It’s Time For States To Measure The Effectiveness Of Their OUD Treatment Systems

Although medications for opioid use disorder (MOUD) are the most effective form of treatment for OUD, not enough people have access to them. In 2020, just 11 percent of all people with OUD received medication treatment. Of those who start MOUD, most discontinue it before six months—even though long-term treatment is more effective.

State policy makers are eager for solutions to address the opioid crisis and help more people recover. Many, however, are stymied by limited information about how well their treatment systems work and where to target improvements to help more people start and stay in effective treatment. They also lack targeted, disaggregated data that allow them to address disparities in care.

To gain these insights, states must measure the continuum of addiction treatment—from diagnosis to recovery—to understand what services patients receive and where they need support. This is a framework known as the cascade of care (see exhibit 1).

Exhibit 1: Opioid use disorder cascade of care stages and definitions

SOURCES Adapted from Substance Abuse and Mental Health Services Administration. SAMHSA’s working definition of recovery: 10 guiding principles of recovery. Rockville (MD): SAMHSA, 2012; Williams AR, Nunes EV, Bisaga A, Levin FR, Olfson M. Development of a cascade of care for responding to the opioid epidemic. Am J Drug Alcohol Abuse. 2019;45(1):1-10; Yedinak JL, Goedel WC, Paull K, Lebeau R, Krieger MS, Thompson C, et al. Defining a recovery-oriented cascade of care for opioid use disorder: a community-driven, statewide cross-sectional assessment. PLoS Med. 2019;16(11):e1002963. NOTES Publications on the OUD cascade of care define the stages slightly differently. This exhibit provides the definitions used by the authors.

However, to date experts have not achieved consensus on the best metrics to measure each stage of the cascade and to improve treatment.

Selecting A Set Of Core Measures

To solve this problem, in September 2021, Pew convened a group of experts with backgrounds in state and federal policy, addiction treatment, health quality measurement, harm reduction, and lived experience to look at existing treatment measures and select a set that states could feasibly implement.

This panel used the cascade of care as a framework to select the measures, taking up the call to action previously published in Health Affairs Forefront to “begin now with what we have available, knowing it is imperfect but offering a starting place from which to improve.”

The panel selected a set of measures (see exhibit 2), which includes metrics for each stage of the cascade of care as well as supporting ones. These supporting measures quantify and evaluate aspects of the treatment system that must be functioning well to improve the associated stage of the cascade. For example, to improve the diagnosis rate, more individuals must be screened for OUD.

Exhibit 2: The core opioid use disorder treatment measures for states

SOURCE Pew Charitable Trusts. NOTES *This exhibit provides National Quality Forum (NQF) numbers for those measures with current endorsements (an indication that they meet NQF standards for importance, reliability, validity, usability and relevance, and feasibility). HEDISâ The Healthcare Effectiveness Data and Information Set (HEDISâ) is a registered trademark of the National Committee for Quality Assurance.

With the exception of recovery, states may already be reporting these measures for various Medicaid programs, such as the Behavioral Health Core Set, Section 1115 Substance Use Disorder (SUD) waivers, and SUD health homes. These measures can feasibly be implemented by states with data they already have.

Measuring Recovery

When it comes to recovery, Pew’s panel issued a challenge to the states: Since endorsed quality measures for this stage do not yet exist, we recommend that state officials should create their own metrics to determine if their treatment systems are ultimately improving lives. With input from with people with substance use disorders (SUDs) and in recovery, as well as providers, they can select from and implement recovery assessment tools, such as the Recovery Capital Index, the Brief Assessment of Recovery Capital, the Addiction Severity Index, or other tools developed to evaluate patients’ quality of life and recovery. To obtain this input, states can leverage existing bodies such as state opioid or overdose taskforces, which often include a diverse group of stakeholders.

We suggest that the ideal recovery measure should:

  1. Focus on functioning and quality of life in the domains that matter most to patients (for example, social connectedness, employment, physical health, and mental health) rather than require abstinence since cessation of all drug use is not necessarily the goal of all patients engaging in treatment;
  2. Be feasible to collect in an ongoing manner, which means it must be imbedded into clinical workflow and not burdensome to patients and providers; and
  3. Be disseminated with benchmarks and expectations for improvement and allow fair comparisons among regions, health plans, populations, providers, and over time.

Some states are already experimenting with ways to understand how treatment improves lives and leads to recovery. Since 2013, to help facilitate quality improvement, Connecticut has reported recovery measures on the provider level; metrics include rates of patients achieving stable housing, not being arrested, being employed, engaging in self-help groups, and being successfully discharged from substance use disorder treatment. In June 2022, the Indiana Family and Social Services Administration announced that they were conducting a survey known as the Recovery Capital Index to understand the well-being of all Hoosiers and inform future state opioid response grant-funding decisions. And in May 2022, Virginia Commonwealth University released the results of a survey conducted for the Virginia Department of Medical Assistance Services on the experiences of Medicaid enrollees with addiction treatment and outcomes such as the ability to deal with daily problems, maintain family relationships, and improve housing and employment status.

