An updated cascade of care model for opioid use disorder treatment

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In 2019, I wrote a blog post about using the cascade of care model as a framework for evaluating opioid use disorder (OUD) treatment programs. The cascade of care was originally developed for HIV/AIDS treatment, laying out steps from initial screening and diagnosis to long-term viral suppression. It has since been translated to OUD treatment, specifically in relation to treatment approaches that use medications such as methadone and buprenorphine, which have strong evidence for efficacy in reducing opioid use and mortality, among other outcomes. The cascade is an incredibly useful framework that healthcare and public health programs can use to track population-level outcomes, measure gaps, and identify areas of improvement to better support people to progress along the cascade. ICH successfully operationalized this model in our evaluation of RIZE Massachusetts Foundation’s Saving Lives, Improvement Health grant program, which funded four community-based OUD treatment programs to improve access to medications for opioid use disorder for populations at high risk of overdose and death. This model gave us a way to quantitatively measure program impact, and also helped identify racial disparities in retention rates.

I continue to find the cascade of care to be a very useful framework for program evaluation and improvement. However, the way I think about this model has evolved over the last few years. In 2019, when we designed the Saving Lives, Improving Health evaluation, I used a model with the following steps:

The model was depicted linearly, and our conceptualization of the final stage (Recovery) was narrow, focusing only on drug use – for that evaluation, we defined recovery to be abstinence from non-prescribed opioids. My understanding of the cascade has deepened over the years as I have continued to do research and evaluation in this space, learning from the scientific literature as well as the experiences and insights of program partners, frontline providers, and people with lived experience, particularly the opioid overdose survivors ICH interviewed for the Boston Overdose Linkage to Treatment Study (BOLTS).

The model that I use now looks like this:

There are two major changes that I think are significant. First, drawing from the work of Williams et al., there is a new step in the cascade labeled Remission, which is distinct from Recovery. Remission means that the patient or participant no longer meets clinical criteria for OUD, which is not defined in terms of abstinence. Recovery remains the final stage in the cascade, and I no longer think of it just in terms of drug use; rather I conceptualize recovery as a person being able to meet their own goals for their health, wellness, and quality-of-life. This is a much broader concept and is aligned with SAMHSA’s four dimensions of recovery, which are Health, Home, Purpose, and Community. I believe that separating Remission and Recovery and including both on the cascade pushes us to think beyond medical care and take a more holistic and person-centered approach to supporting recovery.

The second major change is that I now depict the cascade of care non-linearly. It is important to explicitly acknowledge that OUD is a chronic disease and that people may return to drug use or have a recurrence of their OUD symptoms over time. This means that we must build this in to how we design programs and services – we need systems that offer long-term support and facilitate easy re-engagement or re-entry into treatment when someone needs it. 

As a researcher and evaluator, this updated version of the cascade helps me to think differently and to remember that the overdose crisis, with its widening racial inequities and worsening outcomes, will not be resolved by focusing on any one of the steps alone. ICH has the privilege of working with many incredible programs and funders that are dedicated to this work, and together we need to take a bolder, broader, and longer-term approach to building a system that provides equitable access to treatment and cross-sector recovery support. I am excited to use the updated cascade of care as a framework and work on developing measurement approaches that can help programs improve outcomes at all stages of the cascade. 

Ranjani Paradise, PhD

Director of Evaluation