U.S. Department of Health and Human Services 
O ffice of Inspector General 
 
Issue Brief 
 
De cember 2020, OEI-05-18-00470 
 
Few Patients Received High Amounts of Opioids from IHS-Run 
Pharmacies 
Why OIG Did This Review 
Key Takeaway 
The opioid crisis is a public health emergency.1  In 2018 alone, opioid-related 
Data show that few patients  overdoses in the United States killed 46,802 people.2  The coronavirus 
received high amounts of opioids  disease 2019 (COVID-19) pandemic underscores the importance of opioid 
from IHS-run pharmacies, and  response effortsthe pandemic fuels factors such as unemployment that 
IHS reported positive outcomes  contribute to opioid misuse, and it may make access to treatment or support 
from opioid-related initiatives.   services more difficult.  
However, IHS has opportunities 
The Office of Inspector General (OIG) has been tracking opioid use in 
to improve the efficiency of its 
Department of Health and Human Services (HHS) programs since 2016.3  
opioid monitoring systems and 
Previous OIG work has assessed opioid use in both Medicare and Medicaid, 
IHS officials reported challenges 
including identifying beneficiaries at serious risk of misuse or overdose.4  
in using State-run prescription 
This issue brief focuses on the Indian Health Service (IHS), which serves an 
drug monitoring programs and 
American Indian and Alaska Native (AI/AN) population that may be at 
in tracking care outside of IHS.  
increased risk of opioid misuse or overdose.  Between 2016 and 2017, 
AI/ANs experienced a larger percentage increase in deaths involving 
prescription opioids than any other group.5  In addition, previous OIG work found that some IHS hospitals did not 
always follow IHS policy when prescribing and dispensing opioids.6   
What OIG Found 
OIGs analysis of IHS data on prescription drugs showed that few patients received high amounts of opioids from 
IHS-run pharmacies.  IHS has taken a number of steps to ensure appropriate opioid use among its patients, and 
IHS officials highlighted positive outcomes from these initiatives.  However, IHS has opportunities to improve the 
efficiency of its opioid monitoring systems by further automating its system for electronic health records (EHRs).  
Additionally, IHS officials reported challenges in using State-run prescription drug monitoring programs (PDMPs) 
and in tracking care that patients receive outside of IHS; both factors can limit IHS staffs ability to monitor opioid 
use.   
What OIG Recommends  
We recommend that IHS (1) assess the costs and benefits of updating its EHR system with tools to support more 
automated monitoring and (2) request support from States and Federal partners to address challenges in using 
State-run PDMPs.  IHS concurred with both recommendations. 
How OIG Did This Review 
We analyzed prescription drug data for opioids received from IHS-run pharmacies between May 2018 and 
April 2019.  We calculated patients morphine equivalent dose (MED)a measure that translates various opioid 
formulations and strengths into a standard valueto compare opioids received across patients and prescriptions.  
In addition, we reviewed IHS documents regarding IHSs policies for prescribing and dispensing opioids and steps 
that IHS has taken in response to the opioid crisis.  We also conducted interviews with IHS officials and staff to 
understand (1) the results of IHSs efforts; (2) how IHS monitors opioid use and opioid-related activities; and 
(3) challenges that IHS faces in preventing and detecting opioid misuse.  
  BACKGROUND 
 
Indian Health Service 
IHS is the principal Federal health care agency for AI/ANs, providing comprehensive 
health services to an estimated 2.56 million people.7  IHS provides health services in 
three ways: (1) through IHS-operated facilities; (2) through Tribally operated facilities 
funded through IHS contracts and compacts; and (3) through Urban Indian 
Organizations that receive funding through IHS contracts and grants.  More than 
60 percent of IHS appropriations are administered by Tribes.8  Not all AI/ANs receive 
care from facilities operated by IHS, and those who do may also receive health care 
servicesincluding prescription drugsfrom facilities not directly operated by IHS.  
These outside sources of care include Tribally operated facilities, Urban Indian Health 
Programs, other Federal programs such as the Department of Veterans Affairs, and 
private providers.9   
IHS pharmacies 
There are 12 IHS Areas, 9 of which have 80 pharmacies directly operated by IHS 
(hereinafter referred to as IHS-run pharmacies).  The remaining 3 Areas do not have 
any pharmacies directly operated by IHS.  See Appendix A for a map of the IHS Areas, 
the locations of IHS-run pharmacies, and the distribution across Areas of patients with 
any prescriptions. 
IHS-run pharmacies use IHSs EHR system, which contains individual patients 
health-related information, including medical history, laboratory testing information, 
and prescription drug information.   
IHS prescriptions 
IHS-run pharmacies may directly fill a patients prescription or may electronically 
transfer it to a non IHS-run pharmacy of the patients choice.  IHS might need to 
electronically transfer a prescription if there is no IHS-run pharmacy near a patients 
home or if a specific drug is not on a locations formulary.  Prescriptions that are filled 
by an IHS-run pharmacy or are electronically transferred from an IHS-run pharmacy 
are referred to throughout this report as received from an IHS-run pharmacy.  
Scope 
To assess IHSs efforts to ensure appropriate opioid use among its patients, we 
analyzed opioid prescriptions received from IHS-run pharmacies and we reviewed 
steps that IHS has taken to improve opioid-related care at facilities it operates.  This 
issue brief does not address care that AI/ANs do not receive directly through IHS (e.g., 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 2  prescriptions written and filled by non-IHS-run pharmacies or services provided by 
Tribally operated facilities), but rather focuses on IHSs efforts to combat the opioid 
crisis through the care it provides to patients. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 3   
RESULTS 
 
