A little more than half a million Medicare Part D beneficiaries received high amounts of opioids in 2016, raising concerns about beneficiaries receiving medically unnecessary prescriptions and then redistributing them for resale or recreational use, according to a recent report from the HHS Office of Inspector General (OIG).
The report is based on an analysis of prescription drug event (PDE) records in 2016 for opioids prescribed through Part D. OIG analyzed opioid use among beneficiaries as well as opioid prescription patterns among physicians and beneficiaries. Investigators matched the PDE records to data from other sources—such as First Databank, National Claims History File, and National Plan and Provider Enumeration System (NPPES)—to obtain details on the drugs, prescribers, and Part D beneficiaries. The data sources contained information on:
- Claims from Medicare Parts A and B, including diagnosis codes;
- Medical claims for beneficiaries enrolled in Medicare Advantage plans;
- Prescribed drugs, including names, strengths and therapeutic classes—such as opioid—and controlled substance schedule—such as Schedule II or III; and
- Prescribers, including names, addresses, and specialties.
The report found a total of 14.4 million Part D beneficiaries—or about one in three beneficiaries—received at least one opioid prescription in 2016, with Part D spending nearly $4.1 billion on 79.4 million opioid prescriptions that year. Of those prescriptions, 80 percent were for Schedule II or III controlled substances, which OIG wrote have the highest potential for misuse among legal drugs.
The proportion of Part D beneficiaries receiving opioid prescriptions varied across the United States—with rates ranging from 21 and 22 percent in Hawaii and New York, respectively, to 46 and 45 percent in Alabama and Mississippi, respectively.
Overall, the report found that, in 2016, one in 10 Part D beneficiaries received an opioid prescription on a regular basis. In particular, OIG found in 2016:
- More than 11 percent of Part D beneficiaries, or 5 million beneficiaries, received an opioid prescription for at least three months;
- 3.6 million received opioid prescriptions for at least six months; and
- 610,000 received opioid prescriptions for a year.
Previous CDC research shows the risk of dependence on opioids increases substantially for individuals who receive opioid prescriptions continuously for three months.
Further, OIG found 501,008 Part D beneficiaries—excluding those with cancer or in hospice care—received high amounts of opioids in 2016. According to the report, those beneficiaries received an average morphine equivalent dose greater than 120 mg per day for at least three months, which exceed the levels recommended by manufacturers and CDC for individuals with chronic pain.
OIG also identified a total of 89,843 beneficiaries who in 2016 appeared to at serious risk of misusing or overdosing on prescription opioids, including:
- 69,563 beneficiaries who received excessive amounts of opioids;
- 22,308 beneficiaries who appeared to be engaged in so-called "doctor shopping;" and
- 2,028 beneficiaries who were in both groups.
Among the beneficiaries with excessive amounts of opioids, the average daily morphine equivalent dose exceeded 240 mg for the entire year—which is more than twice the dose CDC recommends providers avoid prescribing for individuals with chronic pain.
OIG found 678 beneficiaries received an average daily morphine equivalent dose of opioids greater than 1,000 mg for the entire year. In one instance, OIG found a beneficiary in New Hampshire received 134 prescriptions for opioids from a single prescriber in 2016.
Among the beneficiaries who appear to be doctor shopping, the average daily MED exceeded 120 mg for at least three months. A total of 162 beneficiaries received opioids from more than 10 prescribers and pharmacies last year—with one particular beneficiary receiving opioid prescriptions from 46 different prescribers and 20 different pharmacies.
The report also spotlighted a beneficiary in Washington, D.C., who in one month last year filled prescriptions for 2,330 pills of oxycodone, hydromorphone, and morphine, which were written by just one of the 42 health care providers who prescribed the person such drugs throughout the year.
According to the report, 115,851 prescribers, including physicians and nurses, ordered opioids for at least one beneficiary who was at serious risk of opioid misuse or overdose. The majority of such prescribers ordered opioids for a total of one or two at-risk beneficiaries. However, about 400 prescribers ordered opioids for a high number of at-risk beneficiaries. In particular, OIG found:
- 264 prescribers ordered opioids for a high number of beneficiaries who appeared to be doctor shopping;
- 198 prescribers who ordered high numbers of opioids for beneficiaries receiving excessive amounts of opioids; and
- 61 prescribers who ordered a high number of opioids for beneficiaries in both groups.
According to the report, prescribers with questionable patterns issued 256,260 opioid prescriptions to beneficiaries at serious risk, which cost Part D a total of $66.5 million. Among prescribers with questionable prescribing patterns, one-third were nurse practitioners or physician assistants.
OIG officials in the report wrote, "Although beneficiaries may receive opioids for legitimate purposes, these high amounts raise concern," as "many experts have noted that opioid dosages should not be increased over a MED of 90 mg a day without careful justification."
OIG called on "Part D sponsors to work with OIG and CMS to further improve efforts to combat opioid misuse in Medicare" and encouraged "Part D sponsors to effectively use CMS's Overutilization Monitoring System," which identifies beneficiaries who are potentially overusing opioids. Further, OIG recommended sponsors implement drug management programs for at-risk beneficiaries.
CMS in a statement said combating opioid misuse is priority for the Trump administration. The agency said, "We are working with patients, physicians, health insurance plans, and states to improve how opioids are prescribed by health care providers and used by patients, how opioid use disorder is diagnosed and managed, and how alternative approaches to pain management could be promoted" (Ornstein, ProPublica, 7/13; Bernstein, "To Your Health," Washington Post, 7/13; Lopez, Vox, 7/13; HHS OIG report, 7/13).
Join us this Thursday: 3 initiatives to reduce opioid misuse and abuse
Given the rising incidence of opioid misuse and abuse, provider organizations are implementing initiatives to reduce opioid misuse and abuse within the hospital and their communities. However, many of these initiatives are aimed at treating existing opioid misuse and abuse, rather than preventing them in the first place.
Join the webconference this Thursday, July 27 at 1 pm ET to learn how to engage providers, patients, and community members in collaborative efforts to adequately address misuse and abuse.