Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation

PURPOSE

To explore the relationship between oral mucositis and selected clinical and economic outcomes in blood and marrow transplant patients.

PATIENTS AND METHODS

Subjects consisted of 92 transplant patients from eight centers who participated in a multinational pilot study of a new oral mucositis scoring system (Oral Mucositis Assessment Scale [OMAS]). In the pilot study, patients were evaluated for erythema and ulceration/pseudomembrane formation beginning on the first day of conditioning and continuing for 28 days. We examined the relationship between patients' peak OMAS scores and days with fever (body temperature > 38.0 degrees C), the occurrence of significant infection, days of total parenteral nutrition (TPN), and days of injectable narcotic therapy (all over 28 days), days in hospital (over 60 days), total hospital charges for the index admission, and vital status at 100 days.

RESULTS

Patients' peak OMAS scores spanned the full range of possible values (0 to 5) and were significantly (P <.05) correlated with all of the outcomes of interest except days with fever (P =.21). In analyses controlling for type of graft (autologous v allogeneic) and study center, a 1-point increase in peak OMAS score was associated with (1) 1.0 additional day with fever (P <.01), (2) a 2.1-fold increase in risk of significant infection (P <.01), (3) 2.7 additional days of TPN (P <.0001), (4) 2.6 additional days of injectable narcotic therapy (P <.0001), (5) 2.6 additional days in hospital (P <.01), (6) $25,405 in additional hospital charges (P <.0001), and (7) a 3.9-fold increase in 100-day mortality risk (P <.01). Mean hospital charges were $42,749 higher among patients with evidence of ulceration compared with those without (P =.06).

CONCLUSION

Oral mucositis is associated with significantly worse clinical and economic outcomes in blood and marrow transplantation.

Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward

We review evidence for effectiveness, cost-effectiveness, and coverage of antiretroviral therapy (ART) for injecting drug users (IDUs) infected with HIV, with particular attention to low-income and middle-income countries. In these countries, nearly half (47%) of all IDUs infected with HIV are in five nations--China, Vietnam, Russia, Ukraine, and Malaysia. In all five countries, IDU access to ART is disproportionately low, and systemic and structural obstacles restrict treatment access. IDUs are 67% of cumulative HIV cases in these countries, but only 25% of those receiving ART. Integration of ART with opioid substitution and tuberculosis treatment, increased peer engagement in treatment delivery, and reform of harmful policies--including police use of drug-user registries, detention of drug users in centres offering no evidence-based treatment, and imprisonment for possession of drugs for personal use--are needed to improve ART coverage of IDUs.

Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers

Abuse of prescription opioid medications has increased dramatically in the United States during the past decade, as indicated by a variety of epidemiological sources. However, few studies have systematically examined the relative reinforcing effects of commonly abused opioid medications. The current double-blind, placebo-controlled in-patient study was designed to compare the effects of intravenously delivered fentanyl (0, 0.0625, 0.125, 0.187, and 0.250 mg/70 kg), oxycodone (0, 6.25, 12.5, 25, and 50 mg/70 kg), morphine (0, 6.25, 12.5, 25, and 50 mg/70 kg), buprenorphine (0, 0.125, 0.5, 2, and 8 mg/70 kg), and heroin (0, 3.125, 6.25, 12.5, and 25 mg/70 kg) in morphine-maintained heroin abusers (N=8 completers maintained on 120 mg per day oral morphine in divided doses (30 mg q.i.d.)). All of the participants received all of the drugs tested; drugs and doses were administered in non-systematic order. All of the drugs produced statistically significant, dose-related increases in positive subjective ratings, such as 'I feel a good drug effect' and 'I like the drug.' In general, the order of potency in producing these effects, from most to least potent, was fentanyl>buprenorphine>or=heroin >morphine=oxycodone. In contrast, buprenorphine was the only drug that produced statistically significant increases in ratings of 'I feel a bad drug effect' and it was the only drug that was not self-administered above placebo levels at any dose tested. These data suggest that the abuse liability of buprenorphine in heroin-dependent individuals may be low, despite the fact that it produces increases in positive subjective ratings. The abuse liabilities of fentanyl, morphine, oxycodone, and heroin, however, appear to be similar under these experimental conditions.