Few patients received high amounts of opioids from IHS-run 
pharmacies between May 2018 and April 2019  
Between May 2018 and April 2019, approximately one in six IHS patients who 
received a prescription from an IHS-run pharmacy received at least one opioid 
prescription from an IHS-run pharmacy.  Sixteen percent of patients57,134 of the 
nearly 367,683 who received prescriptions from an IHS-run pharmacyreceived 
opioids from an IHS-run pharmacy.  This represents all opioids received from an 
IHS-run pharmacy, regardless of the reason the opioids were prescribed or the 
amount that was prescribed.  It includes the 2,106 patients who had cancer or who 
were in hospice care during our study period.   
The number of IHS patients receiving opioids and the amounts they received may be 
higher than reported in this issue brief because this review analyzes only those 
opioids received from an IHS-run pharmacy. 
See Appendix B for more information and the characteristics (e.g., sex, age) of patients 
who received at least one opioid from an IHS-run pharmacy, and information on the 
opioids that were most commonly prescribed to them. 
Only 159 patients received high amounts of opioids from IHS-run 
pharmacies 
Only 159 IHS patientsless than half of one percent of IHS patients who received 
opioidsreceived high amounts of opioids from IHS-run pharmacies.  This does not 
include patients who had cancer or were in hospice during our study period and does 
not include prescriptions used for medication-assisted treatment of opioid use 
disorder.    
The 159 patients who received high amounts of opioids each received an average 
MED of more than 120 mg daily for at least 3 months.  MEDwhich is also known as 
morphine milligram equivalent (MME)is a measure that equates all the various 
opioids and strengths to one standard value.10  The Indian Health Manual (IHM), 
which is the reference manual for IHS employees, instructs clinicians to use caution in 
prescribing greater than or equal to 50 MED per day and to avoid increasing or 
carefully justify decisions to increase dosages beyond 90 MED per day for chronic 
pain.11   
Although patients may have received opioids for legitimate purposes, any high 
amount raises concern.  In addition to the risk of abuse and misuse, opioids also carry 
health risks, including respiratory depression, constipation, drowsiness, and 
confusion.12 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 4  For more information about patients who received high amounts of opioids, see 
Appendixes B and C. 
Some of the 159 patients who received high amounts of opioids may not always 
have received care suggested by IHS policies.  Although few patients received high 
amounts of opioids, some of these patients may not have received care suggested by 
IHS policies.  Receiving such care is especially important for patients who received 
high amounts of opioids.  Patients receiving high amounts of opioids are at higher 
risk of overdose.13  The IHM establishes policy for IHS-employed providers to follow 
when prescribing opioids to promote appropriate opioid prescribing and reduce 
opioid misuse.  For instance, providers should consider coprescribing naloxone, which 
can reverse the effects of an opioid overdose, and to order initial and periodic urine 
drug tests,14 and avoid coprescribing benzodiazepines whenever possible.15  See 
Exhibit 1 for more information. 
Exhibit 1: The 159 IHS patients who received high amounts of opioids may 
not always have received suggested care. 
 
Note:  Providers may deem it appropriate to coprescribe benzodiazepines and opioids for an individual patient.  
However, given the high amounts of opioids received by these patients, their cases may warrant additional review to 
ensure appropriate prescribing. 
Source: OIG analysis of IHS prescription data and review of IHM, 2020. 
IHS has taken several steps to prevent, detect, and reduce 
overprescribing and misuse of opioids at its facilities, and IHS 
officials highlighted some positive outcomes  
Since 2012, IHS has taken a number of steps to help ensure appropriate opioid use 
among its patients.  Many of these steps are documented in the IHM.  Some of the 
specific steps that IHS has taken include the following: requiring IHS-employed 
providers to routinely check State-run PDMPselectronic databases that collect 
designated data on dispensing of controlled substanceswhen prescribing or 
dispensing opioids; adopting the Centers for Disease Control and Preventions (CDCs) 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 5  Guideline for Prescribing Opioids for Chronic Pain; requiring prescribers to take a 
training course on pain and addiction; and increasing its monitoring of opioid use and 
opioid-related activities.16, 17  These and other key steps that IHS has taken are 
outlined in Exhibit 2.  For more details about IHSs opioid-related efforts, see 
Appendix D.   
Exhibit 2: Key steps that IHS has taken to combat the opioid epidemic  
 
Source: OIG summary of IHSs Indian Health Manual, documents, and interviews, 2020. 
 
In March 2018 congressional testimony, IHSs Chief Medical Officer described many of 
IHSs opioid-related initiatives and reported that there were promising signs of 
positive outcomes as a result of IHSs efforts.18  Specifically, the Chief Medical Officer 
said that available IHS data indicated a 13-percent decrease in the average number of 
opioid prescriptions per 100 of all IHS users from fiscal year (FY) 2013 to FY 2016.  In 
addition, he noted that naloxone prescriptions increased 518 percent from FY 2013 to 
FY 2017.  (Naloxone is a medication that can reverse the effects of an opioid 
overdose.  When naloxonesuch as the brand-name drug Narcanis administered in 
a timely fashion, it can save lives by blocking the effects of opioids and restoring 
normal breathing.)  The IHS Chief Medical Officer attributed this increase in 
prescriptions to IHSs policy of encouraging naloxone prescriptions for patients who 
are at higher risk for opioid overdose.   
In addition, IHS officials in four Areas noted particular successes on some 
opioid-related measures.  The respective successes they reported include: 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 6    Over 4 years, a 40-percent decrease in purchases for one Areas top 
nine opioids and a 71-percent decrease in methadone19;  
  A 60-percent decrease in another Areas total MED from 2017 to 2019;  
  A 27-percent decrease in a third Areas average MED per prescription since 
FY 2017; and 
  A 50-percent decrease in opioid-related metrics at one facility in a fourth Area 
following a CDC training. 
IHS has opportunities to improve the efficiency of its opioid 
monitoring systems  
While IHS conducts opioid monitoring and has seen some positive outcomes, IHS has 
opportunities to improve the efficiency of its internal systems for monitoring 
opioids.20  IHS officials identified monitoring tools thatas of August 2019IHSs 
existing systems did not include.  If these tools were available, they could improve the 
efficiency of IHSs opioid monitoring.  Because they are not, IHS staff sometimes use 
manual techniques to conduct specific aspects of opioid monitoring.  All IHS-run 
facilities use the same EHR system, so these opportunities to gain efficiency apply 
across IHS.21   
IHS officials reported that the agencys EHR system, which it uses to manage patient 
care, lacks some tools to monitor care for patients receiving opioids.  They reported 
that the EHR system does not have the ability to calculate MED for individual patients 
or to alert providers if a patient receiving opioids is also prescribed a benzodiazepine.  
Instead, IHS staff might rely on MEDs calculated from a PDMP or by hand and rely on 
manually reviewing a patients file to find any benzodiazepine prescriptions.  IHS is 
working to modernize its EHR system, but an IHS official reported that the 
modernization effort will not address these gaps.22  
IHS officials also reported that some information from the EHR system is not captured 
in summary-level reports.23  (These reports aggregate opioid-related data at the 
facility level or Area level to provide an overall view of opioid prescribing.)  For 
instance, when IHS staff export data from the EHR system, the exported file lacks an 
indicator for which patients have cancer.  This means that all patients receiving 
opioids are included in the summary-level reports, and if staff note anything 
concerning, they have to manually review each patients record to determine whether 
the opioid use is appropriate.  The exported file also does not indicate whether or 
how many times providers completed PDMP checks.  This makes it difficult for IHS 
staff to assess IHS providers compliance with IHS policy. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 7  IHS officials reported challenges in using State-run PDMPs and 
in tracking care provided outside of IHS 
IHS officials reported challenges in (1) using State-run PDMPs and (2) tracking care 
that patients receive from non-IHS providers.  PDMPs can help providers avoid drug 
interactions and identify drug-seeking or doctor shopping behavior.  They can also be 
used by professional licensing boards to identify patterns of inappropriate prescribing 
or dispensing, or by law enforcement to identify cases of diversion of controlled 
substances.  PDMPs are run by individual States.  PDMPs can help track 
controlled-substance prescriptions that patients receive outside of IHS, but do not 
track other, nonpharmaceutical care that patients might receive outside of IHS.24 
PDMPs.  IHS requires that (1) IHS-employed prescribers and pharmacists check the 
State PDMP prior to prescribing or dispensing, (2) IHS-employed prescribers conduct 
monthly self-audits, and (3) IHS-run pharmacies report their opioid prescribing data 
to State PDMPs.25   
IHS officials reported challenges in checking State-run PDMPs.  They reported 
difficulty in (1) obtaining permission to access PDMPs in different States, (2) logging 
in to multiple States PDMPs, and (3) searching (e.g., because of name misspellings or 
variations).  Obtaining access to State PDMPs could be more difficult for 
IHS-employed providers because PDMPs often require a license in the State in which 
a provider is located to obtain access, but as Federal employees, IHS-employed 
providers can be licensed in any State, not necessarily the one in which they practice.  
IHS providers might experience a delay in receiving requested information or may 
have to use a workaround, such as a prescriber asking a pharmacist to run a patient 
report.  
IHS officials also reported that PDMP information may not be complete, due to 
delayed or nonexistent reporting.  For instance, Tribes are not required to report to 
PDMPs, though some do so voluntarily.    
Outside care.  IHS officials reported that their opioid-related monitoring efforts are 
complicated by difficulties in tracking care received outside of IHS.  While PDMPs can 
provide information about opioids dispensed outside of IHS, IHS providers may still 
lack key opioid-related information about their patientsfor example, whether 
a patient is participating in a treatment program.  Not having complete information 
about a patients care could impact a providers ability to treat patients effectively.  
For example, some opioid treatment services are provided by Tribes or other non-IHS 
entities.  This could mean that IHS-employed providers can make referrals for those 
opioid treatment services, but they may not be able to directly monitor that treatment 
or learn about the outcomes of treatment.  Additionally, if a patient experiences an 
opioid overdose and is taken to a non-IHS hospital, the IHS-employed provider might 
not know that an overdose occurred unless the patient discloses it.  Knowing whether 
a patient has experienced an opioid overdose could change the providers plan for 
care.   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Results | 8   
RECOMMENDATIONS 
 
