The cost of providing methadone maintenance treatment in Ontario, Canada

Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada

OBJECTIVES

Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use (IDU) at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada.

STUDY DESIGN AND SETTING

Data from cohorts of people with recent (past 12 months) IDU, including those participating in community-based research studies or seeking drug treatment, were linked to health administrative data in Ontario from 1992 to 2020. We assessed the validity of algorithms to identify IDU over varying look-back periods (ie, all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department (ED) visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT).

RESULTS

Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts and 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, ED visit, or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity and 94.2% specificity) and recent IDU (using 3-year look back: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment.

CONCLUSION

Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite their high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of IDU in the population in which they are applied.

The Role of Adverse Childhood Experiences on People in Opiate Agonist Treatment: The Importance of Feeling Unloved

INTRODUCTION

Adults in opiate agonist treatment (OAT) often have a background of adverse childhood experiences (ACEs) and are more likely to be exposed to a variety of risks that may trigger post-traumatic stress disorder (PTSD). Summative ACE scores are often used to identify individuals at risk of PTSD and continued substance use. What has not been addressed is whether specific ACE factors are exerting a greater influence on the individual. This study investigated whether specific ACEs predicted PTSD, and current continued substance use among adults in long-term OAT.

METHODS

An analysis of data that were collected at the follow-up stage of a study among 131 adults who attended OAT was conducted. Participants attended one of six OAT settings, covering 45% (n = 890) of clients in a defined area of Dublin, Ireland in 2017. Interviews were conducted with 104 participants, 66 males (63%) and 38 females (37%), with an average age of 43 years (SD = 7.4). The Adverse Childhood Questionnaire (ACQ); PTSD checklist (PCL-5); heroin; tranquilliser; cannabis; alcohol; and cocaine used in the previous 28 days were measured using the quantity used score within the Opiate Treatment Index. Socio-demographics and age of first use of these four substances were also collected. The analysis has focussed on relating ACEs to PTSD, age of first drugs use, and current drug use of the participants.

RESULTS

Bivariate analysis showed that the summative ACQ score was significantly correlated with age of first opiate use (p = 0.004). Multiple regression analysis showed that the summative ACQ score and tranquilliser use predicted higher levels of PTSD (R2 = 0.50). Four specific ACEs predicted 54% of the variance in PTSD, these were feeling unloved (β = 0.328) living with a household member who had a problem with alcohol or used illicit street drugs (β = 0.280); verbal abuse (β = 0.219); and living with a person who had a mental illness (β = 0.197).

CONCLUSIONS

While a summation of all ten ACEs predicted higher levels of PTSD, the factor "feeling unloved" as a child provided the single strongest predictor and may represent an overarching risk of PTSD and continued substance use in later life among adults in treatment for an opiate use disorder.

Treatment of opioid dependence with depot buprenorphine (CAM2038) in custodial settings

BACKGROUND AND AIMS

Opioid agonist treatment is effective but resource intensive to administer safely in custodial settings, leading to significant under-treatment of opioid dependence in these settings world-wide. This study assessed the safety of subcutaneous slow-release depot buprenorphine in custody.

DESIGN

Open-label, non-randomized trial.

SETTING

Correctional centres in New South Wales, Australia.

PARTICIPANTS

Sixty-seven men and women, aged ≥ 18 years of various security classifications with a diagnosis of moderate to severe DSM-5 opioid use disorder currently serving a custodial sentence of ≥ 6 months were recruited between November 2018 and July 2019. Patients not in opioid agonist treatment at recruitment commenced depot buprenorphine; patients already stable on oral methadone treatment were recruited to the comparison arm.

INTERVENTION AND COMPARATOR

Depot buprenorphine (CAM2038 weekly for 4 weeks then monthly) and daily oral methadone.

MEASUREMENTS

Safety was assessed by adverse event (AE) monitoring and physical examinations at every visit. Participants were administered a survey assessing self-reported diversion and substance use at baseline and weeks 4 and 16.

FINDINGS

Retention in depot buprenorphine treatment was 92.3%. Ninety-four per cent of patients reported at least one adverse event, typically mild and transient. No diversion was identified. The prevalence of self-reported non-prescribed opioid use among depot buprenorphine patients decreased significantly between baseline (97%) and week 16 (12%, odds ratio = 0.0035, 95% confidence interval = 0.0007-0.018, P < 0.0001).

