Budget Impact Analysis of the Introduction of Injectable Prolonged-Release Buprenorphine on Opioid Use Disorder Care Resource Requirements

Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration

OBJECTIVE

To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens.

DATA SOURCES AND STUDY SETTING

We measured implementation costs for three MCPCs over 2 years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs.

STUDY DESIGN

Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded.

DATA COLLECTION/EXTRACTION METHODS

Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data.

PRINCIPAL FINDINGS

Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs.

CONCLUSIONS

Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.

Implementing buprenorphine prolonged-release injection using a health at the margins approach for transactional sex-workers

Background

Access to prescribed interventions and retention in treatment services are associated with improved health outcomes and reduced premature mortality rates for people living with opioid use disorder (OUD). In Leeds, transactional sex-workers frequently cycled in and out of treatment for OUD such that they never reached a level of engagement that permitted opportunities to meet their healthcare or housing needs. Barriers to accessing care provision include an itinerant lifestyle, difficulties with travel at unpredictable hours, impacting upon adherence to medication regimens including daily supervised consumption.

Objectives

To use a co-produced, "health at the margins" approach, to reach the sex-working population in Leeds, and support informed choices about the potential to receive buprenorphine prolonged-release injection (BPRI) as a treatment option for OUD.

Methods

BPRI was introduced using a theory of change model and improvements in sex-worker care delivery was reviewed. Strategies included buprenorphine micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based and trauma-informed approach.

Results

Benefits of BPRI included removal of the need for daily pharmacy visits, reducing the risk of diversion, improved medication adherence, stability and engagement with treatment and supportive services.

Conclusion

BPRI may offer an additional option for pharmacological interventions for people with OUD where there may be increased barriers to accessing treatment for example due to sex-working. Strategies for effective BPRI include micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based approach.

Evaluating the feasibility of prolonged-release buprenorphine formulations as an alternative to daily opioid agonist therapy regardless of prior treatment adherence: a pilot study

BACKGROUND

Effective opioid agonist therapy (OAT) depends on good patient adherence. However, the daily, supervised administration of standard OAT represents a significant burden to patients and often drives poor adherence. Prolonged-release buprenorphine (PRB) formulations may mitigate some of this burden, enabling clinic visits to be substantially reduced. For treatment guidelines to be effective, the likely benefit of a transition to PRB therapy in different patient populations must be established.

METHODS

The aim was to determine the feasibility of assessing PRB as an alternative to daily OAT in two groups: those currently adhering well to daily OAT (group 1, N = 5) and those not currently showing adherence or a positive response to daily OAT (group 2, N = 10). This open-label, prospective, non-controlled pilot study was conducted at the Kaleidoscope Drug Project in South Wales, UK. Participants were assessed for history, drug use, psychosocial assessment scores, and clinical severity at baseline and after 6 months of treatment. Primary outcomes were the feasibility of assessing PRB as an alternative to daily OAT and the acceptability of PRB therapy in each group. Secondary outcomes were treatment response, on-top drug use, psychosocial measures, and assessment of clinical severity.

RESULTS

Participants from both groups demonstrated high levels of participation with assessment protocols at both baseline and 6-month follow-up, indicating study feasibility. PRB treatment was acceptable to the majority of participants, with all of group 1 and 70% of group 2 adhering to PRB therapy for the duration of the study and opting to persist with PRB therapy over other OAT options after study completion. All participants who remained on treatment demonstrated marked improvements in psychosocial and clinical severity assessment scores, with some returning to employment or education. On-top drug use remained absent in group 1 and was reduced in group 2.

CONCLUSIONS

Evaluation of transition of participants from daily OAT to PRB therapy was shown to be feasible, acceptable, and effective across both groups. A larger randomised controlled trial is warranted, particularly to assess PRB therapy in participants with a history of poor treatment engagement, as the need for therapy is greater in this group and their management is associated with higher costs of care.

Depot buprenorphine as an opioid agonist therapy in New South Wales correctional centres: a costing model

BACKGROUND

In 2019 daily liquid methadone and sublingual buprenorphine-naloxone were primary opioid agonist treatments for correctional centres in New South Wales, Australia. However, both had significant potential for diversion to other patients, and their daily administration was resource intensive. An alternative treatment in the form of subcutaneous depot buprenorphine became a viable option following a safety trial in 2020 - the UNLOC-T study. Depot preparation demonstrated advantages over current treatments as more difficult to divert and requiring fewer administrations. This paper reports the results of economic modelling of staffing costs in medication administration comparing depot buprenorphine, methadone, and sublingual buprenorphine provision in UNLOC-T trial facilities.

METHODS

The costing study adopted a micro-costing approach involving the synthesis of cost data from the UNLOC-T clinical trial as well as data collected from Justice Health and Forensic Mental Health Network records. Labour and materials data were collected during site observations and interviews. Costs were calculated from two payer perspectives: a) the New South Wales (state) government which funds custodial and health services; and b) the Australian Commonwealth government, which pays for medications. The analysis compared the monthly-per-patient cost for each of the three medications in trial-site facilities during July 2019. This was followed by simulation of depot buprenorphine implementation across the study population. Costs associated with medical assessment and reviews were excluded.