Effectiveness and cost effectiveness of expanding harm reduction and antiretroviral therapy in a mixed HIV epidemic: a modeling analysis for Ukraine

BACKGROUND

Injection drug use (IDU) and heterosexual virus transmission both contribute to the growing mixed HIV epidemics in Eastern Europe and Central Asia. In Ukraine-chosen in this study as a representative country-IDU-related risk behaviors cause half of new infections, but few injection drug users (IDUs) receive methadone substitution therapy. Only 10% of eligible individuals receive antiretroviral therapy (ART). The appropriate resource allocation between these programs has not been studied. We estimated the effectiveness and cost-effectiveness of strategies for expanding methadone substitution therapy programs and ART in mixed HIV epidemics, using Ukraine as a case study.

METHODS AND FINDINGS

We developed a dynamic compartmental model of the HIV epidemic in a population of non-IDUs, IDUs using opiates, and IDUs on methadone substitution therapy, stratified by HIV status, and populated it with data from the Ukraine. We considered interventions expanding methadone substitution therapy, increasing access to ART, or both. We measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, infections averted, and incremental cost-effectiveness. Without incremental interventions, HIV prevalence reached 67.2% (IDUs) and 0.88% (non-IDUs) after 20 years. Offering methadone substitution therapy to 25% of IDUs reduced prevalence most effectively (to 53.1% IDUs, 0.80% non-IDUs), and was most cost-effective, averting 4,700 infections and adding 76,000 QALYs compared with no intervention at US$530/QALY gained. Expanding both ART (80% coverage of those eligible for ART according to WHO criteria) and methadone substitution therapy (25% coverage) was the next most cost-effective strategy, adding 105,000 QALYs at US$1,120/QALY gained versus the methadone substitution therapy-only strategy and averting 8,300 infections versus no intervention. Expanding only ART (80% coverage) added 38,000 QALYs at US$2,240/QALY gained versus the methadone substitution therapy-only strategy, and averted 4,080 infections versus no intervention. Offering ART to 80% of non-IDUs eligible for treatment by WHO criteria, but only 10% of IDUs, averted only 1,800 infections versus no intervention and was not cost effective.

CONCLUSIONS

Methadone substitution therapy is a highly cost-effective option for the growing mixed HIV epidemic in Ukraine. A strategy that expands both methadone substitution therapy and ART to high levels is the most effective intervention, and is very cost effective by WHO criteria. When expanding ART, access to methadone substitution therapy provides additional benefit in infections averted. Our findings are potentially relevant to other settings with mixed HIV epidemics. Please see later in the article for the Editors' Summary.

Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions

INTRODUCTION

Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination.

METHODS

Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price.

RESULTS

Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities.

DISCUSSION

Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

The cost-effectiveness of methadone maintenance as a health care intervention

AIMS

Cost-effectiveness analysis using life-years of survival as the measure of treatment benefit is widely used in the economic evaluation of health care interventions but has not been applied to substance abuse treatment. The cost-effectiveness of methadone maintenance was evaluated to demonstrate the feasibility of applying this method to substance abuse treatment.

DESIGN

A literature review was undertaken to determine the effect of methadone treatment on the rate of mortality associated with opiate addiction. Information was also obtained on the average cost and duration of treatment. A two-state Markov model was used to estimate the incremental effect of methadone on the life span and treatment cost of a cohort of 25-year-old heroin users.

FINDINGS

Providing opiate addicts with access to methadone maintenance has an incremental cost-effectiveness ratio of $5915 per life-year gained (that is, for every year of life that is saved by providing methadone to opiate addicts, an additional $5915 in treatment costs are incurred). One-way sensitivity analysis determined that the ratio was less than $10,000 per-life year over a wide range of modeling assumptions.

CONCLUSIONS

The ratio determined for methadone is lower than that of many common medical therapies, and well within the $50,000 threshold for judging cost-effectiveness. Even if decision makers do not wish use the same ratio that is applied to the general population, this method allows substance abuse treatment enhancements to be compared to improvements in health services offered to individuals with substance abuse disorders. Future work will require information on the impact of methadone treatment on the cost of health care and public programs, the indirect costs incurred by patients, and adjustments to reflect quality of life.

