Table 3.

The OUD services cascade: key actors and challenges in The services cascade.

Cascade step	Step outcome	Key actors	Challenges
Screening	Need Identification	Providers in settings where people with opioid misuse and OUD present, such as Primary Care, Emergency Departments, Justice Settings, Mental Health Specialty, and School-based health centers.	• Referral is required for screening to take place • In some settings, screening for OUD may not considered a priority • Screening often must take place rapidly or in settings with competing demands
Need Identification and referral to services	Need identified	Services referred to	• Non-diagnostic instruments are often used • Referral and tracking across systems can be difficult • Patients may have complex treatment needs, including comorbid psychiatric conditions • Few evidence-based approaches to facilitate successful transition across settings • Referrals may be both intra-organizational or inter-organizational • Referral may not always be possible due to lack of relationships or other barriers • Availability of services may be unknown
	None	N/A
	Preventative or low intensity services indicated	Brief interventions prevention services settings
	Behavioral health services needed	Outpatient specialty treatment settings
	Pharmacotherapy needed	OUD treatment settings (see Table 2)
	Intensive services needed	Inpatient treatment settings
	Other services	E.g., Mental health, HIV, housing
Initiation of and retention in services	Type of service	Key actors	• Brief interventions for OUD may not be effective • Can be difficult to train clinicians or peers to consistently deliver brief interventions
	Brief interventions	Clinicians or peers properly trained in brief interventions
	Prevention services	E.g., educational settings, occupation/workplace, faith-based organizations, social services.	• Preventative services do not exist in a well-established service ecosystem • Few targeted prevention interventions exist specifically for opioids
	Outpatient addiction treatment	See Table 2 for care settings for medications. Care may occur in a single integrated care setting, or more commonly, multiple discrete care settings (e.g., psychiatric treatment, treatment of other SUD)	• Diagnostic assessment must often be completed to determine appropriate referrals • Integrated care is desirable to address comorbid conditions including psychiatric services, but this goal is not always easily achieved • Mortality risk is elevated after inpatient care, and care is not always well coordinated • Bi-directional information sharing can be challenging
	OUD treatment settings
	Inpatient addiction treatment settings
	Other services (e.g., HIV)