 
IHS has made efforts to prevent its patients from receiving dangerous amounts of 
opioids through IHS-run pharmacies, and overall, our results indicate that it has been 
successful.  OIG found that less than half of one percent of patients who received 
opioids from IHS pharmacies received high amounts.  Furthermore, IHS officials 
reported positive outcomes as a result of the agencys efforts, including reduced 
opioid purchasing and prescribing.  IHS has taken several steps to ensure appropriate 
opioid use among its patientsfor instance, it has updated its prescribing guidelines, 
required that IHS providers routinely check State PDMPs, and increased its monitoring 
of opioid use.  To support IHSs efforts, OIG will provide the appropriate IHS clinical 
staff with information on the specific patients who received high amounts of opioids 
so that those staff can review and determine whether followup with any of those 
patients is necessary. 
Although IHS monitors opioid use, some of its monitoring efforts currently involve 
manual processes that could be made more efficient with automated tools.  These 
existing methods of monitoring may take more time, miss information, and introduce 
more opportunities for error.  For instance, IHSs EHR system cannot calculate MED for 
an individual patient or alert providers if a patient who is receiving opioids is 
prescribed a benzodiazepine.  Moreover, IHS staff are not able to export all EHR data 
to summary-level reports.   
In addition, IHS officials reported challenges in using State-run PDMPs and in tracking 
care that patients receive from non-IHS providers.  Because of these challenges, 
providers do not have complete information about the medical care a patient 
receives, which could make providing appropriate care complicated.  While this review 
did not directly address solutions to the challenge of tracking outside care, IHS 
agreed in response to another OIG review to reinforce a requirement to review and 
document care received from non-IHS providers.26  We support this effort.      
We recognize that IHS has acted to address the opioid crisis, and our results indicate 
that it has been successful in its efforts.  The following recommendations aim to 
enhance the efficiency of IHSs monitoring and to reduce the challenges that officials 
reported in using State-run PDMPs effectively. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Recommendations | 9  We recommend that IHS: 
Assess the costs and benefits of updating its EHR system with 
tools to support more automated monitoring  
IHS should explore its ability to modify or update its EHR system and subsequent 
summary-level reports to automate monitoring that is currently done manually.  Such 
additional automation is not possible within the current EHR system and could 
enhance individual patient care; add to existing summary-level reports; and decrease 
error and provider burden.  IHS should consult with Area or local facility staff to assess 
specific needs and potential solutions that could be implemented across IHS.  IHS 
could also work with the team that is overseeing the project to modernize IHS health 
information technology to determine whether this project will address any of the 
desired automation.  
Request support from States and from Federal partners to 
address challenges with State-run PDMPs 
IHS should reach out to States and to Federal partners to determine whether they can 
resolve or mitigate the challenges that IHS providers identified related to accessing 
and effectively using PDMPs.  For instance, IHS could ask States to except 
IHS-employed providers from requirements that providers requesting access to 
a States PDMP be licensed in that State.  These exceptions could be included as part 
of each Areas negotiated memorandum of understanding (MOU) with each PDMP for 
the States in that Area.27  IHS could also explore whether additional training or 
technical assistance on PDMPs could be helpful for IHS-employed providers, and the 
agency could request such training from States.  IHS could also work with Federal 
partners to ensure that its health care facilities fully benefit from Federal PDMP 
efforts.28
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Recommendations | 10   
AGENCY COMMENTS AND OIG RESPONSE 
 
