HEDIS® Tip Sheet

Risk of Continued Opioid Use (COU)

Measure Description

Percentage of members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:

  1. The percentage of members with at least 15 days of prescription opioids in a 30-day period.
  2. The percentage of members with at least 31 days of prescription opioids in a 62-day period.

Measure Definitions:

  • Intake Period: November 1 of the year prior to the measurement year to October 31 of the measurement year.
  • Index prescription start date (IPSD): The earliest prescription dispensing date for an opioid medication during the intake period.
  • New episode of opioid use: an IPSD preceded by a period of 180 days during which the member had no pharmacy claims for either a new or refill for an opioid medication.

Steps to identify a new episode of opioid use:
1. Determine the IPSD
2. Test for negative medication history. Remove persons who were dispensed an opioid medication within 180 days prior to the IPSD.

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Notes

  • A lower rate indicates better performance.
  • Supplemental data can be used only to identify required exclusions. 
  • This measure does not include:
    • Injectables
    • Cough and cold products that contain opioids.
    • Single-agent and combination buprenorphine products used as part of a medication assisted treatment of opioid use disorder (buprenorphine sublingual tablets, subcutaneous implants, and all buprenorphine/naloxone combination products)
    • Lonsys ® (fentanyl transdermal patch) because it is used only inpatient and is only available through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS)
    • Methadone for the treatment of opioid use disorder. 
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Exclusions

  • Members who had at least one of the following at any time during the 365 days prior to the IPSD through 61 days after the IPSD:
    • Cancer diagnosis.
    • Sickle cell disease.
    • Member receiving palliative care.
  • Members in hospice during the measurement year.
  • Members who died during the measurement year.
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Best Practices

  • Prescribe the lowest effective opioid dose for the shortest appropriate duration.
  • Consider non-opioid medications, treatments, or therapies for pain management.
  • Monitor the cumulative number of days in the year that a member is prescribed opioids.
  • Consider screening for other opiates or illicit drug use in patients receiving opioid prescriptions.
  • Collaborate with your patients to establish pain management goals and measure progress during follow-up visits.
  • Educate patients on risks of using multiple providers to obtain opioid prescriptions, benefits of non-opioid pain management, importance of consistency and adherence to prescription regimen, crisis intervention options, and side-effects of opioids including risk of addiction.
  • Engage the patient’s social support system such as family members or caregivers in the treatment plan when appropriate.
  • Maintain timely appointment availability for patients receiving opioid prescriptions.
  • Encourage communication between the behavioral health provider and primary care provider.

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

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Updated 8/28/2026