CONCLUSIONS

This first study of depot buprenorphine in custodial settings showed treatment retention and outcomes comparable to those observed in community settings and for other opioid agonist treatment used in custodial settings, without increased risk of diversion.

Estimate cost of providing methadone maintenance treatment at a methadone clinic in Nairobi Kenya: direct costs

Methadone maintenance treatment is reported as cost-effective in treatment of opioid use disorder. Estimated cost of providing methadone varies widely in different regions but there is no data regarding cost of methadone treatment in Kenya. The aim of this study was to estimate the cost of methadone maintenance treatment at a methadone maintenance treatment clinic in Nairobi, Kenya from the perspective of the government, implementing partner and the clients. Data was collected for the period of February 2017 to September 2018 for 700 enrolled clients. The cost of providing methadone treatment was estimated as the sum of salaries, laboratory test, methadone and other commodities costs. The outcome was daily cost of methadone per client. The costs are given in Kenya Shillings (Ksh). The cost of treating one client is approximately Ksh. 149 (US$1.49) per day which amounts to Ksh 4500 (US$ 45) per month. This is from the estimated direct costs such as salaries which accounted for 86.4%, methadone 9.6%, tests and other consumables at 4%. The estimated average dose per patient per day is 60mg.This excludes indirect costs such as capital and set up cost, maintenance cost, training, drug import and distribution and other bills. The findings of this study show that the estimate cost of providing methadone at Nairobi, Kenya is comparable to that in other centers. This can help to inform policy makers on continued provision of methadone treatment in the country.

Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders

The global rise in opioid-related harms has impacted the United States severely. Current efforts to manage the opioid crisis have prompted a re-evaluation of many of the existing roles in the healthcare system, in order to maximize their individual effects on reducing opioid-associated morbidity and preventing overdose deaths. As one of the most accessible healthcare professionals in the US, pharmacists are well-positioned to participate in such activities. Historically, US pharmacists have had a limited role in the surveillance and treatment of substance use disorders. This narrative review explores the literature describing novel programs designed to capitalize on the role of the community pharmacist in helping to reduce opioid-related harms, as well as evaluations of existing practices already in place in the US and elsewhere around the world. Specific approaches examined include strategies to facilitate pharmacist monitoring for problematic opioid use, to increase pharmacy-based harm reduction efforts (including naloxone distribution and needle exchange programs), and to involve community pharmacists in the dispensation of opioid agonist therapy (OAT). Each of these activities present a potential means to further engage pharmacists in the identification and treatment of opioid use disorders (OUDs). Through a careful examination of these approaches, we hope that new strategies can be adopted to leverage the unique role of the community pharmacist to help reduce opioid-related harms in the US.

Concurrent psychiatry for patients enrolled in opioid agonist treatment: a propensity score matched cohort study in Ontario Canada

Objective

The objective was to characterize the relationship between geography, concurrent psychiatric services, all-cause mortality, and acute health care use for individuals enrolled in Opioid Agonist Treatment, in Ontario, Canada.

Methods

We conducted a propensity score matching study of patients enrolled in Opioid Agonist Treatment in Ontario for the first time between January 1, 2011, and December 31, 2015. We first compared outcomes between patients who were actively engaged and patients who were not actively engaged in Opioid Agonist Treatment. We created treatment and a control groups on the basis of an individual’s access to psychiatric care within an episode of Opioid Agonist Treatment. Relative risk and number needed to treat were calculated to determine the correlation between psychiatric care and health outcomes among patients enrolled in Opioid Agonist Treatment at two time points within an episode of care and for two geographic regions in Ontario (north and south).

Results

During the first year of Opioid Agonist Treatment, concurrent psychiatric care was associated with a reduction in all-cause mortality in southern Ontario (RR 0.80, 95% CI, 0.73–0.87), a reduction in emergency department visits in both northern and southern Ontario (north: RR = 0.76, 95% CI, 0.72–0.81; south: RR = 0.87, 95% CI, 0.86–0.88), and a reduction in hospitalizations (north: RR = 0.88, 95% CI. 0.82–0.94, south: RR = 0.92, 95% CI, 0.91–0.93).

Conclusion

Our findings have significant clinical and political implications for health system planning highlighting the need for integrated mental health and addiction services for individuals with Opioid Use Disorder.

Electronic supplementary material

The online version of this article (10.1186/s13011-019-0213-6) contains supplementary material, which is available to authorized users.