 
IHS concurred with our recommendation to assess the costs and benefits of updating 
its EHR system with tools to support more automated monitoring.  IHS summarized 
four actions it has taken to enhance the tools available for monitoring patient care in 
the EHR system, including reminders to assist prescribers in meeting policy 
requirements.  IHS also indicated that it is working to integrate PDMPs into its EHR 
system by late summer 2021.  We appreciate IHSs commitment to enhancing tools 
available for managing patient care.  We encourage IHS to also work to enhance 
summary-level reports, and we look forward to the updates in its Final Management 
Decision. 
IHS also concurred with our recommendation to request support from States and 
from Federal partners to address challenges with State-run PDMPs.  IHS indicated that 
it has engaged in discussions with CDC, the Department of Justices Bureau of Justice 
Assistance, and the PDMP Training and Technical Assistance Center to evaluate 
options to integrate PDMP data into its EHR system.  IHS expects its internal design 
discussions to be completed in December 2020.  We look forward to receiving IHSs 
Final Management Decision, including information on IHSs progress on integrating 
PDMP data into its EHR system. 
For the full text of IHSs comments, see Appendix E. 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Agency Comments and OIG Response | 11  METHODOLOGY 
 
We based this issue brief on three key data sources: an analysis of IHS's prescription 
drug and patient records; a document review of IHS policies; and structured 
interviews with IHS officials and staff.    
Scope 
This issue brief includes prescriptions that patients received directly from 77 of 
80 IHS-run pharmacies or that were electronically transferred by an IHS-run 
pharmacy.29  Prescriptions may be received onsite at an IHS-run pharmacy or 
transferred electronically to a non-IHS pharmacy to be filled.  Between May 2018 and 
April 2019, IHS-run pharmacies dispensed or electronically transferred a total of 
8,087,054 prescriptions.  Nearly allmore than 99 percentof these were dispensed 
by IHS-run pharmacies; very few were electronically transferred from IHS-run 
pharmacies to non-IHS pharmacies. 
This issue brief does not include prescriptions that were transferred by nonelectronic 
means or prescriptions that were received from pharmacies not run directly by IHS.  It 
also does not include prescriptions for medication-assisted treatment of opioid use 
disorders, such as buprenorphine, naltrexone, and methadone.    
IHS prescription drug records and patient information 
We collected prescription drug and patient information directly from IHSs EHR 
system.  IHSs prescription drug recordsthat is, IHSs records of prescriptions filled 
or electronically transferred by IHS-run pharmaciescontain information about each 
prescription (e.g., the National Drug Code, days supply, etc.), as well as the patient, 
prescriber, and pharmacy.  The patient data contains demographic and characteristic 
information about patients such as their date of birth and sex.   
Analysis of IHS opioid utilization   
We identified prescriptions for opioids and prescriptions for benzodiazepines that 
patients received over the 12-month period of May 2018 through April 2019.  We did 
this by matching IHS prescription drug records to CDCs MME conversion and 
benzodiazepine files.  CDC files contain information about each drug such as the drug 
name, strength of the drug, its therapeutic class (e.g., opioid, benzodiazepine), and its 
controlled-substance schedule (e.g., Schedule II or Schedule III), as well as (for 
opioids) information about each drugs morphine milligram equivalent (MME).30 
We calculated the number of patients who received opioids and the total number of 
opioid prescriptions.  Using all prescription and patient information, we also 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Methodology | 12  determined the proportion of patients with opioid prescriptions across IHS and the 
proportions in each of the nine IHS Areas with IHS-run pharmacies.  We then 
identified the most commonly prescribed opioids by calculating the total number of 
prescriptions for each active pharmaceutical ingredient (delineated by strength and 
form).   
Next, we determined the amount of opioids that each patient received during our 
study period.  To do this, we calculated each patients average daily MED.31  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 patients daily opioid level.  
To calculate each patients average daily MED, we first calculated the MED for each 
prescription.  To do this, we used the following equation:  
strength per unit  x  quantity dispensed  x (MME conversion factor)
MED=  
(days supply)
( ) ( )
Next, we summed each patients MED for each day of the year based on the dates of 
service and days supply on each prescription record.  We refer to this analysis as the 
daily MED.   
Next, we calculated each patients average daily MED over each 90-day period during 
our study period.  We excluded from this analysis patients who had a diagnosis of 
cancer or had a hospice stay at any point during our study period.32    
Next, we determined the extent to which patients received high amounts of opioids.  
We analyzed the MED data using the same criteria as previous OIG work.33  We 
considered a patient to have received high amounts of opioids if the patient 
exceeded an average daily MED of 120 mg for any 90-day period and had received 
opioids for 90 or more days in our 12-month study period (not necessarily 
90 consecutive days).  The MED of 120 mg exceeds the 90-mg MED level that the IHM 
recommends avoiding for patients with chronic pain.34  This recommendation reflects 
the IHMs adoption of the CDC prescribing guideline. 
We then determined the extent to which patients received extreme amounts of 
opioids.  We calculated each patients average daily MED over the entire 12-month 
study period.  We considered a patient who exceeded an average daily MED of 
240 mg for the entire study period and had received opioids for 360 days or more to 
have received an extreme amount of opioids.  Fewer than 10 patients received 
extreme amounts of opioids.  Therefore, we did not present the results in this issue 
brief.  
Patient characteristics   
We calculated frequencies for select patient characteristics and information including 
age; sex; location; the number of pharmacies and prescribers the patient visited; and 
the most common opioids prescribed.  
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Methodology | 13  For the patients who received high amounts of opioids, we calculated additional 
measures.  For these patients, we identified the most common diagnoses overall.35  
We also determined whether they received care suggested by IHS policies, such as 
receiving naloxone prescriptions and undergoing urine drug testing, and whether 
there was overlapping benzodiazepine use.   
Naloxone.  We determined the number of patients who received high amounts of 
opioids who did not receive a naloxone prescription from May 2018 through April 
2019.  We based this analysis on the prescription drug records provided by IHS.   
Urine Drug Testing.   We determined the number of patients who received high 
amounts of opioids who also had a urine drug test from May 2018 through April 
2019.  We based this analysis on the patient medical record provided by IHS. 
Benzodiazepines.  We determined the number of patients who received high 
amounts of opioids who also received an overlapping benzodiazepine prescription 
from May 2018 through April 2019.  We included all drugs in the CDC file in the class 
of benzodiazepines.  We based this analysis on the prescription drug records 
provided by IHS. 
Document review 
We reviewed IHS documents about IHSs policies for prescribing and dispensing 
opioids and steps that IHS has taken in response to the opioid crisis.  We analyzed the 
documents to identify IHSs requirements for providers who prescribe and dispense 
opioids, as well as its efforts to monitor patient opioid use.   
Interviews with IHS officials and staff   
We conducted 12 interviews with officials and staff from IHS headquarters and Area 
offices to understand how IHS monitors opioid use and opioid-related activities; 
limitations that IHS faces in preventing and detecting opioid misuse; and the results 
of IHSs efforts.  These interviews included officials and staff who were responsible for 
developing and implementing policies; providing technical assistance and guidance; 
and monitoring opioid use.  We employed semistructured interview protocols that 
allowed us to follow up on additional issues as we learned new information.  We 
conducted the interviews between June and August 2019.  We conducted a 
qualitative analysis of interview data to identify common themes across interviews. 
Limitations   
Our analysis of opioid utilization is based on an analysis of prescription and patient 
data from IHS-run pharmacies; it is not based on a review of medical records.   
Our analysis may therefore underestimate patients opioid use.  IHS patients in this 
analysis may have received additional drugs from pharmacies outside of IHS, such as 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Methodology | 14  Tribally operated pharmacies or private pharmacies.  IHS prescription drug records 
would not capture these outside drugs. 
Conversely, our analysis may slightly overestimate opioid use for a subset of patients.  
A small fraction of prescriptions in our data0.24 percentwere electronically 
transferred to non-IHS pharmacies to be filled, which means that we did not have 
dispensing information in our data.  We assumed that patients filled and received 
these prescriptions, but we did not verify this.  If patients did not in fact fill or receive 
prescriptions transferred to non-IHS pharmacies, then our analysis overstates the 
number of prescriptions they received.  
Our analysis of steps that IHS has taken to combat the opioid epidemic, the outcomes 
from opioid-related initiatives, and IHSs limitations relied on interviews and IHS 
documents.  We did not independently verify information reported in interviews. 
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.
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Methodology | 15   
APPENDIX A 
 
