Development of a Cascade of Care for responding to the opioid epidemic

Figures & data

Figure 1. OUD Cascade of Care, 2016 estimates among publicly reporting providers.

Table 1. Populations at risk for OUD by risk level, setting, and related interventions.

Risk factors/Populations	Assessment settings	Interventions for prevention, identification, and bridging to specialized treatment for OUD*
Acute presentations	- Emergency departments	- Urine drug screens
- Overdose reversals	- Hospitals	- Harm reduction services
- ED complications (infection, injury)	- Substance abuse treatment	- Overdose prevention training and reversals
- Entering SUD treatment	- Criminal justice settings	- Warm hand-offs to treatment
- Inpatient/residential/outpatient		- Supervised MOUD induction (e.g. from ED)
- Criminal Justice involvement		- Police referrals to treatment (e.g. PAARI, LEAD)
Patients using opioids	- Pain clinics	- Frequent clinical assessments
High risk	- Physician offices	- Alternative treatments for chronic pain (e.g. non-opioid, non-pharmacologic)
->90 mg MEQ daily	- Primary care	- Urine drug screens (random)
- Receiving LTOT for non-cancer pain	- Behavioral health clinics	- Prescriber guidelines
- Prior acute presentation	- Adolescent health programs	- Academic detailing of physicians
- Prior SUD treatment/diagnosis	- Outreach programs	- Pill counts
- Psychiatric comorbidity	- Employee assistance programs	- Refill limits
At risk	- Schools	- PDMPs
- Family history of SUD		- Naloxone distribution
- Young male adults (age 18–35)		- SBIRT
- Active risky substance use		- Targeted prevention programs
General population	- Public venues	- Resiliency enrichment programs (e.g. Life skills)
- Ages 12+	- Social media	- Health promotion and skills training
	- Primary care	- Public service announcements
	- Schools	- Drug take-backs

*Interventions may be relevant to multiple populations but are listed once alongside the category most relevant for simplicity. MOUD = medications for opioid use disorder; OUD = opioid use disorder; ED = Emergency Department; PAARI = police-assisted addiction and recovery initiative; LEAD = law enforcement-assisted diversion; MEQ = morphine equivalents (mg); LTOT = long-term opioid therapy; SUD = substance use disorder; PDMP = prescription drug monitoring program; SBIRT = Screening, Brief Intervention and Referral to Treatment

Table 2. Key research challenges.

Clinical research

- Develop clinical and systems level interventions to improve medication adherence and treatment retention

- Identify clinical decision support tools and programming to better match patients at the individual level with adjunctive psychosocial and behavioral treatments

- Determine optimal duration of care for treatment responders for each MOUD modality

- Evaluate safe and effective methods for transitioning patients in long-term recovery off of MOUD if indicated

Implementation Science

- Identify barriers to treatment engagement and retention

- Devise effective implementation strategies in real world and various settings

- Characterize which patients would do better being managed in primary care vs. mental health vs. specialty settings

Policy

- Improve data collection and reporting methods

- Assess potential benefits and risks of making OUD an (anonymously) reportable disorder at the state or federal level, such as TB or HIV

- Define when to require observation and related emergency stabilization protocols

- Develop guidelines consistent with other areas of medicine and mental health for treatment over objection for patients with impaired capacity

MOUD = Medications for opioid use disorder; OUD = opioid use disorder