'Cascade of Care' framework aims to reduce opioid deaths

Drug overdose is now the leading cause of death for individuals under the age of 50, as the opioid epidemic continues unabated. One reason is that the majority of the estimated 2.4 million Americans with opioid use disorder aren't getting evidence-based treatment, including medications to treat opioid addiction.

In a paper out today in The American Journal of Drug and Alcohol Abuse, Columbia researchers present an expanded model to reduce opioid overdose and death by addressing gaps in addiction care and by monitoring treatment outcomes.

A group of researchers led by Arthur Robin Williams, MD, MBE, assistant professor of clinical psychiatry at Columbia University's Division on Substance Use Disorders, developed a "Cascade of Care" model for treating individuals with opioid use disorder based on lessons learned in the HIV/AIDS field. The model identifies key stages through which people with opioid use disorder must successfully, and sequentially, progress to increase the chance of reaching remission.

The care model expands an earlier framework, published in Health Affairs, that has become a key element in the response to the opioid epidemic from the National Institute on Drug Abuse (NIDA) and the Centers for Disease Control. The expanded model includes diagnosis, linkages to care, medication initiation, retention in a treatment program, and remission. The model also emphasizes prevention services targeting populations by risk level. Mark Olson, MD, MPH, professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons and the paper's senior author says, "The cascade of care model provides a common language to identify gaps, measure progress, highlight successes, and share best practices in the community treatment of opioid use disorder."

The framework has been embraced not only by NIDA and the CDC, but by other organizations as well. Dr. Charles Barron (CDC), Deputy Chief Medical Officer of NYC Health + Hospitals, the nation's largest public health care system, reports, "At NYC Health + Hospitals, we understand that navigating a complex health care system is difficult for anyone, and even more so for vulnerable patients with numerous competing psychosocial priorities. The Opioid Cascade of Care model we are building will be a valuable tool to target areas for quality improvement and to ensure that the greatest number of people receive life-saving treatment in our efforts to combat the opioid epidemic."

Recent efforts to curb the opioid epidemic have included legislation charging the Substance Abuse and Mental Health Services Administration (SAMHSA) with disbursing nearly $1 billion for treatment services, with priority given to those states hit hardest by the opioid epidemic. The funding requires states to perform needs assessments and to develop strategic plans for increasing access to opioid addiction medications under a chronic care model. The team of Columbia researchers sees the application of this new framework as a valuable means to track use of medications and patient outcomes across states and localities in a standardized way.

"This report demonstrates how research can be brought to bear on this pernicious public health challenge," says Dr. Jeffrey Lieberman, the Lawrence C. Kolb Professor of Psychiatry and Chair of the Department of Psychiatry at CUIMC. "The task now will be to make available and extend the scope of services based on this model more widely."

"While the scale of the opioid crisis presents states and policymakers with a daunting and urgent task, adapting the OUD Cascade of Care for today's crisis will help expedite and scale programs needed for an effective response," says Williams. "Applying quality measures informed by the Cascade of Care to treatment of opioid use disorder holds great promise to help ensure optimal returns on federal funding for areas hardest hit by overdose. Treatment programs with historically low use of evidence-based practices in the face of the worsening epidemic need compelling incentives to change. Identifying which patients struggle at which stages of the Cascade to help target clinical and policy interventions can help State Targeted Response funding achieve its greatest impact."

The paper is titled "Development of a Cascade of Care for Responding to the Opioid Epidemic."