Overview of IHS Areas and Pharmacies 
Exhibit A-1: This analysis covers 9 IHS Areas with 77 pharmacies. 
Note: (1) There are 80 IHS-run pharmacies.  Three IHS-run pharmacies responded to our data request; however, because of a 
transmission error, the data files were not usable for our analysis and those three pharmacies are therefore not represented on this 
map. 
*Three IHS Areasthe Alaska Area, the California Area (which includes Hawaii), and the Tucson Areado not have any IHS-run 
pharmacies. 
Because of software limitations, the Navajo and Tucson Areas are not perfectly depicted. 
Source: OIG analysis of IHS prescription data, 2020. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix A | 16  Exhibit A-2: The Phoenix Area had the most patients with prescriptions.  
 
Note: Patients may receive prescriptions from multiple IHS Areas. 
Source: OIG analysis of IHS prescription data, 2020. 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix A | 17   
APPENDIX B 
 
Characteristics of patients who received any opioid and who 
received high amounts of opioids  
 
Exhibit B-1: Most patients who received opioids were adults.   
 
Source: OIG analysis of IHS prescription data, 2020. 
 
Exhibit B-2: Most patients who received opioids were female. 
 
Source: OIG analysis of IHS prescription data, 2020. 
 
 
 
 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix B | 18   
Exhibit B-3: The Great Plains Area had the highest percentage of patients 
who received any opioid, while the Phoenix Area had the most patients who 
received high amounts of opioids.  
 
Note: Patients may receive prescriptions from multiple areas.   
Source: OIG analysis of IHS prescription data, 2020. 
 
Exhibit B-4: Patients who received opioids most commonly received 
acetaminophen/hydrocodone. 
 
Source: OIG analysis of IHS prescription data, 2020. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix B | 19  Exhibit B-5: Patients who received high amounts of opioids most commonly 
received morphine. 
 
Source: OIG analysis of IHS prescription data, 2020. 
 
Exhibit B-6: Most patients who received opioids visited three or fewer 
prescribers.   
 
Note: Missing means that no prescriber National Provider Identifiers were identified for the patient.   
Source: OIG analysis of IHS prescription data, 2020. 
   
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix B | 20  Exhibit B-7: Most patients who received opioids visited one IHS-run 
pharmacy.   
 
Note: Prescriptions that were electronically transferred outside of IHS are not included in this analysis, because we do 
not have data on when or where they were filled.  The data in this exhibit reflect only prescriptions filled at an IHS-run 
pharmacy.  Missing means that all prescriptions for a given patient were not filled by an IHS-run pharmacythe 
patient had only prescriptions that were transferred electronically to a non-IHS pharmacy.  Because of rounding, row 
totals do not sum to 100 percent.  
Source: OIG analysis of IHS prescription data, 2020. 
 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix B | 21  APPENDIX C 
Common Diagnoses for Patients Who Received High Amounts 
of Opioids 
Exhibit C-1: Most patients who received high amounts of opioids had 
chronic pain; many also had one or more common chronic diseases or 
conditions.  
 
Note: These diagnoses do not necessarily represent the reason for which patients received opioids.  Instead, this table 
represents the most common diagnoses found among patients who received high amounts of opioids.  This table does 
not include administrative (Z) codes.  The patient record for one patient who received high amounts of opioids had only 
these administrative Z-codes.  A given patient may have more than one diagnosis code.   
Source: OIG analysis of IHS prescription data, 2020. 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies  
OEI-05-18-00470  Appendix C | 22  APPENDIX D 
 
Overview of IHSs Opioid Initiatives
IHS has taken a number of steps to address its opioid crisis.  In this appendix, we 
provide specific information about IHSs requirements for training and when providers 
are required to check State PDMPs, as well as IHSs prescribing guidelines.  We also 
summarize many of IHSs other initiatives and provide links to IHS resources for more 
detail. 
Provider requirements  
Assuring Appropriate Documentation of Prescriptions (effective August 2020)36 
 
Ensures appropriate documentation of all prescriptions written by IHS prescribers, whether a 
prescription will be filled by an IHS pharmacy or a non-IHS pharmacy.  Reiterates proper 
documentation to prescribers and describes how to enter prescriptions into the EHR system. 
Essential Training on Pain and Addiction (effective July 2016)37 
  Required for all IHS Federal prescribers, contractors (who spend 50 percent or more of 
their clinical time under contract with the Federal government), clinical residents, and 
trainees within the first 6 months of employment 
  Required refresher training every 3 years 
PDMP Requirements (effective July 2016)38 
IHS was one of the first Federal agencies to require providers to check State PDMPs. 
Prescribers must check State PDMPs when doing any of the following: accepting a new 
patient, prescribing opioids exceeding 7 days for acute pain, and progressing a patient from 
acute to chronic opioid pain therapy.  Prescribers must also check State PDMPs periodically 
during opioid therapy for chronic pain. 
Pharmacists must check State PDMPs at the following points: prior to processing an outside 
(i.e., non-IHS) prescription for a controlled substance; and every 3 months, prior to reissuing 
or refilling for a chronic controlled-substance prescription. 
Prescribing policy and recommendations 
Chronic non-cancer pain management policy (effective February 2018)39 
 
