping.  
(2) The prescriber is ordering medically unnecessary drugs, which could  The nurse practitioner ordered 
be diverted for resale or recreational use. all, or nearly all, of the 
 These prescribers may be operating pill mills.  A pill mill is a doctors  prescriptions for 6 of the 
office, clinic, or health care facility that routinely prescribes controlled  9beneficiaries who received 
substancessuch as oxycodoneoutside the scope of professional  extreme amounts, including 
practice and without a legitimate medical purpose.  28prescriptions for a beneficiary 
 These prescribers identification may have been sold or stolen and may  who had an average MED of 
be being used for illegal purposes.  nearly 400mg per day for the 
year. 
Exhibit 1: The 19 prescribers with questionable prescribing practices had a disproportionate impact 
on some beneficiaries at serious risk. 
Although these 19 prescribers made  ... they ordered opioids for  ... and ordered 87% of the 
up just 2% of all 890prescribers 93beneficiaries at serious risk, or  2,334 opioid prescriptions 
who ordered opioids for  20% of the 463 beneficiariesat  those 93 beneficiaries received 
beneficiaries at serious risk,  serious risk, in 2018.  
Nearly all of the prescribers with questionable prescribing practices in 2018 were located in 
Ohio and Kentucky. See Appendix B for details.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 5 Why This Matters
Medicaid beneficiaries across six Appalachian States are at risk for opioid misuse or overdose, and 
the COVID-19 pandemic may be putting more beneficiaries at risk.  
Several groups of Medicaid beneficiaries across the six Appalachian StatesAlabama, Kentucky, Ohio, 
Tennessee, Virginia, and West Virginiamay be at risk for opioid misuse or overdose.  Of the approximately 
1million beneficiaries who received at least one opioid prescription in 2018, 120,000 were children age 18 and 
younger.  Any opioids prescribed to children are concerning because research shows that even opioids used 
for legitimate purposes before high school graduationsuch as an opioid prescribed by a dentist after 
extracting a wisdom toothare associated with an increase in future opioid misuse.  Further, nearly 
6,000beneficiaries across the 6 States received potentially harmful amounts of opioids that exceed the levels 
that CDC recommends prescribers avoid without careful justification.  Of particular concern, 463 of these 
beneficiaries were at serious risk of opioid misuse or overdose because they received extreme amounts of 
opioids or appeared to be doctor shopping, and 19 prescribers in the region had questionable opioid 
prescribing practices.  Previous OIG work has found that beneficiaries at serious
risk may experience serious outcomes related to their opioid use, including opioid 
use disorder or overdose.
Beneficiaries may have received 
additional prescription opioids 
Beyond the beneficiaries identified in this data snapshot, 
outside of Medicaid. 
additional Medicaid beneficiaries may have been at risk for 
This data snapshot measures only opioids 
opioid misuse or overdose in 2018.  Specifically, additional 
paid for through Medicaid.
beneficiaries may have received prescription opioids outside of 
Medicaid by using Medicare, private insurance, or cash  Medicare  Private  Cash 
insurance payments
payments.  For example, a previous OIG study showed that in  Part D
2017, across 5 Appalachian statesAlabama, Kentucky, Ohio, 
Tennessee, and West Virginiamore than 1 in 3 Medicare Part D
beneficiaries received opioid prescriptions, and almost 6,000were 
at serious risk.20 Additionally, some beneficiaries may have
been using illegal opioids.  Medicaid
Further, the COVID-19 pandemic may be putting Medicaid beneficiaries at greater risk of opioid misuse      
or overdose in 2020 and beyond.  Multiple reports from across the six Appalachian States show 
dramatic increases in opioid-related overdoses and deaths since the start of the COVID-19 pandemic.
Measures taken to address the COVID-19 pandemic may have contributed to these increases.  Like the 
Medicare program, some State Medicaid programs have relaxed rules related to telehealth and the prescribing 
of opioids.  These changeswhich temporarily suspend some beneficiary safeguards, like the requirement for 
face-to-face visits with prescribers to receive opioid prescriptionsmay have unintentionally increased the risk 
of doctor shopping and inappropriate opioid prescribing in 2020.  Additionally, the shelter-in-place and social 
distancing orders implemented in many places to address the pandemic may have resulted in increased 
isolation, a potential trigger for opioid misuse.  These policies may have also resulted in decreased access to 
medical interventions designed to help people struggling with opioid misuse, including in-person screenings 
for opioid misuse and treatment options for opioid use disorder.  Finally, individuals with opioid use disorder 
could be particularly hard hit by COVID-19 as COVID-19 attacks the lungs, and respiratory disease is known 
to increase the risk of fatal overdose among people taking opioids.  