Changes in patterns of drug injection concurrent with a sustained reduction in the availability of heroin in Australia

Between 1996 and 2000, heroin was the drug most frequently injected in Australia, and viable heroin markets existed in six of Australia's eight jurisdictions. In 2001, there was a dramatic and sustained reduction in the availability of heroin that was accompanied by a substantial increase in its price, and a 14% decline in the average purity of seizures analysed by forensic laboratories. The shortage of heroin constitutes a unique natural experiment within which to examine the impact of supply reduction. This paper reviews one important correlate of the shortage, namely changes in patterns of illicit drug injection. A number of studies have consistently suggested that between 2000 and 2001, there was a sizeable decrease in both prevalence and frequency of heroin injection among injecting drug users. These changes were accompanied by increased prevalence and frequency of stimulant injection. Cocaine was favoured in NSW, the sole jurisdiction in which a cocaine market was established prior to the heroin shortage; whereas methamphetamine predominated in other jurisdictions. Some data suggest that, at least in the short-term, some drug injectors left the market altogether subsequent to the reduced heroin availability. However, the findings that (1) some former heroin users switched their drug preference to a stimulant; and (2) subsequently attributed this change to the reduced availability of heroin, suggests that reducing the supply of one drug may serve to increase the use of others. Given the differential harms associated with the use of stimulants and opiates, this possibility has grave implications for Australia, where the intervention and treatment system is designed primarily to accommodate opiate use and dependence.

Supply control and harm reduction: lessons from the Australian heroin 'drought'

AIMS

To examine the effects of supply-side drug law enforcement on the dynamics of the Australian heroin market and the harms associated with heroin.

SETTING

Around Christmas 2000, heroin users in Sydney and other large capital cities in Australia began reporting sudden and significant reductions in the availability of heroin. The changes, which appear to have been caused at least in part by drug law enforcement, provided a rare opportunity to examine the potential impact of such enforcement on the harm associated with heroin.

DESIGN

Data were drawn from a survey of 165 heroin users in South-Western Sydney, Australia; from the Drug Use Monitoring in Australia (DUMA) project; from NSW Health records of heroin overdoses; and from the Computerized Operational Policing System (COPS) database.

FINDINGS

Heroin price increased, while purity, consumption and expenditure on the drug decreased as a result of the shortage. The fall in overall heroin use was accompanied by a significant reduction in the rate of overdose in NSW. However, the health benefits associated with the fall in overdose may have been offset by an increase in the use of other drugs (mainly cocaine) since the onset of the heroin shortage. There does not appear to have been any enduring impact on crime rates as a result of the heroin 'drought'.

CONCLUSION

Supply control has an important part to play in harm reduction; however, proponents of supply-side drug law enforcement need to be mindful of the unintended adverse consequences that might flow from successfully disrupting the market for a particular illegal drug.

Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials

OBJECTIVE

To determine the cost utility of medical co-prescription of heroin compared with methadone maintenance treatment for chronic, treatment resistant heroin addicts.

DESIGN

Cost utility analysis of two pooled open label randomised controlled trials.

SETTING

Methadone maintenance programmes in six cities in the Netherlands.

PARTICIPANTS

430 heroin addicts.

INTERVENTIONS

Inhalable or injectable heroin prescribed over 12 months. Methadone (maximum 150 mg a day) plus heroin (maximum 1000 mg a day) compared with methadone alone (maximum 150 mg a day). Psychosocial treatment was offered throughout.

MAIN OUTCOME MEASURES

One year costs estimated from a societal perspective. Quality adjusted life years (QALYs) based on responses to the EuroQol EQ-5D at baseline and during the treatment period.

RESULTS

Co-prescription of heroin was associated with 0.058 more QALYs per patient per year (95% confidence interval 0.016 to 0.099) and a mean saving of 12,793 euros (8793 pounds sterling, 16,122 dollars) (1083 to 25,229 euros) per patient per year. The higher programme costs (16 222 euros; lower 95% confidence limit 15,084 euros) were compensated for by lower costs of law enforcement (- 4129 euros; upper 95% confidence limit - 486 euros) and damage to victims of crime (- 25,374 euros; upper 95% confidence limit - 16,625 euros). The results were robust for the use of national EQ-5D tariffs and for the exclusion of the initial implementation costs of heroin treatment. Completion of treatment is essential; having participated in any abstinence treatment in the past is not.

CONCLUSIONS

Co-prescription of heroin is cost effective compared with treatment with methadone alone for chronic, treatment resistant heroin addicts.

