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Combating Opioid Misuse and Abuse

The Department of Health and Human Services (HHS) has a multipronged five-point Opioid Strategy, which provides the overarching framework to leverage the expertise and resources of HHS agencies in a strategic and coordinated manner. The comprehensive, evidence-based Opioid Strategy aims to:

  • Improve access to prevention, treatment, and recovery support services;
  • Expand the availability and distribution of overdose-reversing medications;
  • Strengthen public health data reporting and collection to inform a real-time public health response as the epidemic evolves;
  • Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments to reduce opioid-related health harms; and
  • Advance pain management to enable access to high-quality, evidence- based pain care

In February 2019, CMS released an informational bulletin to support the goal of reducing the use of opioids in pain management and expand on earlier guidance by providing information to states seeking to promote non-opioid options for chronic pain management. With the aim of leading to more appropriate prescribing of opioids the guidance describes:

  • A multidisciplinary approach to chronic pain management that incorporates non-opioid pharmacologic and non-pharmacologic therapies,
  • well-communicated treatment goals and expectations
  • careful consideration of the individual and the benefits and risks of a range of available treatment options

In October of 2018, Opioid DUR provisions were included in Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also referred to as the SUPPORT for Patients and Communities Act or the SUPPORT Act, are designed to reduce opioid related fraud, misuse and abuse. These provisions establish drug utilization review standards in section 1902(a)(85) and (oo) of the Act and supplement existing requirements under section 1927(g) of the Act, in an effort to reduce opioid-related fraud, abuse and misuse and expand existing DUR requirements. These required provisions include: 

  • Opioid prescription safety edits at the point of sale (POS) including automated claim reviews (for subsequent opioid fills and exceeding Morphine Milligram Equivalent (MME) levels)
  • Monitoring opioids and benzodiazepines and opioids and antipsychotics
  • Monitoring and management of antipsychotic medication in children
  • Identification of processes to detect fraud and abuse
  • State Plan Amendment (SPA) submission to address the new DUR requirements and ensure state compliancy
  • Reporting of activities carried out annually via submission of the state’s yearly DUR report to assess compliance with the SUPPORT Act.

States also must include new SUPPORT Act required DUR provisions in managed care contracts with MCOs. Additionally, Section 1004 of the SUPPORT for Patients and Communities Act requires all states to implement these requirements by October 1, 2019, and to submit an amendment to their state plan no later than December 31, 2019 in order to describe how the state plans to address these provisions. CMS informational bulletin can be found on Medicaid.gov.

In January of 2016, CMCS issued an informational bulletin highlighting emerging best practices for preventing opioid-related harms. The bulletin:

  • Describes several Medicaid pharmacy benefit management strategies for mitigating prescription drug abuse.
  • Discusses strategies to increase the provision of naloxone to reverse opioid overdose and reduce opioid-related overdose deaths.
  • Provides examples of strategies states can use to target the prescribing of methadone for pain relief, given the disproportionate share of opioid-related overdose deaths associated with methadone when used as a pain reliever.

42 CFR Subpart K – Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims Section 456.700-456.725 provides the requirements for the DUR program. 

Please direct all communications to the CMSDUR@cms.hhs.gov resource mailbox.

Disclaimer: Please note that the information provided on this web page does not bind or obligate the Centers for Medicare and Medicaid Services (CMS). The statements included on this web page are intended to provide information on CMS Medicaid Drug Utilization Review and do not in any way revise or modify the requirements set forth in Section 1927 of the Act, regulations or program releases.

Page last updated on November 8, 2021