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 6 OIGs Ongoing Commitment to Fighting the Opioid Crisis
OIG continues its efforts to address the opioid crisis across the six Appalachian States and 
nationwide.  
OIG is committed to ensuring that the prescribers and beneficiaries identified in this data snapshot receive the 
appropriate level of review and followup.  OIG, along with its law enforcement partners, will review the 
prescribers with questionable prescribing patterns for possible investigation.  OIG will also refer the 
beneficiaries at serious risk for opioid misuse or overdose to their respective State Medicaid agencies for 
review and possible followup to ensure that they are receiving appropriate care, including access to treatment 
options for opioid use disorder if necessary.
Additionally, OIG remains committed to working with our law 
enforcement partners to bring resources and expertise to these  In April 2019, the Strike Force 
six States through the ARPO Strike Force.  The mission of the  participated in the largest-ever 
Strike Force is to prevent patient harm and identify and  law enforcement operation 
investigate health care fraud related to medically unnecessary  regarding prescription opioids, which 
prescribing and illegal distribution of opioids, with a particular  resulted in charges against 53 
focus on medical professionals.  Continued Strike Force  medical professionals across the 
operations remain an important tool for ensuring patient safety  Appalachian region.
as opioid overdose deaths rise across the region during the 
COVID-19 pandemic.  
Further, OIG is conducting evaluations and audits in 2020 and beyond on opioid use and access to treatment.  
Topics for these evaluations and audits include access to medication-assisted treatment for opioid use 
disorder; controls on programs for treating opioid use disorder; grants for prescription drug monitoring 
programs; and challenges in treating opioid use disorder during the COVID-19 pandemic.
OIG supports States efforts nationwide to combat the opioid crisis. 
States have taken numerous actions to address the opioid crisis, and OIG encourages States to continue these 
efforts and expand on them.  For example, OIG supports States efforts to 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 data from prescription drug 
monitoring programs, including sharing these data with State Medicaid agencies.  We also encourage States to 
analyze data to help identify patients who may be at risk and to promote appropriate opioid prescribing 
practices.  To help Statesas well as other public and private partnersanalyze opioid prescribing data, OIG 
has published an opioid analysis toolkit.21 This toolkit provides detailed, step-by-step instructions for using 
prescription drug data to identify patients who are at risk for opioid misuse or overdose.  By working together 
and expanding our efforts, we can help curb the opioid crisis in our Nation.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 7 Appendix A: Methodology
We based this review on an analysis of data from the  We analyzed the types of opioids prescribed to these 
Transformed Medicaid Statistical Information System  beneficiaries to identify beneficiaries who received at least one 
(T-MSIS)the national Medicaid claims databasefor six  prescription for fentanyl in 2018.
States.  Claims data contains information about prescription 
We then identified beneficiaries at serious risk of opioid misuse 
drugs, beneficiaries and providers.  This review includes 
or overdose.  We considered a beneficiary to be at serious risk 
prescriptions that beneficiaries received through Medicaid.  It 
if the beneficiary received extreme amounts of opioids or 
does not include prescriptions paid for through other programs 
appeared to be doctor shopping.  We used the same definitions 
or those paid for in cash.
as in previous OIG work to identify these two groups of 
T-MSIS Data Quality beneficiaries. 
Because of ongoing concerns with the quality and   We considered a beneficiary to have received an extreme 
completeness of T-MSIS data, we conducted a variety of quality  amount of opioids if the beneficiary exceeded an average 
assessments on each States data.  We reviewed whether  daily MED of 240 mg for the entire year and at least 360 
required variables were populatedand whether data were  days of opioid use within the year. 
populated with valid values.  For instance, National Provider 
 We considered a beneficiary to have appeared to be doctor 
Identifiers (NPIs) should be numeric and 10 digits long.  Also, 
shopping if the beneficiary exceeded an average daily MED 
certain variables, like type of service, have specific lists of valid 
of greater than 120 mg MED for 3 months and received 
codes defined in the T-MSIS data dictionary.
opioids from four or more prescribers and four or more 
On the basis of the results of our quality checking, we  pharmacies.  To identify these beneficiaries, we calculated 
determined that data from all six States was of sufficient quality  the total number of prescribers and pharmacies from which 
to use for our analysis.  Our quality checking did not evaluate  each beneficiary received opioids in 2018. We identified 
the accuracy of information submitted to the States by  prescribers and pharmacies on the basis of their NPI 
Medicaid providers and managed care plans. numbers.