Serving as public health laboratories, the states implementing these measures will accelerate our ability to understand how treatment impacts quality of life.

Alabama And Colorado Are Leading The Way

Alabama and Colorado, with support from the Pew Charitable Trusts, are early adopters of the core OUD treatment measure set.


The Alabama Department of Mental Health (ADMH) is coordinating with the state Medicaid agency to calculate the claims-based measures for Alabama’s Medicaid population. The data—broken down by age group, race/ethnicity, county, and eligibility category—will be publicly displayed on the Central Data Repository, Alabama’s opioid dashboard. The ADMH has also reached out to the largest private insurer in the state and plans to partner with this organization to obtain data on the commercially insured population.

Initial results show high and increasing rates of treatment continuity for at least six months; between 2019 and 2020, the rate of continuity of pharmacotherapy for OUD increased from 60 percent to 65 percent among people receiving buprenorphine. In comparison, a study of the Medicaid population in six states found that between 2015 and 2016, 52 percent of people with OUD who begin treatment with medication were still using it six months later.

The data also helped Alabama identify areas for improvement. For example, the number of active buprenorphine prescribers in the Medicaid program decreased each year from 2018 to 2020, and just 5 percent of adult Medicaid enrollees who visit the emergency department for OUD have a follow-up visit within 30 days.

Now equipped with these critical data points, Alabama is taking action to improve treatment access and quality. Members of the Governor’s Opioid Overdose and Addiction Council, which includes people in recovery from OUD, are using the measures to inform requests to the state legislature for the use of opioid settlement funds. Moreover, the ADMH and Medicaid staff will update the measures on an annual basis, in time for the data to inform agency budget development in the summer.


Colorado is using a different implementation strategy, illustrating that approaches need to be adapted to fit local contexts. The Colorado Consortium for Prescription Drug Abuse Prevention, which coordinates the state’s response to the opioid crisis, is partnering with the Center for Improving Value in Health Care (CIVHC), the state’s all-payer claims database administrator, to develop and disseminate measures using claims data from both publicly and commercially insured people with OUD in the state.

The consortium will use data from the Colorado All Payer Claims Database—which includes claims data from all major commercial payers, Medicaid, and Medicare—to report on the core measures. The consortium will share findings with members of the legislative Opioid and Other Substance Use Disorder Study Committee, which has a history of relying on consortium reports and subject matter expertise to inform substance use treatment and prevention policy. For instance, since 2017, information provided by the consortium contributed to the passage of 14 bills with more than 80 policies related to prevention, harm reduction, treatment, and recovery services for opioid and other substance use disorders.

The data will also be available to inform policy on the local level. In addition to providing data disaggregated by demographic factors, such as race/ethnicity, age, and sex, the CIVHC will provide local-level aggregated data to 19 Regional Opioid Abatement Councils that are receiving opioid settlement funds so that local leaders have the data they need to use funds effectively toward mitigating the opioid crisis.

Measurement Needs To Be Accompanied By Planning And Action

In different ways, Alabama and Colorado have committed not just to measuring treatment quality but also to ensuring this data inform policy. Gathering data is not enough; states need plans and structures to incorporate it into the policymaking process.

Informed by the expert panel, Pew recommends that states implement the measures and create a data-use plan that includes:

  • Reporting data publicly to create accountability on the effectiveness of the state’s efforts to address the opioid crisis,
  • Reviewing and acting on the data regularly by developing quality improvement initiatives or implementing value-based payment strategies; and
  • Working with people with OUD and treatment providers to understand the numbers and develop quality improvement initiatives.

To help states achieve these goals, RTI International created a toolkit for implementing the measures. This toolkit includes an implementation checklist, in-depth information on the measures, and guidance on working with people with lived experience to understand the data.

Disaggregated Data Is Needed To Address Health Equity

As states implement the measures, it’s critical that they disaggregate data to identify differences in the care cascade by race, ethnicity, geography, age, and other demographic factors. Not all communities are equally impacted by the overdose crisis. For example, deaths have disproportionately increased among Black populations, yet despite the need, Black people are less likely to receive and continue to use medication for at least six months than White people.

State officials need disaggregated data to identify these disparities, develop plans to address them, and be held accountable for making improvements.

Looking Forward

Leaders in Alabama and Colorado are examples of how states can chart a path toward transforming the way opioid treatment policy is made. By implementing the OUD care cascade and quality measure set, they will gain a deeper understanding of how their treatment systems perform across the continuum, allowing them to make improvements and track progress over time. More states across the country should adopt this approach so that policy makers can make more informed decisions leading to higher-quality, more equitable care—decisions that will save lives.

Authors’ Note

Frances McGaffey and Jane Koppelman are employed by the Pew Charitable Trusts, which recommends states adopt the measures described in this article.