Experts outline new framework to improve care for opioid use disorder

Every day, more than 100 Americans lose their lives to the opioid crisis, and researchers from across the nation are racing to find solutions. One of the latest strategies - a cascade of care model for the State of Rhode Island - was developed collaboratively by a diverse group of stakeholders, including experts from Brown University, state agency leaders and community advocates.

The research team detailed the model in a paper published in the journal PLOS Medicine on Tuesday, Nov. 19.

We hope we've created a tool that policymakers and state agencies can use to make data-driven decisions that improve care in our state."
Jesse Yedinak, study's lead author and a project director at the Centers for Epidemiology and Environmental Health at the Brown University School of Public Health

To create the model, the team revised an existing framework to define five stages of care for people with opioid use disorder (OUD):

Stage 0: at risk for OUD
Stage 1: diagnosed with OUD
Stage 2: initiated a medication-based treatment plan
Stage 3: continuously engaged with this treatment plan
Stage 4: recovery

Next, the team consulted national surveys and statewide insurance claims databases to estimate the number of Rhode Islanders in each stage. These estimates help to identify gaps in care, the researchers said.

For instance, 47,000 Rhode Islanders were estimated to be at risk for OUD in 2016, meaning that they reported using heroin or taking other opioids for non-medical purposes. However, only about 26,000 of those individuals - 55 percent - had received an OUD diagnosis.

This first gap suggests that we need a lot more screening to identify people who have active opioid use disorder or are significantly high risk of overdose."
Brandon Marshall, associate professor of epidemiology at Brown and senior author of the paper

The model also highlights a significant gap between diagnosis and linkage to treatment: Of those estimated 26,000 individuals who had been diagnosed, less than half had initiated medication-based treatment. As a follow-up to this finding, further research is being done to evaluate the factors that make people more likely to seek treatment after an OUD diagnosis.

Stage 3, which contained an estimated 8,300 Rhode Islanders, consisted of individuals who stayed in medication-based treatment for more than 180 days. Stage 4 - recovery - contained about 4,200 and was a unique feature of this model.

"In many of the other opioid use disorder care continuums, the final stage is remission, which is clinically defined as the absence of opioid-related problems," Marshall said. "The committee did not feel this was very inspiring or patient-centered, so they strongly encouraged us to define the final stage as recovery - which is more positive and moves beyond the absence of OUD-related problems to look at the person as a whole."

During the development process, the team was also conscious of the broader impact the model could have. To that end, they tried to make it adaptable for implementation in other states. The paper includes a specific glossary, for example, and the data sources that the model drew from should be available throughout the nation.

Marshall and Yedinak added that they hope to update the model at least once a year, and they have several long-term goals in mind.

One goal is to use the model's data to aid in the prevention of OUD by reducing the number of people who are classified as at risk. As a longer-term implication, they also hope to start generating population health targets. For example, the United Nations AIDS organization, UNAIDS, set a 90-90-90 target for HIV: By 2020, they aim for 90 percent of all people living with HIV to have received a diagnosis. Of those, 90 percent will receive treatment. And of the 90 percent receiving treatment, 90 percent will have achieved viral suppression.

"We don't have a target like that for opioid use disorder yet," Marshall said. "But now that we have the estimates, we can start thinking: What should we reach toward, given our current resources - and given more resources, what would be realistic to achieve?"

Brown University

Journal reference:

Yedinak, J.L., et al. (2019) Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment. PLOS Medicine. doi.org/10.1371/journal.pmed.1002963.