Prescribers should: 
  use caution when increasing dosage to 50 MED or more per day; 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix D | 23    avoid increasing dosage to 90 MED or more per day, or carefully justify that decision; 
  perform urine drug screening prior to initiating chronic opioid treatment and 
periodically (every 612 months) during treatment; 
  consider prescribing naloxone with all patients on chronic opioids; highly 
recommended for patients who exceed 50 MED per day; and 
  avoid coprescribing benzodiazepines. 
IHS also outlined a number of policies and procedures including informed consent; use of 
treatment agreements; acute pain; initial assessment; initiating chronic opioid treatment; 
ongoing monitoring and management; and use of a pain management team. 
Clinical recommendations on AI/AN pregnant women and women of childbearing age with 
opioid use disorder (released March 2019)40 
  Recommendations are tailored for AI/AN women and use national standards of care 
for establishing treatment for opioid use disorder in pregnant and reproductive-age 
women, as well as treatment for those who are at risk for developing an opioid use 
disorder 
  Collaborated with the American College of Obstetricians and Gynecologists Committee 
on American Indian and Alaska Native Womens Health 
Management of acute dental pain (released August 2018)41 
Provides evidence-based guidance for general dentists on prescribing for acute dental pain 
Clinical recommendations on neonatal opioid withdrawal syndrome (released 
December 2019)42 
  Recommendations provide standards of care surrounding screening, diagnosing, and 
treatment of pregnant mothers and infants affected by prenatal opioid exposure 
  Collaborated with the American Academy of Pediatrics Committee on Native American 
Child Health 
IHSs efforts geared toward prevention 
Training 
    Essential training on pain and addiction (as described above) 
  Weekly TeleECHO clinics on chronic pain and opioid management, through a 
partnership with the University of New Mexico.  The clinics connect providers to 
experts on the topic and include brief lectures or hands-on demonstrations.  
Community clinicians also present clinical cases for feedback and recommendations.  
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix D | 24  HOPE Committee (Indian Health Service National Committee on Heroin, Opioids, and Pain 
Efforts) 
  Established March 2017; evolved out of Prescription Drug Abuse Workgroup  
  Purpose: To promote appropriate and effective pain management; reduce overdose 
deaths from heroin and prescription opioid misuse; and improve access to culturally 
appropriate treatment. 
Other prevention initiatives  
  Published the prescribing policy and guidelines described above 
  Culturally appropriate patient education  
  Programs for drug takeback and disposal 
  Home lockboxes for controlled substances 
IHSs efforts geared toward detection 
IHM outlines responsibilities related to opioid monitoring for multiple staffing levels within 
IHS (i.e., Chief Medical Officer, Area Chief Medical Officer, facility Chief Executive Officer, 
 
facility Medical/Clinical Director, and Pharmacy Director).  The IHM also outlines the role of a 
pain management team, which most Area staff reported using for review of pain management 
treatment plans. 
IHS Safe Opioid Monitoring Tool (ISOM) (effective January 2019) 
  All facilities are required to report the ISOM to Area Pharmacy Consultants every 
month.  It is also submitted to facility and Area leadership, as well as the Principal 
Pharmacy Consultant in IHS. 
  Measures include the number of opioid prescriptions, the number of patients over 
90 MME, the number of patients between 50 and 90 MME, the number of naloxone 
prescriptions, and the average MME per facility. 
RPMS Report and Information Processor  
Allows staff to export data from IHSs EHR system to a more user-friendly format.  There is a 
tool for controlled substances that generates opioid-related measures for individual service 
units.43  RPMS is IHSs information system that contains many software applications, including 
the EHR system. 
Area monitoring initiatives 
Some Areas reported creating a scorecard tool or quality management plan for local 
monitoring efforts.  These tools are generally used for reporting to the local governing body.44  
They generally include elements from the ISOM, but they may include more, as they are 
designed to address local concerns.  In March 2020, the Billings Area Opioid Stewardship 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix D | 25  Dashboard Team won an award from HHS for its use of innovative technology to create a 
dashboard that enhances the use of data, accountability, and transparency to help address the 
national opioid crisis. 
IHSs efforts geared toward treatment 
  In September 2018, IHS released a new policy on designating providers eligible to 
prescribe controlled substances via the Internet.45  The policy is designed to increase 
 
access to treatment of opioid use disorder for AI/ANs living in rural or remote areas. 
  In June 2019, IHS instructed all IHS-run facilities to identify resources in their local 
areas for treatment of opioid use disorder and to create an action plan, no later than 
December 11, 2019, to provide or coordinate patient access to medication-assisted 
treatment, increasing access to culturally appropriate treatment and recovery support 
services.46 
  IHS has worked to make naloxone available and accessible. 
o  In December 2015, IHS signed an MOU with the Department of Interiors Bureau 
of Indian Affairs (BIA) that allows IHS providers to provide BIA law enforcement 
officers with training and naloxone kits.  BIA is the agency with law enforcement 
responsibility for AI/AN lands.  IHSs Area Offices may also enter into MOUs with 
Tribes to allow transfer of naloxone kits from an IHS facility to Tribal first 
responders.  IHM outlines requirements for providing naloxone to law 
enforcement agencies and first responders.47 
o  Published the prescribing guidelines described above that prescribers should 
consider coprescribing naloxone 
Additional resources 
  IHS infographic"How IHS is Supporting HOPE for Patients Affected by Heroin, 
Opioids, and Chronic Pain: 
 
https://www.ihs.gov/sites/opioids/themes/responsive2017/display_objects/documents
/supportinghopeinfograph.pdf   
  IHSs website on opioid use disorder and pain: https://www.ihs.gov/opioids/ 
  IHS IHM, Part 3 (see chapters 7, 30, 32, 35, and 38): https://www.ihs.gov/ihm/pc/part-
3/ 
  IHS HOPE Committee newsletters: https://www.ihs.gov/opioids/hope/newsletters/ 
  IHS training opportunities related to opioids: 
https://www.ihs.gov/opioids/trainingopportunities/ 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Appendix D | 26  APPENDIX E 
 
  Agency Comments 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies  
OEI-05-18-00470  Appendix E | 27  Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies  
OEI-05-18-00470  Appendix E | 28  ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Nicole Hrycyk served as the team leader for this study, and Kayla Phelps served as the 
lead analyst.  Others in the Office of Evaluation and Inspections who conducted the 
study include Lauren Anderson, Randi Hall, Samantha Handel-Meyer, and 
Abigail Wydra.  Office of Evaluation and Inspections staff who provided support 
include Joe Chiarenzelli, Althea Hosein, and Christine Moritz.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Mandy Brooks, Lisa Minich, and Hilary Slover.   
This report was prepared under the direction of Laura T. Kordish and 
Thomas F. Komaniecki, Regional Inspectors General for Evaluation and Inspections in 
the Chicago regional office, and Adam Freeman and Kelly Waldhoff, Deputy Regional 
Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies  
OEI-05-18-00470  Acknowledgments and Contact | 29   
EEEENNNNDDDDNNNNOOOOTTTTEEEESSSS    
 
