Commentary on Piske <i>et al</i>. (2020): Medication initiation is key to reduce deaths amid opioid crisis

Commentary on Piske et al. (2020): Medication initiation is key to reduce deaths amid opioid crisisThe OUD Cascade of Care is a public health framework for guiding efforts to more effectively respond to the opioid epidemic.Officials can track progress across each stage, from diagnosis to recovery, to help identify gaps across systems.This may be especially meaningful for improving outcomes among more complex patient populations.The OUD Cascade of Care has become a preferred framework for public health agencies monitoring progress amid the opioid epidemic [1,2].Similar to trends in many parts of the United States, Piske and colleagues [3] observed a greater than threefold increase in the number of individuals diagnosed with opioid use disorder (OUD) across British Columbia, which has the highest provincial opioid-related death rate in Canada.Canada, however, has developed a much more capacious and low-threshold treatment system for OUD which other countries, especially the United States, could learn from.Indeed, the authors explain that the most commonly used forms of opioid agonist treatment (OAT), methadone and buprenorphine/naloxone, can be prescribed by primary physicians [with no need for a Drug Enforcement Administration (DEA) 'X-waiver'] and dispensed via community-based pharmacies-something that US federal agencies have long refused to allow [4].Since mid-2017 alternative forms of OAT, including slow-release oral morphine and injectables, have also been offered in these low-threshold settings.The authors identified annual increases of up to 12% in the number of people with OUD who had ever initiated OAT, probably a reflection of long-standing provincial efforts to expand access to low-barrier addiction treatment.The authors also describe how, to expand access to OAT, the province of British Columbia has opened integrated care clinics, addiction treatment support programs, approved new forms of OAT with new clinical guidelines and eliminated copayment fees for the vast majority of clients, in addition to most physician eligibility requirements for prescribing capabilities.While there are clinical pilot programs in forward-thinking states such as Vermont and Massachusetts [5], none have been as all-encompassing as the level of regulatory reform referenced by the authors.It is not a surprise, then, that the authors' findings along the OUD Cascade of Care far surpass estimates for US populations.They found that, in 2017, 71% of those diagnosed had engaged in past-year OAT and 33% were currently on OAT; however, only 16% had been retained on medication for more than a year.The comparable

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