Rates of abuse of tramadol remain unchanged with the introduction of new branded and generic products: results of an abuse monitoring system, 1994-2004

PURPOSE

The analgesic Tramadol HCl (Ultram) was approved in 1994 as a non-scheduled drug under the CSA provided that a novel risk-management program would be developed by an Independent Steering Committee (ISC). The risk-management program began in 1995 with the launch of Ultram, and has been modified over the past decade to accommodate Ultracet (Ultram and acetaminophen) in 2001 and generic tramadol in 2002. This provided a unique opportunity to study the potential changes in abuse as the generic and combination products became available.

METHODS

To proactively detect cases of abuse and diversion, the ISC developed a comprehensive questionnaire which was completed quarterly by an extensive network of drug abuse experts (n = 309) and police agencies (n = 100) who were asked to indicate how many diversion cases involving Ultram, Ultracet, and generic tramadol were identified during the preceding 3 months and what were the ten most commonly diverted drugs in their catchment area during that period.

RESULTS AND CONCLUSIONS

The data generated demonstrate that the abuse of tramadol remained very low despite new branded and generic formulations. Contrary to the hypothesis that cheaper generic drugs would lead to higher rates of abuse, we found no increase in abuse with the introduction of generic tramadol. Ultracet abuse rates, unlike those found with other widely used hydrocodone and oxycodone combination products, have been even lower than that observed for tramadol. Since the FDA has now mandated that proactive risk-management plans be implemented for new drugs, the tramadol risk-management plan may be useful as a prototypic model which can be modified to accommodate other drugs with abuse potential.

Opioid purchases and expenditure in nine western European countries: 'are we killing off morphine?'

BACKGROUND

In clinical practice the major role of opioid drugs is the management of malignant and nonmalignant pain. The primary aim of this study is to evaluate the trend in sales of four opioid analgesic drugs (codeine, tramadol, morphine, fentanyl), from wholesalers to community pharmacies, as an indicator of opioid consumption in nine European countries in 2001, 2002 and 2003. Secondary aims are to compare: (a) the amount of each drug purchased by different countries in 2003; (b) the average price for each drug in the different countries in 2003; and (c) the total expenditure for each opioid from 2001 to 2003.

METHODS

Data from the Statistical Report on drugs purchased by pharmacies was supplied by IMS Health, an internationally accepted information provider for the pharmaceutical and health care industries.

FINDING

In the period 2001 2003, while the percentage increase of purchases of fentanyl and tramadol was considerable, that of morphine was the lowest in most of the nine countries. The largest consumer of codeine was the UK and of tramadol was Belgium. The consumption of morphine was the lowest reported in all the countries together and was three times lower than that of transdermal fentanyl. There was a high variability in the costs of the opioids among the different countries. In 2003, the total expenditure for fentanyl reached the highest total expenditure [corrected] followed by codeine. Morphine presents the lowest expenditure in all nine countries and over all three years.

INTERPRETATION

These results open up many questions. What factors influence opioid purchasing and costs in these European countries? It would be interesting to have the answers from those people who know the actual situation in the individual countries.

What do we get for our money? Cost-effectiveness of adding contingency management

AIMS

To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse.

DESIGN

Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial.

SETTING

Two community-based treatment centers.

PARTICIPANTS

Patients (n = 120) enrolled in out-patient treatment for cocaine abuse.

INTERVENTION

Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won.

MEASUREMENTS

Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence; (2) percentage completing treatment; and (3) percentage of samples drug-free.

FINDINGS

The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis.

CONCLUSIONS

Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.

Decreased heroin availability in Sydney in early 2001

AIM

To examine the veracity of reports of a substantial decrease in the availability of heroin in Sydney in January 2001.

DESIGN

Cross-sectional survey.

SETTING

Sydney, Australia.

PARTICIPANTS

Forty-one injecting drug users (IDUs) and 10 key informants (KIs).

FINDINGS

Almost all IDUs (93%) reported that heroin was harder to obtain at the time of interview (mid-February 2001) than it was before Christmas 2000 and KIs concurred. IDUs (83%) and KIs (70%) also reported that the price of heroin had increased since Christmas, and that the purity of heroin had decreased (IDUs 73%; KIs 80%). Almost all IDUs reported a reduction in their heroin use and a subsequent increase in other drug use, particularly cocaine, benzodiazepines and cannabis. Similar reports about IDUs came from nine of the 10 KIs. Over half the KIs reported an increase in both property and violent crime as a result of the heroin shortage. This crime was reportedly occurring mainly between heroin suppliers and/or IDUs. Reports from other Australian jurisdictions suggest that the shortage was not specific to Sydney.