Opioid Utilization Analysis We identified the States in which beneficiaries who received any 
opioids, beneficiaries who received high amounts of opioids, 
For this review, we implemented the same methodology as in 
and beneficiaries who were at serious risk were located.  We 
previous OIG work on opioid use in Medicare Part D and Ohio 
excluded beneficiaries from this analysis who did not have an 
Medicaid.  For selected States in the Appalachian region, we 
address in T-MSIS or who had a potentially erroneous address, 
determined the number of unique beneficiaries enrolled in 
or who lived in two or more States in the Appalachian region 
Medicaid who received at least one opioid during 2018.  We 
during 2018.
identified all drug claims for opioids with dates of service in 
2018.  To do this, we matched drug data to CDCs morphine  We summarized characteristics of beneficiaries at serious risk, 
milligram equivalent (MME) conversion table, which contains  including age and gender.
information about each drugs type and name.22
Beneficiaries with a diagnosis of cancer or sickle cell disease or 
For all analyses in our review, we excluded prescriptions for  who were in hospice care in 2018 were excluded from our 
opioids indicated for medication-assisted treatment.  For  analyses identifying beneficiaries with high amounts of opioids 
example, we excluded methadone prescriptions when ordered  and beneficiaries at serious risk of opioid misuse or overdose.  
for beneficiaries with diagnoses of opioid use disorder.
Prescriber Analysis
Beneficiary Analysis
We identified prescribers with questionable opioid prescribing 
We identified beneficiaries who received high amounts of  practices for beneficiaries at serious risk.  We first identified all 
opioids in 2018.  We considered a beneficiary to have received  prescribers who ordered opioids for at least one beneficiary at 
high amounts if the beneficiary had an average daily MED of  serious risk in 2018.  We then identified prescribers who 
greater than 120 mg for 3 months.  This amount exceeds the  ordered opioids for a high number of these beneficiaries.  We 
amount that CDC recommends prescribers avoid without  identified the States in which these providers were located and 
careful justification.  the specialties of these providers.  
To calculate each beneficiarys average daily MED, we first  Limitations
calculated the MED for each prescription.  To do this, we used 
This analysis is based on Medicaid claims data; it is not based 
the following equation: MED =
on a review of medical records.  The analysis does not include 
data on opioids that beneficiaries may have received from 
(strength per unit) x (quantity dispensed) x (MME conversion factor) sources other than Medicaid, such as Medicare Part D.
(days supply) We did not compare our results to national trends because 
Buprenorphine products, including suboxone, were dropped 
timely, nationwide information about opioid use in the 
from our analysis at this point because they do not have a 
Medicaid program is not available.23
conversion factor in CDCs MME conversion table.
