CMS to Focus on Data Reporting and Monitoring, Prevention, and Treatment to Address Opioid Crisis

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The Centers for Medicare & Medicaid Services (CMS) released the “CMS Roadmap to Address the Opioid Epidemic” in June 2018 (1). CMS stated at the time that “although some progress has been made in efforts to combat the opioid epidemic, the latest data from the Centers for Disease Control and Prevention (CDC) indicate the crisis is not slowing down” (2).

Highlights of the crisis are:

  • Opioids killed more than 42,000 people in the United States in 2016 or 116 people a day.

  • 40% of all opioid overdose deaths involve a prescription opioid.

  • 11.5 million people misused prescription opioids at the same time.

  • 3 out of 4 people who used heroin misused prescription opioids first.

As part of the roadmap, CMS details its three-pronged approach to combating the opioid epidemic:

  • Prevention of new cases of opioid use disorder.

  • Treatment of patients who have already become dependent on or addicted to opioids.

  • Utilization of data from across the country to target prevention and treatment activities.

Current estimates show that over 2 million people suffer from opioid use disorder, with a prevalence in Medicare of 6 out of every 1000 beneficiaries. In order to decrease that number, CMS believes it is crucial that Medicare beneficiaries and providers are aware that there are options available both to help prevent the development of new cases of opioid use disorder and to help treat existing cases. CMS stated it wants to ensure that beneficiaries are not inadvertently put at risk of misuse by closely monitoring prescription opioid trends, strengthening controls at the time of opioid prescriptions, and encouraging healthcare providers to promote a range of safe and effective pain treatments, including alternatives to opioids.

CMS outlined some clear steps and objectives in the three areas outlined in its Roadmap.


  • Implementing a new authority to limit Medicare beneficiaries to certain pharmacies and doctors (or “lock-in”).

  • Strengthening real-time prescription controls with the use of prescription databases and point of sale pharmacy edits.

  • Establishing other standard pharmacy protocols across programs for new or changed prescriptions.

Additionally, CMS would like to 1) incorporate incentives for appropriate prescribing into future Medicare Quality Star Ratings and the Quality Payment Program; 2) align monitoring of systemic overprescribing to CDC guidelines and partner with law enforcement to stop egregious prescribing; 3) disseminate best practices for state Medicaid agencies and other payers on alternative pain management strategies and other tactics to address the opioid crisis.


CMS plans to address these areas in order to identify and develop solutions for treatment barriers for pain and opioid use disorders across Medicare, Medicaid, and private health plans:

  • Access to non-opioid pain treatments,

  • Access to medication-assisted treatments, and

  • Access to providers in rural and other low-access communities.


In order to focus its data efforts and provide tools for states, plans, and providers, CMS will address these areas:

  • Monitoring the success of prevention measures related to reducing overuse and misuse of prescription opioids.

  • Improving data transparency and interoperability and expanding tools like the Medicare “heat map” of prescribing rates that help determine where to target safe prescribing efforts (Figure 1).

  • Analyzing prescription opioid use patterns across CMS programs and in special populations such as individuals in rural areas, with dual Medicare/Medicaid eligibility, and with certain health conditions.

  • Supporting state Medicaid programs’ capacity to track and report data.

Figure 1.
Figure 1.

Opioid prescribing under Medicare Part D by state, 2016

Citation: Kidney News 10, 7

Courtesy Centers for Medicare & Medicaid Services

Kidney News will continue monitoring and reporting further developments in opioid-related policy.