CONCLUSIONS

The reduction in the availability of heroin provides a unique opportunity to investigate the impact of supply reduction.

Randomized trial of supervised injectable versus oral methadone maintenance: report of feasibility and 6-month outcome

AIM

To assess the feasibility of a randomized clinical trial of supervised injectable versus oral methadone maintenance and to assess medium-term treatment outcomes.

DESIGN

Randomized clinical trial of supervised injectable versus supervised oral methadone maintenance treatment (MMT). Trial participants were dependent illicit opiate injectors allocated at intake to supervised injectable or oral methadone maintenance treatment.

SETTING

Specialist addictions treatment centre in South London.

SUBJECTS

Forty dependent illicit opiate injectors seeking methadone maintenance treatment.

INTERVENTIONS

Daily supervised injectable and oral methadone maintenance, delivered at the treatment centre.

MAIN OUTCOME MEASURES

Frequency of illicit heroin use and frequency of illicit drug injecting during 30 days before intake to treatment and prior to 6-month follow-up.

SECONDARY OUTCOME MEASURES

frequency of use of illicit methadone, crack cocaine, benzodiazepines and alcohol, physical and psychological health symptoms and acquisitive crime.

RESULTS

Injectable and oral MMT were both generally acceptable to the study participants: there was a high level of agreement to enter the randomized trial, and subsequent retention in treatment was good. The average number of days of illicit heroin use reduced from 22.2 to 7.6 for the injectable MMT group and from 22.4 to 8.7 for the oral MMT group. The average number of days of illicit injecting reduced from 25.7 to 10.8 days for the injectable group and from 20.1 to 11.9 days for the oral group. Patients' physical and psychological health symptoms and involvement in acquisitive crime also reduced in both groups. Treatment satisfaction ratings at follow-up were higher among patients in the injectable MMT group. The ratio for the actual medication costs between injectable and oral MMT was 6.8:1, and for the direct operational costs was 4.7:1. There was some evidence of a differential patient response with greater reductions in heroin use occurring among patients who were daily illicit injectors and had poorer psychological and physical health (at entry) who were allocated to injectable MMT.

CONCLUSIONS

Conduct of the trial has demonstrated that it is feasible to implement supervised injectable methadone maintenance treatment in the context of (although separate from) a specialist oral methadone maintenance service. Patients assigned to receive either supervised injectable or oral MMT had broadly equivalent, positive during-treatment outcomes at 6-month follow-up. Future studies should seek to identify patient characteristics which are linked to good outcome in injectable MMT. Practical evidence-based guidance to physicians about determining which patients are more suitable for injectable MMT is urgently needed.

Behavioral economic analysis of opioid consumption in heroin-dependent individuals: effects of unit price and pre-session drug supply

Behavioral economic analysis has been used to investigate factors underlying drug consumption in laboratory animals and, increasingly, in human drug abusers. However, there are few studies in heroin abusers, especially those who are not in treatment; such studies may be valuable for understanding the mechanisms of persistent drug use. This study investigated effects of unit price (UP) and pre-session supply of hydromorphone (HYD) on choice and consumption of HYD. Heroin-dependent research volunteers (n=13) stabilized on buprenorphine 8 mg/day completed this eight-session inpatient study. In sessions 1-2, participants sampled two total HYD doses (12 and 24 mg IM) that could be earned in later sessions. In each of the final six sessions, volunteers were given access to a 12-trial choice progressive ratio schedule lasting 3h. On each trial, volunteers could earn a HYD unit dose (1 or 2 mg, for a maximum of 12 or 24 mg, respectively) or money (US dollars 2, for a maximum of US dollars 24). Fixed ratio requirements increased exponentially, generating 24 unit prices for behavioral economic analysis. Before some choice sessions, volunteers could choose (FR 1) to receive extra HYD (12 or 24 mg; at 0915), whereas on other days no supplement was available. HYD choice and peak responding (breakpoint, O(max)) measures increased with unit dose, decreased with pre-session supplements, and were greater among volunteers who used cocaine prior to the experiment. Taking pre-session supplements decreased P(max) and made group-percent HYD consumption more demand-elastic. Consumption was functionally equivalent at differing FR/unit dose combinations. Thus, opioid demand in heroin-dependent individuals not in treatment is a function of drug supply, unit price, and cocaine use.