Standards
Next, we summed each beneficiarys MED for each day of the 
year based on the dates of service and days supply on each  We conducted this study in accordance with the Quality 
prescription.  We refer to this as daily MED.  Standards for Inspection and Evaluation issued by the Council of 
the Inspectors General on Integrity and Efficiency.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 8 Appendix B: Results by State
West 
Alabama Kentucky Ohio Tennessee Virginia Virginia
Total Medicaid 
1.0M 1.6M 3.3M 1.8M 1.4M 632,000
beneficiaries
Beneficiaries 
who received 
101,135 206,342 399,847 158,227 77,321 71,136
at least one 
(10%) (13%) (12%) (9%) (5%) (11%)
prescription 
opioid
Children who 
received at 
26,868 18,215 27,039 23,043 14,825 6,540
least one 
(27%) (9%) (7%) (15%) (19%) (9%)
prescription
opioid
Beneficiaries  377 924 2,923 570 626 402
who received  (38 per  (57 per  (88 per  (32 per  (43 per  (64 per 
high amounts 100k) 100k) 100k) 100k) 100k) 100K)
Beneficiaries 
with high 
amounts who  106 182 531 58 145 119
had at least  (28%) (20%) (18%) (10%) (23%) (30%)
one fentanyl 
prescription
27 67 302 21 29 12
Beneficiaries 
(3 per  (4 per  (9 per  (1 per  (2 per  (2 per 
at serious risk
100k) 100k) 100k) 100k) 100k) 100k)
Prescribers 
with 
questionable  - 5 13 - 1 -
prescribing 
patterns
Source:  OIG analysis of T-MSIS data, 2020.  Rows may not always sum to regional totals because we excluded beneficiaries with missing or potentially 
erroneous addresses and beneficiaries who lived in multiple States in 2018.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 9 Appendix C: Demographic Data
Exhibit C-1: Most beneficiaries 
Any  High  Extreme  Doctor 
who received high or extreme 
opioids amounts amounts shopping
amounts of opioids and who 
appeared to be doctor shopping  018 11% <1% 0% 0%
were ages 4564.
1944 52% 25% 24% 32%
4564 33% 69% 72% 63%
65 and  3% 6% 4% 6%
older
Exhibit C-2: Most beneficiaries  Any  High  Extreme  Doctor 
who received any opioid,  opioids amounts amounts shopping
received high or extreme 
Female 67% 57% 55% 56%
amounts, or appeared to be 
doctor shopping were  Male 33% 43% 45% 44%
female.
Unknown <1% <1% 0% 0%
Source:  OIG analysis of T-MSIS data, 2020.  Rows may not always sum to 100% because of rounding.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 10 Endnotes
1 SAMHSA, 2018 National Survey on Drug Use and Health: Detailed Tables, Table 1.77A.  Accessed on July 27, 2020, at  
https://www.samhsa.gov/data/report/2018-nsduh-detailed-tables.
2CDC, Data Brief 356. Drug Overdose Deaths in the United States, 19992018, January 2020.
3National Association of Counties (NACo) and Appalachian Regional Commission (ARC), Opioids in Appalachia: The Role of Counties in Reversing a 
Regional Epidemic, May 2019.  Accessed on July 27, 2020 at https://www.naco.org/sites/default/files/documents/Opioids-Full.pdf.
4 American Medical Association, Issue brief: Reports of increases in opioid related overdose and other concerns during COVID pandemic, July 2020 (updated 
December 9, 2020).  Accessed on December 9, 2020, at https://www.ama-assn.org/system/files/2020-12/issue-brief-increases-in-opioid-related-
overdose.pdf.
5 OIG, Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D, OEI-02-15-00190, June 2015; OIG, High 
PartD 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; OIG, Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased, OEI-02-19-00390, July 2019. 
6 OIG,Concerns About Opioid Use in Medicare Part D in the Appalachian Region, OEI-02-18-00224, April 2019.
7 OIG, Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing, OEI-05-18-00010, July 2018.
8OIG, FACTSHEET: Alabamas Oversight of Opioid Prescribing and Monitoring of Opioid Use, A-04-19-00125, November 2019.  OIG, FACTSHEET: 
Kentucky's Oversight of Opioid Prescribing and Monitoring of Opioid Use, A-04-19-02022, March 2020.  OIG, FACTSHEET: Ohios Oversight of Opioid 
Prescribing and Monitoring of Opioid Use, A-05-19-00036, July 2020.  OIG, FACTSHEET: Tennessee's Oversight of Opioid Prescribing and Monitoring of 
Opioid Use, A-04-18-00124, February 2019.  OIG, FACTSHEET: West Virginias Oversight of Opioid Prescribing and Monitoring of Opioid Use, A-03-18-
03302, March 2019. 
9OIG, Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder, OEI-12-17-00240, January 2020; OIG, States Use of Grant 
Funding for a Targeted Response to the Opioid Crisis, OEI-BL-18-00460, March 2020.