Quality of primary care among individuals receiving treatment for opioid use disorder

OBJECTIVE

To determine if people receiving opioid agonist treatment (OAT), a long-term treatment approach, are also receiving high-quality primary care.

DESIGN

Retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

Recipients of public drug benefits who had at least 6 months of continuous use of methadone or buprenorphine between October 1, 2012, and September 30, 2013.

MAIN OUTCOME MEASURES

Rates of cancer screening and diabetes monitoring among those who had at least 6 months of continuous OAT were compared with matched controls. Conditional logistic regression models were used to assess differences after adjusting for confounders. In secondary analyses, outcomes by type of OAT and factors related to health care delivery were compared.

RESULTS

A cohort of 20 406 OAT patients was identified; they had a mean (SD) of 31 (15) physician clinic visits during the 6-month study period. Compared with the control group, OAT patients were less likely to receive screening for cervical cancer (48.7% vs 62.6%; adjusted odds ratio [AOR] of 0.34, 95% CI 0.31 to 0.36), breast cancer (23.3% vs 49.1%; AOR = 0.19, 95% CI 0.16 to 0.24), and colorectal cancer (32.5% vs 49.0%; AOR = 0.34, 95% CI 0.30 to 0.38), and less likely to have monitoring for diabetes (11.7% vs 28.5%; AOR = 0.16, 95% CI 0.13 to 0.21). Patients receiving OAT who were taking buprenorphine, enrolled in a medical home, or seeing a low-volume prescriber were generally more likely to receive cancer screening and diabetes monitoring.

CONCLUSION

Patients receiving OAT were less likely to receive chronic disease prevention and management than matched controls were despite frequent health care visits, indicating a gap in equitable access to primary care.

Cost of provision of opioid substitution therapy provision in Tijuana, Mexico

BACKGROUND

Mexico recently enacted drug policy reform to decriminalize possession of small amounts of illicit drugs and mandated that police refer identified substance users to drug treatment. However, the economic implications of drug treatment expansion are uncertain. We estimated the costs of opioid substitution therapy (OST) provision in Tijuana, Mexico, where opioid use and HIV are major public health concerns.

METHODS

We adopted an economic health care provider perspective and applied an ingredients-based micro-costing approach to quantify the average monthly cost of OST (methadone maintenance) provision at two providers (one private and one public) in Tijuana, Mexico. Costs were divided by type of input (capital, recurrent personnel and non-personnel). We defined "delivery cost" as all costs except for the methadone and compared total cost by type of methadone (powdered form or capsule). Cost data were obtained from interviews with senior staff and review of expenditure reports. Service provision data were obtained from activity logs and senior staff interviews. Outcomes were cost per OST contact and cost per person month of OST. We additionally collected information on patient charges for OST provision from published rates.

RESULTS

The total cost per OST contact at the private and public sites was $3.12 and $5.90, respectively, corresponding to $95 and $179 per person month of OST. The costs of methadone delivery per OST contact were similar at both sites ($2.78 private and $3.46 public). However, cost of the methadone itself varied substantially ($0.34 per 80 mg dose [powder] at the private site and $2.44 per dose [capsule] at the public site). Patients were charged $1.93-$2.66 per methadone dose.

CONCLUSIONS

The cost of OST provision in Mexico is consistent with other upper-middle income settings. However, evidenced-based (OST) drug treatment facilities in Mexico are still unaffordable to most people who inject drugs.

Patterns of methadone maintenance treatment provision in Ontario: Policy success or pendulum excess?

OBJECTIVE

To describe recent trends and patterns in methadone maintenance treatment (MMT) practice regionally and over time in the province of Ontario.

DESIGN

Population-based descriptive study using health administrative data between September 1, 2011, and December 31, 2014.

SETTING

Ontario.

PARTICIPANTS

All active MMT-prescribing physicians and patients receiving MMT in the study period.

MAIN OUTCOME MEASURES

Characteristics of MMT-prescribing physicians, including age, sex, specialty type, practice region, and practice volume; characteristics of patients receiving MMT, including age, sex, neighbourhood income, and region of residence.

RESULTS

Between September 1, 2011, and December 31, 2014, the number of MMT-prescribing physicians and patients who received MMT increased by 26% and 42%, respectively. In 2014, there was a total of 312 MMT-prescribing physicians and 49 703 patients receiving MMT. In 2014 and on a per capita basis, patients receiving MMT were more prevalent in rural regions; and within rural regions, there were disproportionately large numbers of young female MMT patients residing in low-income neighbourhoods.