Chronic pain of spinal origin: the costs of intervention

The cost of chronic benign spinal pain is large and growing. The costs of interventional treatment for spinal pain were at a minimum of $13 billion (U.S. dollars) in 1990, and the costs are growing at least 7% per year. Medical treatment of chronic pain costs $9000 to $19,000 per person per year. The costs of interventional therapy is calculated. Methods of evaluating differential treatments in terms of costs are described. Cost-minimization versus cost-effectiveness approaches are described. Spinal cord stimulation and intraspinal drug infusion systems are alternatives that can be justified on a cost basis. Cost minimization analysis suggests that epidural injections under fluoroscopy may not be justified by the current literature.

Implementing Buprenorphine Treatment in Community Settings in Australia: Experiences from the Buprenorphine Implementation Trial

Buprenorphine was registered in Australia as a maintenance and detoxification agent for the management of opioid dependence in November, 2000, and became widely available in August, 2001. This paper provides an overview of key developments in the introduction of buprenorphine treatment in Australia, with an emphasis upon the delivery of services in community-based (primary care) settings. A central study in this work was the Buprenorphine Implementation Trial (BIT), a randomized, controlled trial comparing buprenorphine and methadone maintenance treatment delivered under naturalistic conditions by specialist and community-based service providers (general practitioners and community pharmacists) in 139 subjects across nineteen treatment sites. In addition to conventional patient outcome measures (treatment retention, drug use, psychosocial functioning, and cost effectiveness), the BIT study also involved the development and evaluation of clinical guidelines, training programs for clinicians, and client literature, which are described here. Integration of treatment systems (methadone with buprenorphine, specialist and primary-care programs) and factors thought to be important in the uptake of buprenorphine treatment in Australia since registration are discussed.

Benefits and costs of methadone treatment: results from a lifetime simulation model

Several studies have examined the benefits and costs of drug treatment; however, they have typically focused on the benefits and costs of a single treatment episode. Although beneficial for certain analyses, the results are limited because they implicitly treat drug abuse as an acute problem that can be treated in one episode. We developed a Monte Carlo simulation model that incorporates the chronic nature of drug abuse. Our model represents the progression of individuals from the general population aged 18-60 with respect to their heroin use, treatment for heroin use, criminal behavior, employment, and health care use. We also present three model scenarios representing an increase in the probability of going to treatment, an increase in the treatment length of stay, and a scenario in which drug treatment is not available to evaluate how changes in treatment parameters affect model results. We find that the benefit-cost ratio of treatment from our lifetime model (37.72) exceeds the benefit-cost ratio from a static model (4.86). The model provides a rich characterization of the dynamics of heroin use and captures the notion of heroin use as a chronic recurring condition. Similar models can be developed for other chronic diseases, such as diabetes, mental illness, or cardiovascular disease.

Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification

AIMS

To compare the cost and cost-effectiveness of methadone maintenance treatment and 180-day methadone detoxification enriched with psychosocial services.

DESIGN

Randomized controlled study conducted from May 1995 to April 1999.

SETTING

Research clinic in an established drug treatment program.

PARTICIPANTS

One hundred and seventy-nine adults with diagnosed opioid dependence. Intervention Patients were randomized to methadone maintenance (n = 91), which required monthly 1 hour/week of psychosocial therapy during the first 6 months or 180-day detoxification (n = 88), which required 3 hours/week of psychosocial therapy and 14 education sessions during the first 6 months.

MEASUREMENTS

Total health-care costs and self-reported injection drug use. A two-state Markov model was used to estimate quality-adjusted years of survival. Findings Methadone maintenance produced significantly greater reductions in illicit opioid use than 180-day detoxification during the last 6 months of treatment. Total health-care costs were greater for maintenance than detoxification treatment ($7564 versus $6687; P < 0.001). Although study costs were significantly higher for methadone maintenance than detoxification patients ($4739 versus $2855, P < 0.001), detoxification patients incurred significantly higher costs for substance abuse and mental health care received outside the study. Methadone maintenance may provide a modest survival advantage compared with detoxification. The cost per life-year gained is $16 967. Sensitivity analysis revealed a cost-effectiveness ratio of less than $20 000 per quality-adjusted life-year over a wide range of modeling assumptions.