10 CDC, CDC Guideline for Prescribing Opioids for Chronic PainUnited States, 2016, MMWR Recomm Rep, March 18, 2016, p. 16.  Accessed on July 27, 
2020, at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.  These guidelines specifically exclude patients undergoing active cancer treatment, 
palliative care, or end-of-life care (e.g., hospice care) due to the unique therapeutic goals, ethical considerations, opportunities for medical supervision, 
and balance of risks and benefits with opioid therapy in such care.  Further, due to the challenges of managing the painful complications of sickle cell 
disease, these guidelines defer to the NIH National Heart, Lung, and Blood Institutes guidance on how to use opioids to manage patients with this 
condition.  This Institute allows for the use of opioids to treat pain associated with sickle cell disease.  See National Heart,Lung, and Blood Institute. 
Evidence-based Management of Sickle Cell Disease. Expert Panel Report, 2014.  Accessed on September 9, 2020, at 
https://www.nhlbi.nih.gov/sites/default/files/media/docs/sickle-cell-disease-report%20020816_0.pdf. 
11OIG,Concerns About Opioid Use in Medicare Part D in the Appalachian Region, OEI-02-18-00224, April 2019.
12Richard Miech, Lloyd Johnston, Patrick M. OMalley, et al., Prescription Opioids in Adolescence and Future Opioid Misuse, Pediatrics, Volume 136, 
Number 5, August 2015.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834210/pdf/peds.2015-1364.pdfon August 17, 2020.
13Ibid; CDC, Opioid Overdose: Prescription Opioids. Accessed at https://www.cdc.gov/drugoverdose/opioids/prescribed.htmlon August 17, 2020. 
14 Christopher M. Jones, Joseph Logan, R. Matthew Gladden, et al., Vital Signs: Demographic and Substance Use Trends Among Heroin UsersUnited 
States, 2002-2013,MMWR Weekly Report, Volume 64, Number 26, July 10, 2015, pp. 719-25.  Accessed on July 27, 2020, at 
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm?s_cid=mm6426a3_w.  See also CDC, Opioid Overdose: Prescription Opioids. 
15 Dr. Nora Volkow, Director, National Institute on Drug Abuse, National Institutes of Health, COVID-19: Potential Implications for Individuals with 
Substance Abuse Disorders, April 6, 2020. Accessed on September 9, 2020, at https://www.drugabuse.gov/about-nida/noras-blog/2020/04/covid-19-
potential-implications-individuals-substance-use-disorders.
16 CDC, CDC Guideline for Prescribing Opioids for Chronic PainUnited States, 2016, MMWR RecommRep, March 18, 2016, p. 16.  Accessed on July 27, 
2020, at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
17 U.S. Drug Enforcement Administration, Diversion Control Division, National Forensic Laboratory Information System (NFLIS),  NFLIS 2018 Annual 
Report.  Accessed on August 17, 2020, at https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-Drug-AR2018.pdf.
18Other beneficiaries may also be at serious risk of opioid misuse or overdose but do not fall into either group.  For example,abeneficiary who had an 
average daily MED of 235 mg for 345 days would not meet our definition of serious risk.
19OIG, Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look, OEI-02-19-00130, May 2020.
20OIG, Concerns About Opioid Use in Medicare Part D in the Appalachian Region, OEI-02-18-00224, April 2019.
21OIG, Analysis Toolkit: Using Data Analysis to Calculate Opioid Levels and Identify Patients At Risk of Misuse or Overdose, OEI-02-17-00560, June 2018.
22These files contain MME conversion factors for each National Drug Code.  MED and MME are interchangeable terms. 
23OIG, National Review of Opioid Prescribing in Medicaid Is Not Yet Possible, OEI-05-18-00480, August 2019.
Acknowledgments
Hilary Slover and Lisa Minich served as the team leaders for this study, and Nate Hauger served as the lead 
analyst.  Others in the Office of Evaluation and Inspections who conducted the study include 
Samantha HandelMeyer and Kayla Phelps.  Office of Evaluation and Inspections staff who provided support 
include Althea Hosein, Kevin Manley, and Christine Moritz. 
We would also like to acknowledge the contributions of other Office of Inspector General staff, including 
Debashis Bhattacharya, Lauren McNulty, and Linh Ta.  
This report was prepared under the direction of Laura Kordish, Regional Inspector General for Evaluation and 
Inspections in the Chicago regional office, and Adam Freeman and Kelly Waldhoff, Deputy Regional Inspectors 
General.
Opioids in Medicaid: Concerns About Opioid Use Among Beneficiaries in Six Appalachian States in 2018 11