 
 
1 Alex M. Azar II, Secretary of Health and Human Services, "Renewal of Determination that a Public Health Emergency Exists, 
January 24, 2020.  Accessed at https://www.phe.gov/emergency/news/healthactions/phe/Pages/opioid-24jan2020.aspx on 
April 29, 2020.  
2 Centers for Disease Control and Prevention (CDC), Drug and Opioid-Involved Overdose DeathsUnited States, 2017-2018, 
MMWR 69, no. 11, March 20, 2020, p. 1.  Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6911a4-H.pdf on 
April 13, 2020.  
3 OIG, Opioids in Medicaid: Review of Extreme Use and Overprescribing in the Appalachian Region (OEI-05-19-00410), 
forthcoming (see OIG Work Plan at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-
0000392.asp); OIG, Opioid Use in Medicare Part D Continued To Decline in 2019, but Vigilance Is Needed as COVID-19 Raises 
New Concerns (OEI-02-20-00320), August 2020; OIG, Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: 
A Closer Look (OEI-02-19-00130), May 2020; OIG, Opioid Use in Medicare Part D in Missouri (OEI-02-19-00391), 
September 2019; OIG, Opioid Use Decreased in Medicare Part D, While Medication-Assisted Treatment Increased 
(OEI-02-19-00390), July 2019; OIG, Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing (OEI-05-18-00010), 
July 2018; OIG, Opioid Use in Medicare Part D Remains Concerning, OEI-02-18-00220, June 2018; OIG, Opioids in Medicare Part 
D: Concerns about Extreme Use and Questionable Prescribing, OEI-02-17-00250, July 2017; OIG, High Part D Spending on 
Opioids and Substantial Growth in Compounded Drugs Raise Concerns, OEI-02-16-00290, June 2016.    
4 In 2019, OIG found that about 1 in 4 Medicare Part D beneficiaries received opioids, with nearly 267,000 of them receiving 
high amounts of opioids.  Because a national review of opioid prescribing in Medicaid is not yet possible, OIG has not 
conducted such analysis for Medicaid beneficiaries.  See OIG, Opioid Use in Medicare Part D Continued To Decline in 2019, but 
Vigilance Is Needed as COVID-19 Raises New Concerns, (OEI-02-20-00320), August 2020; and OIG, National Review of Opioid 
Prescribing in Medicaid is Not Yet Possible (OEI-05-18-00480), August 2019. 
5 CDC, Drug and opioid-involved overdose deathsUnited States, 2013-2017, MMWR 67, nos. 51 & 52, January 4, 2019, 
p. 1420.  Accessed at https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm675152e1-H.pdf on April 13, 2020.  Note: Cited 
document notes that potential race misclassification might lead to underestimates for certain categories, primarily AI/ANs, see 
p. 1421. 
6 OIG, IHS Needs To Improve Oversight of Its Hospitals Opioid Prescribing and Dispensing Practices and Consider Centralizing Its 
Information Technology Functions (A-18-17-11400), July 2019. 
7 IHS, IHS Profile, April 2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/factsheets/IHSProfile.pdf on June 23, 
2020. 
8 IHS, Strategic Plan FY 2019-2023, p. 1.  Accessed at 
https://www.ihs.gov/sites/strategicplan/themes/responsive2017/display_objects/documents/IHS_Strategic_Plan_FY%202019-
2023.pdf on April 9, 2020. 
9 Because of the lack of information available on opioid prescriptions written at or dispensed by facilities not directly operated 
by IHS, this report is focused only on those prescriptions written at or dispensed by facilities directly operated by IHS. 
10 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. 
11 IHS, IHM, 3-30. 13(F).  Accessed at https://www.ihs.gov/ihm/pc/part-3/p3c30/ on March 11, 2020. 
12 CDC, CDC Guideline for Prescribing Opioids for Chronic PainUnited States, March 18, 2016, MMWR 65, no. 1, March 18, 
2016, pp. 13, 44.  Accessed at https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf on March 8, 2020. 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Endnotes | 30   
13 Ibid., p. 10.   
14 IHS, IHM, 3-30.17 and 3-30.18.  Accessed at https://www.ihs.gov/ihm/pc/part-3/p3c30/ on March 11, 2020. 
15 Ibid., 3-30.10(J).   
16 Ibid., 3-30. 29(A).   
17 PDMPs should have information about all opioids that a patient received, regardless of the source.   
18 RADM Michael E. Toedt, M.D., FAAFP, Opioids in Indian Country: Beyond the Crisis to Healing the Community, testimony 
before the United States Senate Committee on Indian Affairs, March 14, 2018.  Results noted in testimony come from 
available IHS data, taken from IHSs National Data Warehouse.  The data warehouse includes some data from Tribes or Urban 
Indian Organizations. 
19 In this context, methadone prescriptions are for pain management purposes, not treatment.  At the time of our review, IHS 
did not operate Opioid Treatment Programs that administered methadone.   
20 OIG has a related recommendation for IHS to work with hospitals to analyze opioid data to make decisions and oversee 
providers to minimize prescribing practices that do the following: exceed daily MME guidelines established by IHS; coprescribe 
opioids and benzodiazepines; and use opioids for acute pain.  See OIG, IHS Needs To Improve Oversight of Its Hospitals Opioid 
Prescribing and Dispensing Practices and Consider Centralizing Its Information Technology Functions, July 2019, A-18-17-11400.   
21 IHSs EHR system is part of the Resource and Patient Management System (RPMS)the system that IHS uses to manage 
both clinical and administrative information in its health care facilities. 
22 IHS launched an effort to modernize RPMS, including the EHR system, in October 2018.  The effort is intended to identify a 
modern system that will address clinical, process, and technical gaps for improving health care outcomes within the Indian 
health system (i.e., IHS and the Tribes and Urban Indian Organizations that use IHSs EHR system).  For more details, see 
https://www.ihs.gov/newsroom/ihs-blog/october2018/ihs-and-hhs-launch-a-health-information-technology-modernization-
research-project/.  Accessed on April 15, 2020. 
23 IHS staff also use data in the EHR system to conduct system-level analysis.  They export data from the EHR system into 
analytics programs to create summary-level reports of opioid use and opioid-related activities across IHS facilities.  See 
Appendix D, IHSs efforts geared toward detection, for details about how IHS currently monitors opioid use and 