CONCLUSIONS

Compared with enriched detoxification services, methadone maintenance is more effective than enriched detoxification services with a cost-effectiveness ratio within the range of many accepted medical interventions and may provide a survival advantage. Results provide additional support for the use of sustained methadone therapy as opposed to detoxification for treating opioid addiction.

Treatment choice, duration, and cost in patients with interstitial cystitis and painful bladder syndrome

INTRODUCTION AND HYPOTHESIS

In order to better understand provider treatment patterns for interstitial cystitis (IC)/painful bladder syndrome, we sought to document the therapies utilized and their associated expenditures using a national dataset.

METHODS

A cohort was created by applying the ICD-9 diagnosis of IC (595.1) to INGENIX claims for the year 1999. Subjects were followed for 5 years, and patterns of care and related expenditures were evaluated.

RESULTS

Of 553,910 adults insured in 1999, 89 subjects had a diagnosis of IC with 5-year follow-up data. All subjects were treated with oral medication(s), 26% received intravesical treatments, and 22% underwent hydrodistension. Total expenditures per subject were $2,808.

CONCLUSIONS

The majority of IC expenditures were attributable to oral medical therapy. Hydrodistension and intravesical instillations were utilized in less than 25% of patients. Hydrodistension was used more frequently among subjects with a new diagnosis; this may reflect its utilization as part of a diagnostic algorithm.

On-site medical care in methadone maintenance: associations with health care use and expenditures

To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (>/=6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients (n = 423, with 1,161 person-years of observation). After adjustment, linked care participants had more outpatient visits (p < .001), fewer emergency department (ED) visits (24% vs. 33%, p = .02) and fewer hospitalizations (27% vs. 40%, p = .002) than the "neither" group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Long-term drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures.

Medicaid coverage, methadone maintenance, and felony arrests: outcomes of opiate treatment in two states

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

Value for money in drug treatment: economic evaluation of prison methadone

BACKGROUND

Although methadone maintenance treatment in community settings is known to reduce heroin use, HIV infection and mortality among injecting drug users (IDU), little is known about prison methadone programs. One reason for this is the complexity of undertaking evaluations in the prison setting. This paper estimates the cost-effectiveness of the New South Wales (NSW) prison methadone program.

METHODS

Information from the NSW prison methadone program was used to construct a model of the costs of the program. The information was combined with data from a randomised controlled trial of provision of prison methadone in NSW. The total program cost was estimated from the perspective of the treatment provider/funder. The cost per heroin free day, compared with no prison methadone, was estimated. Assumptions regarding resource use were tested through sensitivity analysis.

RESULTS

The annual cost of providing prison methadone in NSW was estimated to be 2.9 million Australian dollars (or 3,234 Australian dollars per inmate per year). The incremental cost effectiveness ratio is 38 Australian dollars per additional heroin free day.

CONCLUSIONS

From a treatment perspective, prison methadone is no more costly than community methadone, and provides benefits in terms of reduced heroin use in prisons, with associated reduction in morbidity and mortality.

An analysis of optimal resource allocation for prevention of infection with human immunodeficiency virus (HIV) in injection drug users and non-users

Millions of dollars are spent annually to prevent infection with human immunodeficiency virus (HIV) without a thorough understanding of the most effective way to allocate these resources. The authors' objective was to determine the allocation of new resources among prevention programs targeted to a population of injection drug users (IDUs) and a population of non-injection drug users (non-IDUs) that would minimize the total number of incident cases of HIV infection over a given time horizon. They developed a dynamic model of HIV transmission in IDUs and non-IDUs and estimated the relationship between prevention program expenditures and reductions in HIV transmission. They evaluated three prevention programs: HIV testing with routine counseling, HIV testing with intensive counseling, and HIV testing and counseling linked to methadone maintenance programs. They modeled a low-risk IDU population (5% HIV prevalence) and a moderate-risk IDU population (10% HIV prevalence). For different available budgets, they determined the allocation of resources among the prevention programs and populations that would minimize the number of new cases of HIV infection over a five-year period, as well as the incremental value of additional prevention funds. The study framework provides a quantitative, systematic approach to funding programs to prevent HIV infection that accounts for HIV transmission dynamics, population size, and the costs and effectiveness of the interventions in reducing HIV transmission. The approach is general and can be used to evaluate a broader group of prevention programs and risk populations. This framework thus could enable policy makers and clinicians to identify a portfolio of programs that provide, collectively, the most benefit for a given budget.