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HEDIS® Tip Sheet

Risk of Continued Opioid Use (COU)

Line of business: BlueAlliance (Commercial) & BlueAlliance Care+ (Medicaid)

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.
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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
    • Opioid-containing cough and cold products
    • 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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Best Practices

  • Prescribe the lowest effective dose of opioids for the shortest time period possible.
  • Consider alternative medications, treatments, or therapies to manage pain.
  • Track the total 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.
  • Develop goals with your patients for pain management and measure progress during office 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 (significant other, parents, family members) in the treatment plan.
  • Keep appointments open on the clinic schedule for patients receiving opioid prescriptions.
  • Encourage communication between the behavioral health provider and PCP.
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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.


Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

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 1/22/2025