opioid-related activities. 
24 IHS requires each Area to create a Memorandum of Understanding (MOU) with State PDMPs that establishes the 
requirements for data disclosure to the State PDMP.  See IHS, Indian Health Manual, 3-32.1(C)(5), 3-32.2(A).  Accessed at 
https://www.ihs.gov/ihm/pc/part-3/p3c32/ on October 8, 2020. 
25 IHS, IHM, 3-32.2.  Accessed at https://www.ihs.gov/ihm/pc/part-3/p3c32/ on June 23, 2020. 
26 OIG, IHS Needs To Improve Oversight of Its Hospitals Opioid Prescribing and Dispensing Practices and Consider Centralizing Its 
Information Technology Functions, July 2019, A-18-17-11400. 
27 The MOUs that each Area negotiates with State-run PDMPs are not required to include information about how IHS providers 
access the PDMP, but they can include those details, if the State and Area agree to include them. 
28 H. Comm. On Appropriations, 116th Con., Further Consolidated Appropriations Act, 2020, p. 110 (Comm. Print 2020).  
29 The remaining three IHS-run pharmacies responded to our data request; however, due to a data transmission error, the data 
files were not usable for our analysis. 
30 These files contain MME conversion factors for each National Drug Code.  MED and MME are interchangeable terms.  
Buprenorphine products do not have an MME conversion factor because they are partial opioid agonists prescribed for pain 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Endnotes | 31   
and as part of medication assisted treatment for opioid use disorder.  Accessed at 
https://www.cdc.gov/drugoverdose/resources/data.html on March 26, 2020. 
31 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 April 6, 2020. 
32 We identified patients who had a cancer diagnosis or hospice stay by using each patients medical record.  In total, we 
identified 2,106 patients with cancer or a hospice stay who received at least 1 opioid.  
33 OIG, Opioid Use in Medicare Part D in Missouri (OEI-02-19-00391), September 2019; OIG, Opioid Use Decreased in Medicare 
Part D, While Medication-Assisted Treatment Increased (OEI-02-19-00390), July 2019; OIG, Opioids in Ohio Medicaid: Review of 
Extreme Use and Prescribing (OEI-05-18-00010), July 2018; OIG, Opioids Use in Medicare Part D Remains Concerning 
(OEI-02-18-00220), June 2018; OIG, Opioids in Medicare Part D: Concerns about Extreme Use and Questionable Prescribing 
(OEI-02-17-00250), July 2017.   
34 IHS, IHM, 3-30.13(F).  Accessed at https://www.ihs.gov/ihm/pc/part-3/p3c30/ on March 31, 2020.  
35 When identifying the most common diagnoses, we did not include diagnoses of ICD-10 Z codes because they indicate 
factors that influence a patients health statussuch as long-term use of the medicationor indicate that a patient received a 
health service, such as an immunization.  In addition, we did not determine whether these diagnosis codes were related to a 
patients opioid prescription(s). 
36 IHS, Special General Memorandum No. 20-02 Assuring Appropriate Documentation of Prescriptions, August 19, 2020.  
Accessed at https://www.ihs.gov/ihm/sgm/2020/assuring-appropriate-documentation-of-prescriptions/ on October 8, 2020. 
37 IHS, IHM, 3-30.29(B).  Accessed at https://www.ihs.gov/ihm/pc/part-3/p3c30/ on March 11, 2020. 
38 Ibid., 3-32.   
39 Ibid., 3-30.   
40 The American College of Obstetricians and Gynecologists, Recommendations to the Indian Health Service on American 
Indian/Alaska Native Pregnant Women and Women of Childbearing Age with Opioid Use Disorder, March 2019.  Accessed at 
https://www.ihs.gov/sites/opioids/themes/responsive2017/display_objects/documents/acogguidelines2018.pdf on May 20, 
2020.  See also IHS, IHS and ACOG release clinical recommendations to improve care of American Indian, Alaska Native 
women with opioid use disorder, March 28, 2019. Accessed at 
https://www.ihs.gov/newsroom/pressreleases/2019pressreleases/ihs-and-acog-release-clinical-recommendations-to-improve-
care-of-american-indian-alaska-native-women-with-opioid-use-disorder/ on May 20, 2020. 
41 IHS, Recommendations for Management of Acute Dental Pain.  Accessed at 
https://www.ihs.gov/doh/documents/Recommendations%20for%20Acute%20Dental%20Pain%20Management.pdf on April 20, 
2020. 
42 American Academy of Pediatrics, Recommendations to the Indian Health Service on Neonatal Opioid Withdrawal 
Syndrome, December 2019.  Accessed at 
https://www.ihs.gov/sites/opioids/themes/responsive2017/display_objects/documents/aapnowsrecommendationstoihs.pdf on 
May 20, 2020.  See also, IHS, IHS and AAP release clinical recommendations to improve care of American Indian, Alaska Native 
women and infants impacted by prenatal opioid exposure, December 5, 2019.  Accessed at 
https://www.ihs.gov/newsroom/pressreleases/2019pressreleases/ihs-and-aap-release-clinical-recommendations-to-improve-
care-of-american-indian-alaska-native-women-and-infants-impacted-by-prenatal-opioid-exposure/ on May 20, 2020. 
43 Service units are administrative entities that serve a geographic area within an IHS Area.  See IHS, Circular No. 88-02, Service 
Unit Boundaries, March 25, 1988.  Accessed at https://www.ihs.gov/ihm/circulars/1988/service-unit-boundaries/ on November 
12, 2020. 
 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Endnotes | 32   
44 Local governing bodies, or Boards, are the primary parties responsible for a hospitals performance.  See 42 CFR  482.12. 
45 IHS, IHS Announces a New Policy to Expand Access to Medication Assisted Treatment in Remote Locations, November 1, 
2018.  Accessed at https://www.ihs.gov/newsroom/ihs-blog/november2018/ihs-announces-a-new-policy-to-expand-access-to-
medication-assisted-treatment-in-remote-locations/ on May 22, 2020. 
46 IHS, Special General Memorandum No. 19-01 Assuring Access to Medication Assisted Treatment for Opioid Use Disorder, 
June 22, 2019.  Accessed at https://www.ihs.gov/ihm/sgm/2019/assuring-access-to-medication-assisted-treatment-for-opioid-
use-disorder/ on April 13, 2020.  
47 IHS, IHM, 3-35.  Accessed at https://www.ihs.gov/ihm/pc/part-3/chapter-35-dispensing-of-naloxone-to-first-responders/ on 
April 15, 2020. 
Issue Brief: Few Patients Received High Amounts of Opioids from IHS-Run Pharmacies 
OEI-05-18-00470  Endnotes | 33