Medication-assisted treatment is at the core of a new care model created by Brown University researchers looking to offer a restructured approach to opioid use disorder.
Follow-up studies, though, may delve into other avenues that don’t incorporate medications such as buprenorphine and methadone.
“The best data we have is on treatment involving medication, and that is one limitation,” said Brandon Marshall, associate professor of epidemiology at Brown and senior author of a paper that outlines a “cascade of care” model for opioid use disorder. “Future work would try to map out what care continuums would look like for other methods of treatment.”
Researchers, led by Marshall and Jesse Yedinak, the lead author of the study and a project director at the Centers for Epidemiology and Environmental Health at Brown, used the model as a framework for a project that defines stages of treatment and supports them with data specific to Rhode Island.
Cascade of care models have existed for more than 10 years but are most commonly seen in connection with HIV/AIDS.
“HIV is where the cascade of care model has its best success. … It’s been wildly successful in getting people to understand risk population, getting them into care and getting them stable,” Yedinak said.
‘Understanding what works and what doesn’t will inform our decisions.’
DR. NICOLE ALEXANDER-SCOTT, R.I. Department of Health director
One benefit of using the model in the context of the opioid crisis is that it provides a clearer picture of how many people are affected while highlighting the number of people who drop off between levels of care.
“We work with transitions between each stage, how do people fall out of care, and how do we better engage them,” Yedinak said.
With input from state agencies and experts in opioid use disorder, a team of about a dozen Rhode Island researchers modified the cascade of care model to show where treatment gaps are occurring.
The resulting model defines and applies data to five stages of care. Based on data from 2016, the population of stage zero – those at risk for opioid use dependency – totaled 47,000. The figure includes people who reported using heroin or misusing other opioids.
Stage one tallies people diagnosed with opioid dependency at 26,000. That means there are another 21,000 people from stage zero who are at-risk with no diagnosis, the study’s authors say.
Stage by stage, the model shows drop-offs from one level to the next, with less than half of those diagnosed with addiction participating in medication-based treatment.
Of those on medications meant to ease withdrawal symptoms and curb cravings, 8,300 followed treatment plans for more than 180 days, stage three shows.
Totals drop further in stage four, the final stage, which reported the number of those in recovery at 4,200.
Analyzing those gaps could provide insight into what keeps people who have been diagnosed with opioid addiction from seeking or continuing treatment, Marshall said.
“This work allowed us to get a sense of how large that drop-off is,” he said, adding financial and housing instability, along with unemployment, are often obstacles.
“I think it speaks to the number of barriers there are in the health care system. It can be difficult for people to initiate treatment. Starting treatment might not be the first thing in the hierarchy of need,” Marshall said.
The study, published recently in PLOS Medicine, a peer-reviewed online journal, has not yet been implemented in Rhode Island, although health officials are looking into how to apply elements of the model to the state’s overdose crisis response.
“We can use this model and our own integrated data to understand the best way, the best time and the best place to help get people back on the road to recovery and to prevent them from falling off in the first place,” said Dr. Nicole Alexander-Scott, director of the R.I. Department of Health and a co-chair of Gov. Gina M. Raimondo’s Overdose Prevention and Intervention Task Force.
Yedinak and Marshall worked closely with task force members, who, along with other state agencies, provided data and guidance for the study.
Researchers scoured state records and statewide insurance claims to tally how many people were diagnosed with opioid dependency, initiated medication-assisted treatment and stayed with the treatment.
Information on how many people were at risk for opioid addiction and how many were recovering from it was unavailable at a state level, so the study relied on national survey data that included Rhode Island, Yedinak said.
All told, the project took about a year and a half to complete, and could improve or change some of the state’s approaches to the opioid crisis, according to Alexander-Scott.
“The model’s framework provides a structure that allows us to quantitatively track the effectiveness of a wide range of initiatives,” she said. “Understanding what works and what doesn’t will inform our decisions moving forward.”
Elizabeth Graham is a PBN staff writer. Contact her at Graham@PBN.com.
