Thousands of Medicare beneficiaries are at extreme risk for opioid use disorder. A federal report urges the Centers for Medicare & Medicaid Services (CMS) to do more to ensure they receive treatment.

The Department of Health & Human Services’ Office of Inspector General (OIG) took a close look at opioid use in Medicare Part D, and its findings indicate an opportunity for CMS to do more to combat opioid misuse and overdose in Medicare beneficiaries.

Using claims from 2017 and 2018, OIG evaluated the opioid use in Medicare Part D to better understand beneficiaries and their opioid amounts, how many had opioid overdoses, the number who received naloxone through Medicare Part D, and the percentage who have a diagnosis of opioid use disorder and received drugs for medication-assisted treatment (MAT) through Part D. 

“Although opioids can be appropriate under certain circumstances, steps should be taken to mitigate the risk of misuse and overdose, especially when beneficiaries receive high amounts of opioids for long periods of time,” the OIG said.

The opioid epidemic has been a longstanding struggle throughout the country, but the recent COVID-19 pandemic has added a newfound pressure to the situation, even drawing the attention of the National Institutes of Health, which recently issued a warning that individuals with opioid use disorder could be particularly vulnerable to the virus as it attacks the lungs.

Key findings

The report found more than 71,000 beneficiaries were at serious risk of opioid misuse or overdose in 2017. Of those beneficiaries, more than 14,800 engaged in “doctor shopping,” which the OIG defined as having four or more prescribers or pharmacies while receiving high amounts of opioids.

Although there was an improvement in the number of beneficiaries who received extreme amounts of opioids from 2017 to 2018, the extent of opioid use remains a concern:

  • In 2017, 57,611 beneficiaries received extreme amounts of opioids for the entire year. The number dropped in 2018 to 27,137.
  • The number of beneficiaries who appeared to be doctor shopping dropped from 14,814 in 2017 to 2,452 in 2018.
  • Despite the improvements, four out of every five beneficiaries at serious risk in 2017 continued to receive high amounts of opioids in 2018.

About half of these beneficiaries at serious risk have been diagnosed with opioid use disorder or other conditions related to the misuse of the opioids. But despite the diagnosis, only seven percent have received medication-assisted treatment (MAT) through Part D, such as buprenorphine and naltrexone which are used to suppress withdrawal symptoms and relieve cravings. Further, about one-quarter of beneficiaries received a prescription for naloxone through Part D, a safe antidote to an opioid overdose.

Recommendation to CMS

Based on the report findings, OIG has recommended that CMS expand its role to mitigate opioid misuse amongst beneficiaries, specifically by educating Part D beneficiaries and providers about access to MAT drugs and naloxone. “CMS plays an important role in education and awareness among beneficiaries and health care providers about treatment and coverage under Medicare,” researchers said in the report.

The OIG suggested CMS enhance its webpage to include coverage of MAT drugs and how to find outpatient treatment programs and providers who can prescribe buprenorphine, as well as information about access to naloxone; collaboration with Part D sponsors to increase awareness among beneficiaries about access to MAT drugs and naloxone; and a partnership with Substance Abuse and Mental Health Services Administration to develop education strategies for beneficiaries and providers.