RESULTS

The monthly-per-patient New South Wales government service costs of depot buprenorphine, methadone and sublingual buprenorphine were: $151, $379 and $1,529 respectively while Commonwealth government medication costs were $434, $80 and $525. The implementation simulation found that service costs of depot buprenorphine declined as patients transitioned from weekly to monthly administration. Costs of treatment using the other medications increased as patient numbers decreased alongside fixed costs. At 12 months, monthly-per-patient service costs for depot buprenorphine, methadone and sublingual buprenorphine-which would be completely phased out by month 13-were $92, $530 and $2,162 respectively.

CONCLUSIONS

Depot buprenorphine was consistently the least costly of the treatment options. Future modelling could allow for dynamic patient populations and downstream impacts for participants and the state health system.

TRIAL REGISTRATION

ACTRN12618000942257 . Registered 4 June 2018.

Prolonged-Release Buprenorphine Therapy in Opioid Use Disorder Can Address Stigma and Improve Patient Quality of Life

Treatment for opioid use disorder (OUD) including opioid agonist therapy (OAT) is effective. Medication with the oral administration of methadone and buprenorphine has well-known limitations (establishing consistent optimal dosing levels, misuse, diversion, and accidental exposure). Treatment may require attendance at treatment services for collection and consumption of medication; this is associated with stigma and discrimination. Novel therapeutic options include approved, injectable, prolonged-release buprenorphine (PRB) products providing consistently optimal drug levels and less frequent dosing. This work assesses the lived experience of persons currently engaged in OUD therapy to define the potential value of novel therapeutic options in order to inform treatment decisions.

One hundred and twenty-two people engaged with treatment services participated in this assessment. Seventy-two percent of participants believed that novel therapeutic options would improve quality of life and 67% stated it would reduce stigma and discrimination. Participants were neither concerned about the efficacy of (net score negative 30%), or lack of control over (net score negative 36%) treatment, nor about reduced contact with treatment services (net score negative 11%). Results from this assessment indicate that the provision of choice including novel therapeutic options is likely to improve quality of life and reduce the stigma of persons with OUD.

Increased Treatment Engagement and Adherence: Flexible Management with Prolonged-Release Buprenorphine in Treatment of Opioid Dependence

Opioid dependence (OD) is effectively treated with well-evidenced regimens including psychosocial and opioid agonist pharmacotherapy. Many do not engage with treatment services; reasons include the burden of mandatory supervision and stigma. Injectable prolonged-release buprenorphine (PRB) offers choice and flexibility in treatment. Experience reported here demonstrates the potential for PRB to enable wider engagement with treatment services. Treatment was successful in patients unable to attend daily observed therapy due to work commitments, unable to use services for fear of stigma, or having not achieved goals on previous attempts with conventional approaches. PRB therapy was clinically successful without withdrawal signs or evidence of use of other drugs. Patient-reported outcomes were positive including maintained ability to work, manageable detoxification experience, and stigma-free treatment. This work provides evidence of PRB benefit in expanding treatment engagement.

Patient-Reported Outcomes, Experiences and Satisfaction with Weekly and Monthly Injectable Prolonged-Release Buprenorphine

Introduction

Prolonged-release buprenorphine (PRB), administered by weekly or monthly injection, for opioid dependence (OD) treatment offers the potential to address some limitations of oral therapy including stigma, difficulty in achieving consistent appropriate dosing, risk of diversion of medications, risk of overdose, and continuing use of other drugs. Patient-reported outcomes (PRO) and experiences are important in the evaluation of OD therapy success. This work aimed to document PRO during PRB therapy to guide future treatment decision-making.

Methods

Qualitative interviews were completed with people on PRB OD treatment. Twenty individuals from four treatment services in England and Wales were asked to participate. A structured interview was developed guided by a person with OD lived experience. Interviews were transcribed, coded and analyzed using iterative categorization.

Results

Fifteen of 20 individuals approached agreed to participate, and 14 completed interviews. The average age of participants was 42 (range 33–54) years, 13 males and 1 woman, the history of problematic opioid use was 14 years (3–25 years), time in treatment was 7 years (1–20 years), and duration on treatment with PRB was 4 months (range 1–8 months). Participants reported treatment experiences leading to coding of 277 unique comments: therapy effectiveness (77% indicated a benefit of, or satisfaction with, PRB therapy, 7% neutral/general, 16% indicated concern or questions about PRB therapy), convenience (81% benefit, 7% neutral/general, 12% concern), and overall satisfaction (81% benefit, 3% neutral/general, 16% concern). Reported benefits include cravings reduction of 10 (71%), self-care improvement of 10 (71%), relationships improvement of 9 (64%), resources management of 6 (43%), positive outlook on life of 12 (86%). Participants reported a range of positive personal experiences; challenges reported included temporary injection discomfort at treatment initiation.

Discussion

In this small, focused population, there was generally a positive level of treatment satisfaction with PRB. These experiences provide insights to explain potential treatment benefit to others and are useful in guiding therapy choices for others in the future.