CONCLUSION

The number of physicians prescribing MMT and patients receiving MMT has increased substantially between 2011 and 2014, with the largest per capita distribution occurring in rural regions and involving young adults. While availability of and access to MMT has improved considerably from before 2000 to levels of high use, these developments are likely influenced by recent trends in the proliferation of prescription opioid misuse across general populations.

Economic evaluation of rituximab in addition to standard of care chemotherapy for adult patients with acute lymphoblastic leukemia

AIMS

Acute lymphoblastic leukemia (ALL) is an aggressive form of leukemia with a poor prognosis in adult patients. The addition of the monoclonal antibody rituximab to standard chemotherapy has been shown to improve survival in adults with ALL. However, it is unknown whether the addition of rituximab is cost-effective. The objective was to determine the economic impact of rituximab in addition to standard of care (SOC) chemotherapy vs SOC alone in newly-diagnosed Philadelphia chromosome-negative, CD20-positive, B-cell precursor ALL.

METHODS

A decision analytic model was constructed, based upon the Canadian healthcare system. It included the following health states over a lifetime horizon (max ≈60 years): event-free survival (EFS), relapsed/resistant disease, cure, and death. SOC was either hyper-CVAD or the Dana Farber Cancer Institute (DFCI) ALL consortium. EFS, overall survival, and serious adverse event (SAE) rates were derived from a large randomized controlled trial. Costs of the model included: first-line treatment and administration, disease management, second-line and third-line treatment and administration, palliative care, and SAE-related treatments. Inputs were sourced from provincial and national public data, the literature, and cancer agency input.

RESULTS

Quality-adjusted life-years (QALYs) increased by 2.20 QALYs with rituximab in addition to SOC. The resulting mean Incremental Cost-Effectiveness Ratio (ICER) was C$21,828/QALY. At a willingness-to-pay threshold of C$100,000/QALY, the probability of being cost-effective was 98%. Decision outcomes were robust to the probabilistic and deterministic sensitivity analyses, including the SOC backbone as either hyper-CVAD or DFCI.

LIMITATIONS

The results of this analysis are limited by generalizability of the chemotherapy backbone to Canadian practice.

CONCLUSIONS

For adults with ALL, rituximab in addition to SOC was found to be a cost-effective intervention, compared to SOC alone. The addition of rituximab is associated with increased life years and increased QALYs at a reasonable incremental cost.

Treatment of prescription opioid disorders in Canada: looking at the 'other epidemic'?

The magnitude and consequences of prescription opioid (PO) misuse and harms (including rising demand for PO disorder treatment) in Canada have been well-documented. Despite a limited evidence-base for PO dependence treatment, opioid maintenance therapy (OMT) - mostly by means of methadone maintenance treatment (MMT) - has become the de facto first-line treatment for PO-disorders. For example in the most populous province of Ontario, some 50,000 patients - large proportions of them young adults - are enrolled in MMT, resulting in a MMT-rate that is 3-4 times higher than that of the United States. MMT in Ontario has widely proliferated towards a quasi-treatment industry within a system context of the public fee-payer offering generous incentives for community-based MMT providers. Contrary to the proliferation of MMT, there has been no commensurate increase in availability of alternative (e.g., detox, tapering, behavioral), and less intrusive and/or costly, treatments which may provide therapeutic benefits at least for sub-sets of PO-dependent patients. Given the extensive PO-dependence burden combined with its distinct socio-demographic and clinical profile (e.g., involving many young people, less intensive or risky opioid use), an evidence-based 'stepped-care' model for PO dependence treatment ought to be developed in Canada where MMT constitutes one, but likely a last resort or option, for treatment. Other, less intrusive treatment options as well as the best mix of treatment options should be systematically investigated and implemented. This case study has relevance and implications for evidence-based treatment also for the increasing number of other jurisdictions where PO misuse and disorders have been rising.

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada

BACKGROUND AND AIMS

Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods.

DESIGN

Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment.

SETTING

Toronto and Ottawa, Canada.

PARTICIPANTS

Simulated population of each city.

INTERVENTIONS

Zero to five supervised injection facilities.

MEASUREMENTS

Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios.

FINDINGS

In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million.

CONCLUSIONS

Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.