Opioid use disorder Cascade of care framework design: A roadmap

Abstract

Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.

Keywords: Opioid use disorder; cascade of care; medication for opioid use disorder (MOUD); opioid crisis.

Figure 1.

Assessing the Scope (Breadth and Depth) of an OUD Cascade of Care in the US. In this figure, adapted from Williams et al AJDAA 2019, the breadth of the CoC ranges from primary prevention to recovery. The CoC depicted has a fair amount of depth as it contains stages 0–7. If the authors added two additional retention stages for “Retained >3 months,” and “Retained >12 months,” the depth would increase by 2 so that the stages would be renumbered 0–9. CoC = Opioid Use Disorder Cascade of Care.

Figure 2.

OUD Cascade of Care Measurement Designs*. *Measurement design domains for the OUD CoC comprises four dimensions related to the use of linked or unlinked data including the (1). Window of observation (longitudinal vs. cross-sectional) as well as the use of (2). Single or multiple populations and whether studies have (3). Denominator-numerator linkage or (4). Denominator-denominator linkage