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

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          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.

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          Most cited references 39

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          Neurobiologic Advances from the Brain Disease Model of Addiction.

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            Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

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              Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later.

              Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded screening, brief interventions, referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and 6 months after drug screening and interventions were administered. SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a 6-month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline. Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6-month follow-up (4 of 6 sites), were 67.7% lower (p<0.001) and heavy alcohol use was 38.6% lower (p<0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p<0.001), mental health (p<0.001), employment (p<0.001), housing status (p<0.001), and criminal behavior (p<0.001) were found. SBIRT was feasible to implement and the self-reported patient status at 6 months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysis
                Role: ConceptualizationRole: Data curationRole: Formal analysis
                Role: Data curationRole: VisualizationRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                19 November 2019
                November 2019
                : 16
                : 11
                Affiliations
                [1 ] Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
                [2 ] Executive Office of Health and Human Services, State of Rhode Island, Cranston, Rhode Island, United States of America
                [3 ] Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, United States of America
                [4 ] Office of the Governor, State of Rhode Island, Providence, Rhode Island, United States of America
                [5 ] Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, State of Rhode Island, Cranston, Rhode Island, United States of America
                [6 ] Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
                Massachusetts General Hospital, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Article
                PMEDICINE-D-19-02173
                10.1371/journal.pmed.1002963
                6863520
                31743335
                a2c86f63-40bd-4318-b15b-7ec6af44c3b7

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                Page count
                Figures: 2, Tables: 1, Pages: 16
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000057, National Institute of General Medical Sciences;
                Award ID: P20GM125507
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000030, Centers for Disease Control and Prevention;
                Award ID: RFA-CE15-1501
                JDR and BDLM are supported by the COBRE on Opioids and Overdose funded by the National Institute of General Medical Sciences of the National Institutes of Health under grant number P20GM125507 https://www.nigms.nih.gov/. Funding for Rhode Island’s statewide overdose surveillance website, www.PreventOverdoseRI.org, is provided to the Rhode Island Department of Health from the Centers for Disease Control & Prevention under grant number CDC RFA-CE15-1501 https://www.cdc.gov/drugoverdose/od2a/index.html. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Opioids
                People and places
                Geographical locations
                North America
                United States
                Rhode Island
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                People and places
                Geographical locations
                North America
                United States
                Medicine and Health Sciences
                Health Care
                Health Services Administration and Management
                Medicine and health sciences
                Infectious diseases
                Viral diseases
                HIV infections
                Medicine and Health Sciences
                Pharmacology
                Behavioral Pharmacology
                Recreational Drug Use
                Heroin
                Custom metadata
                Aggregated data or publicly available survey results were used whenever possible. Data for Stage 0 are available through the National Survey on Drug Use and Health on the website https://nsduhweb.rti.org. For Stage 1 we partnered with third party state institutions who provided us with aggregated data, we therefore do not have permission to share anything other than the aggregated estimates that were in the manuscript. Aggregated data for Stages 2 and 3 are available on the webpage https://preventoverdoseri.org/medication-assisted-therapy/. For Stage 4 we utilized results from the National Recovery Survey conducted in 2016 by Kelly, Bergman, Hoeppner, Vilsaint, and White (2017) https://www.recoveryanswers.org/media/national-addiction-recovery-study/.

                Medicine

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