Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment

Abstract

Background

In light of the accelerating and rapidly evolving overdose crisis in the United States (US), new strategies are needed to address the epidemic and to efficiently engage and retain individuals in care for opioid use disorder (OUD). Moreover, there is an increasing need for novel approaches to using health data to identify gaps in the cascade of care for persons with OUD.

Methods and findings

Between June 2018 and May 2019, we engaged a diverse stakeholder group (including directors of statewide health and social service agencies) to develop a statewide, patient-centered cascade of care for OUD for Rhode Island, a small state in New England, a region highly impacted by the opioid crisis. Through an iterative process, we modified the cascade of care defined by Williams et al. for use in Rhode Island using key national survey data and statewide health claims datasets to create a cross-sectional summary of 5 stages in the cascade. Approximately 47,000 Rhode Islanders (5.2%) were estimated to be at risk for OUD (stage 0) in 2016. At the same time, 26,000 Rhode Islanders had a medical claim related to an OUD diagnosis, accounting for 55% of the population at risk (stage 1); 27% of the stage 0 population, 12,700 people, showed evidence of initiation of medication for OUD (MOUD, stage 2), and 18%, or 8,300 people, had evidence of retention on MOUD (stage 3). Imputation from a national survey estimated that 4,200 Rhode Islanders were in recovery from OUD as of 2016, representing 9% of the total population at risk. Limitations included use of self-report data to arrive at estimates of the number of individuals at risk for OUD and using a national estimate to identify the number of individuals in recovery due to a lack of available state data sources.

Conclusions

Our findings indicate that cross-sectional summaries of the cascade of care for OUD can be used as a health policy tool to identify gaps in care, inform data-driven policy decisions, set benchmarks for quality, and improve health outcomes for persons with OUD. There exists a significant opportunity to increase engagement prior to the initiation of OUD treatment (i.e., identification of OUD symptoms via routine screening or acute presentation) and improve retention and remission from OUD symptoms through improved community-supported processes of recovery. To do this more precisely, states should work to systematically collect data to populate their own cascade of care as a health policy tool to enhance system-level interventions and maximize engagement in care.

Abstract

Brandon Marshall and colleagues describe a cascade of care for opioid use disorder in Rhode Island, USA.

Author summary

Why was this study done?

• In the US, drug overdose represents a leading cause of accidental death. In light of this growing epidemic, frameworks are needed to understand how to improve health systems to identify and engage individuals with substance use disorders in evidence-based treatment modalities.

• Cascades of care have been used to track and improve population health outcomes for multiple complex health conditions by encouraging data-driven policy decisions to adapt and strengthen systems of care for how these conditions are managed, but few cascades of care are available for use for local jurisdictions addressing opioid use disorder (OUD).

What did the researchers do and find?

• We engaged a group of stakeholders—local experts on opioid use and its consequences, leaders from state agencies governing health and social services, directors of nongovernmental organizations providing health and social services to people living with OUD, and community advocates with lived experiences of OUD and recovery—to adapt and define a cascade of care for OUD for use in Rhode Island.

• The stakeholder engagement process resulted in a cascade of care with 5 stages, beginning with individuals at risk for OUD (stage 0), continuing to individuals who are diagnosed with OUD (stage 1) and establish engagement with a medication-based treatment plan (stage 2), and ending with continuous engagement with this treatment plan (stage 3) and recovery (stage 4).

• Using national survey estimates and statewide administrative claims databases, we found that 26,000 Rhode Islanders were diagnosed with OUD (stage 1) in 2016, 12,700 people showed evidence of treatment initiation (stage 2), and 8,300 had evidence of continuous engagement with treatment for at least 6 months (stage 3). Based on a national survey estimate, about 4,200 individuals are estimated to have achieved recovery from OUD using medications (stage 4).

What do these findings mean?

• Engagement with a diverse group of stakeholders can result in the development of a cascade of care to assess and measure the success of statewide health systems in delivering interventions to address opioid-related harms. The cascade of care can be used as a framework to strengthen health systems that may result in reductions in the number of individuals at risk for OUD and increases in the number of individuals with OUD who are able to achieve long-term recovery.

• The estimates of the numbers of individuals in each stage represent a static “snapshot” and are considered preliminary; further efforts are needed to fine-tune these proportions. For example, limitations included having to use the definition of recovery and estimates used in the National Recovery Survey, as there are currently no statewide data sources for measuring recovery. Further research is needed to understand how to best define and operationalize this stage at a statewide level.