Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look

WHY OIG DID THIS REVIEW

As the Nation continues to struggle with the opioid crisis, it is vital to gain a deeper understanding of those who are at risk of misuse or overdose. The 2020 COVID-19 pandemic makes the need to look at this population even more pressing. The National Institutes of Health recently issued a warning that individuals with opioid use disorder could be particularly hard hit by COVID-19, as it is a disease that attacks the lungs. Respiratory disease is known to increase the mortality risk among people taking opioids.

OIG has been tracking opioid use in Medicare Part D throughout the opioid crisis. OIG identified 71,260 Part D beneficiaries at serious risk of misuse or overdose in 2017; each of these beneficiaries received extreme amounts of opioids or appeared to be doctor shopping. This data brief provides a deeper understanding of these beneficiaries by examining their Medicare claims from 2017 and 2018 and determining the following: their opioid amounts; the extent to which they had opioid overdoses; the extent to which they received naloxone through Medicare Part D; and the extent to which they have a diagnosis of opioid use disorder and received drugs for medication-assisted treatment (MAT drugs) through Part D. This information is critical to helping the Department of Health and Human Services (HHS) target its efforts to combat the opioid crisis.

WHAT OIG FOUND

• Most Part D beneficiaries at serious risk of opioid misuse or overdose in 2017 received high amounts of opioids the following year.
• Fewer beneficiaries at serious risk in 2017 received extreme amounts of opioids or appeared to be doctor shopping the following year.
• Eleven percent of beneficiaries at serious risk in 2017 had an overdose or adverse effect from an opioid in 2017 or 2018.
• About one-quarter of beneficiaries at serious risk in 2017 received a prescription through Part D for naloxone, a drug that reverses opioid overdoses.
• About half of beneficiaries at serious risk in 2017 have been diagnosed with opioid use disorder or other conditions related to the misuse of opioids.
• Only 7 percent of beneficiaries at serious risk in 2017 who were diagnosed with opioid use disorder received MAT drugs through Part D, possibly because of challenges that beneficiaries have in accessing prescribers.

WHAT OIG RECOMMENDS

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. This data brief also demonstrates that opportunities exist for CMS to expand its role in ensuring that beneficiaries receive treatment for opioid use disorder. Although CMS is taking some significant steps, we recommend that CMS educate Part D beneficiaries and providers about access to MAT drugs and naloxone. CMS concurred with our recommendation.