CMS criteria do not accurately identify patients at risk for opioid use disorder, overdose

The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose, according to a research letter published in JAMA.

“Based on the CMS opioid overutilization criteria, the majority of the Medicare Part D patients diagnosed with opioid use disorder or overdose were not identified as ‘opioid overutilizers,’ and more than half of ‘opioid overutilizers’ did not develop opioid use disorder or overdose during the study period,” Yu-Jung Jenny Wei, PhD, Msc, assistant professor of pharmaceutical outcomes and policy at the College of Pharmacy, University of Florida, told Healio Primary Care Today. “The CMS criteria seem not to be a good clinical marker for identifying patients at risk for opioid-related adverse events.”

To estimate the predictive value of the CMS opioid overutilization criteria in correctly identifying prescription opioid users at risk for opioid use disorder or overdose, researchers used the 5% Medicare sample from 2011 through 2014 from which they identified between 142,036 and 190,320 beneficiaries who had at least one opioid prescription filled every 6 months, were continuously enrolled in Parts A, B and D and who met the CMS criteria as opioid overutilizers. Opioid utilization was defined as receiving prescription opioids with a mean daily morphine equivalent dose 90 mg from more than three prescribers and pharmacists or receiving a mean daily morphine equivalent dose of 90 mg by more than four prescribers.

Breaking the study period into three 6-month cycles, researchers examined the performance measures over time to assess if accuracy changed with increasing efforts to combat the opioid crisis.

During any 6-month cycle, the proportion of beneficiaries who met CMS overutilization criteria ranged from 0.37% to 0.58%.

Throughout the entire 18-month follow-up, researchers found that the proportion of patients who had a diagnosis of opioid use disorder or overdose increased from 3.91% in the first cycle to 7.55% in the last.

In addition, researchers observed low sensitivity of the criteria which ranged from 4.96% (95% CI, 4.42-5.58) at the beginning of the study period to 2.52% (95% CI, 2.26-2.81) at the end (P < .001).


The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose.
Source: Adobe Stock

Positive predictive values ranged from 35.2% (95% CI, 32.14-38.38) to 50.95% (95% CI, 47-54.86) and specificity was greater than 99% in all cycles.

“CMS has required their Medicare Part D plans to implement the criteria,” Wei said. “It’s unclear the effectiveness of such criteria in stopping our national opioid epidemic and whether there are unintended consequences of such implementation. As we are developing solutions to the opioid crisis, it’s important for policymakers, health care providers, hospitals and health insurance companies to be aware that solely relying on opioid prescription data is likely to be ineffective in identifying the high-risk populations for interventions.” – by Melissa J. Webb

For more information: Yu-Jung Jenny Wei, PhD, MSc, can be reached at

Disclosures: The authors report no relevant financial disclosures.

7 Responses

  1. According to (chronic conditions data warehouse) the largest age group of recipients receiving MedicarePart D are 65-74 yrs old. This next site
    Laments the statistics of the Opioid Use Disorder but I didn’t read about a surge of deaths related to such. Just tighten the reigns to keep people in check.
    But it seems to reason that this age group would have the most health conditions that would cause pain. Post surgery, this age group doesn’t heal as fast, either. I could go on and on, but it’s no big shocker that there’s higher numbers of Rx’s. Pain doesn’t follow a time schedule. Taking an extra or two some days, possibly less on others doesn’t scream irresponsible and made up use disorders. It’s called treating pain.
    But remember your Miranda Rights, “Anything you say can and will be used against you “

    • Well starvation doses are the fast track to requests for efforts to get more. This is nerve pain we are talking about, can’t take half measures with that at all, it doesn’t work.

  2. How can these have missed that old saying; ‘Be nice to those you meet on the way up, because you meet the same ones coming down.’

  3. This……Just really, really chaps my backside!!
    “Opioid Use Disorder” It seems they will come up with any and everything to stigmatize and demonize necessary opioid pain medication for Chronic Pain Patients. And in the process brand us idiots that we cannot….all of a sudden…..handle our medication when we have done just that and for most of us, years.
    But, kids, I want to just tell y’all something in love. We know we are living in uncertain and dangerous times. My grandmother told me something that has stuck with me my whole life. It isn’t eloquent, but it’s to the point.
    “Don’t tell every fart you let.” We are being monitored and scrutinized from every angle. And if you have more pain one day and take extra that day, fine. But be quiet about it!!!
    Remember your Miranda Rights. “Any and every thing you say can and will be used against you.”

  4. If they mean the series of ludicrously unanswerable questions that my doctor keeps nagging me with, I’m not surprised that the results don’t mean much. The questions are all as answerable –or not– as the classic “And have you stopped beating your wife? Yes or no!” Unless you HAVE been beating your wife, there’s no possible way to answer it…but answer them all I must, 3 times in the last 5 months. No matter what you answer, you’re going to end up either with a Dx of OUD, or, if you express no “anxiety” toward or need for the meds, “proof” that you don’t need them at all. It’s a classic case of Catch-22

    • Yes, you noticed. The answer often ‘benefits’ them no matter how it is answered. I wonder who cooked that up for them. Even applications for disability are full of that. Another majorly embarassing issue that they will ALL have to live down or get out of town or force madness on everyone including themselves until it pops.

    • I read your comment. Concerning mine, am I understanding Opioid Use Disorder , correctly??
      That’s how I interpreted this faux Dx…

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