In 2022, drug overdose was the leading cause of death for US residents aged 23 to 46 years, and among the leading causes of death for older US residents.¹ That year, 81 806 opioid-involved overdose deaths were reported in the US, more than in any previous year and more than 6 times as many as in 2002.¹

Many people who die of an opioid-involved overdose have untreated or undertreated opioid use disorder (OUD) and most were not prescribed 1 of the 3 US Food and Drug Administration–approved medications for treating OUD: methadone, buprenorphine, or extended-release naltrexone.² These medications—and particularly the opioid agonists methadone and buprenorphine for moderate to severe OUD—are highly effective, life-saving, first-line treatments.³ All practitioners with a current Drug Enforcement Administration registration that includes Schedule III authority can prescribe buprenorphine, with the 2023 removal of the federally required Drug Addiction Treatment Act of 2000 waiver (X-waiver) that may have previously limited prescribing. Given the high burden, morbidity, and mortality of OUD, it is important that all clinicians become familiar with the medications to treat OUD and that these medications become a routine part of medical practice.⁴

This week, a new Morbidity and Mortality Weekly Report applied data from the 2022 National Survey on Drug Use and Health to estimate the opioid cascade of care, which is a framework to characterize the adult US populations who needed OUD treatment, received any OUD treatment, and received medication as part of OUD treatment.² One of every 27 US adults (3.7%) aged 18 years or older needed treatment. However, just 55.2% of these individuals received any treatment, and only one-quarter (25.1%) who needed treatment received medication. Most adults who needed treatment either did not perceive that need (42.7%) or received treatment that did not include medications to treat OUD (30.0%).

The care cascade—widespread screening regardless of the point of care; ensuring diagnosed patients receive treatment, including medications; and retaining patients in care—has been part of medical care for many years and most clinicians, regardless of medical specialty or practice setting, have understood its importance. The care cascade has been most notably applied to HIV care, where its importance is widely recognized.⁵ The concept of the care cascade is equally applicable to OUD, but US clinicians have been slower to embrace the concept broadly. More than 5 times as many people in the US now live with OUD (estimated 6.1 million⁶) compared with HIV (estimated 1.2 million⁷). With 1 in 27 adults needing OUD treatment, most US clinicians are likely to have patients who need treatment in their practices, whether they are aware of it or not.

Clinicians may be hesitant to prescribe OUD medications to patients who perceive a need for treatment for a range of reasons. They may not know the strong efficacy data for these medications; feel unprepared to prescribe because of lack of training; worry about the impact on their practice flow or inadequate reimbursement; lack local specialist backup, especially for more complex patients with polysubstance use; or have unconscious stigma related to caring for patients with OUD, among other reasons. Clinicians may also struggle to connect patients to needed mental health and recovery supports.

Unfortunately, in this context, when patients seek care for OUD, some clinicians may continue to encourage detoxification alone,⁸ without a connection to Food and Drug Administration–approved medications for OUD. This approach has a higher rate of treatment failure and is associated with an increased risk of mortality (eg, fatal overdose) compared with receiving medications for OUD.^3,4

Many health systems, harm reduction programs, and public health departments have developed innovative approaches to help connect people with OUD to medications. The COVID-19 pandemic allowed more telehealth prescribing, which in turn helped build the evidence base for at-home buprenorphine induction.⁹ Often, peer recovery and navigation programs may be available. More prescribers could help to meet needs and particularly address the persistent disparities in access. For example, in 2022, among adults who needed OUD treatment, non-Hispanic Black and Hispanic or Latino adults were less likely to receive any OUD treatment than non-Hispanic White adults.²

Primary care and obstetrics/gynecology clinicians can make treating OUD with medications a part of routine practice. Clinicians practicing in emergency departments and inpatient settings can provide buprenorphine induction and a warm handoff to ongoing treatment for patients with OUD. Clinicians in specialized settings (eg, mental health or infectious disease clinics, jails and prisons, mobile and shelter settings for people experiencing homelessness) that may care for patients with OUD who may not access other sources of care can routinely prescribe medications for OUD or ensure patients are provided access to medications. Care transitions may be especially important, including when people are released from in carceration; discharged from hospitalization, emergency departments, or substance use treatment programs; or become pregnant, give birth, or progress through the postpartum period.

To achieve the care cascade, clinicians can do the following: