Cost-effectiveness of full and partial opioid agonists for opioid use disorder in outpatient settings: United States healthcare sector perspective

INTRODUCTION

Studies show that medications for opioid use disorder (MOUD) reduce illicit opioid use, emergency healthcare services, opioid-related overdose, and death. However, few studies have investigated the long-term cost-effectiveness of MOUD in office-based opioid treatment (OBOT) and opioid treatment program (OTP) settings. We aimed to estimate the cost, utility, quality-adjusted life years gained (QALYs), and incremental cost-effectiveness ratios (ICERs) of three MOUD compared to each other and counseling without medication from a US healthcare sector perspective.

METHODS

Our study developed a Markov model to conduct a cost-effectiveness analysis of counseling and three MOUD in the OBOT and OTP settings: sublingual buprenorphine/naloxone (BUPNX), buprenorphine extended-release (XR-BUP) injection, and oral methadone. The model included five health states representing combinations of receiving or off treatment while either using or not actively using illicit opioids, and death. The cycle length was one month; the time-horizon was ten years. The study obtained model inputs from systematic reviews of published literature and public data. A 3 % annual discount rate was applied to cost and utility calculation. The primary outcomes included total costs, life-years (LYs), QALYs, and ICERs. We also conducted a scenario analysis using a hypothetical OBOT outpatient setting with methadone.

RESULTS

In the base-case OBOT setting, the total costs and QALYs, respectively, were counseling $22,848, 5.60; BUPNX $29,875, 5.82; and XR-BUP $63,936, 5.87. ICERs were $32,345/QALY (BUPNX vs. counseling) and $625,858/QALY (XR-BUP vs BUPNX). In the OTP setting, the total costs of counseling, methadone, BUPNX, and XR-BUP were $20,124, $27,000, $33,500, and $75,272, respectively. QALYs of methadone were 5.86. QALYs of counseling, BUPNX, and XR-BUP remained the same as in the OBOT setting. Incremental ICERs were $26,714/QALY (methadone vs counseling) and $3,337,623/QALY (XR-BUP vs methadone). BUPNX was dominated by methadone. In the scenario analysis, BUPNX was also dominated by methadone.

CONCLUSIONS

Outpatient MOUD resulted in important gains in quality of life and life expectancy. In both OBOT and OTP settings, XR-BUP was not cost-effective. BUPNX was cost-effective in the OBOT setting, while it was dominated by methadone in the OTP setting. The cost-effectiveness of BUPNX and XR-BUP could be enhanced if the costs of these medications were reduced.

Co-located Heroin Assisted Treatment within primary care: A preliminary analysis of the implications for healthcare access, cost, and treatment delivery in the UK

BACKGROUND

The UK is experiencing its highest rate of drug related deaths in 25 years. Poor and inconsistent access to healthcare negatively impacts health outcomes for people who use drugs. Innovation in models of care which promote access and availability of physical treatment is fundamental. Heroin Assisted Treatment (HAT) is a treatment modality targeted at the most marginalised people who use drugs, at high risk of mortality and morbidity. The first service-provider initiated HAT service in the UK ran between October 2019 and November 2022 in Middlesbrough, England. The service was co-located within a specialist primary care facility offering acute healthcare treatment alongside injectable diamorphine.

METHODS

Analysis of anonymised health records for healthcare costs (not including drug treatment) took place using descriptive statistics prior and during engagement with HAT, at both three (n=15) and six (n=12) months. Primary outcome measures were incidents of wound care, skin and soft tissue infections (SSTIs), overdose (OD) events, unplanned overnight stays in hospital, treatment engagement (general and within hospital care settings) and ambulance incidents. Secondary outcome measures were costs associated with these events.

RESULTS

A shift in healthcare access for participants during HAT engagement was observed. HAT service attendance appeared to support health promoting preventative care, and reduce reactive reliance on emergency healthcare systems. At three and six months, engagement for preventative wound care and treatment for SSTIs increased at the practice. Unplanned emergency healthcare interactions for ODs, overnight hospital stays, serious SSTIs, and ambulance incidents reduced, and there was an increase in treatment engagement (i.e. a reduction in appointments which were not engaged with). There was a decrease in treatment engagement in hospital settings. Changes in healthcare utilisation during HAT translated to a reduction in healthcare costs of 58% within six months compared to the same timeframe from the period directly prior to commencing HAT.

CONCLUSION

This exploratory study highlights the potential for innovative harm reduction interventions such as HAT, co-located with primary care services, to improve healthcare access and engagement for a high-risk population. Increased uptake of primary healthcare services translated to reductions in emergency healthcare use and associated costs. Although costs of HAT provision are substantial, the notable cost-savings in health care should be an important consideration in service implementation planning.

Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design

BACKGROUND

The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown.

METHODS

We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD.

RESULTS

Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone.

CONCLUSIONS

Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.

The effectiveness and value of digital health technologies as an adjunct to medication-assisted therapy for opioid use disorder

DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Whittington, Campbell, and Pearson are employed by ICER. Tice reports contracts to his institution, University of California, San Francisco, from ICER during the conduct of this study.

Associations Between Copays, Coverage Limits for Opioid Use Disorder Medications, and Prescribing in Medicaid, 2018

BACKGROUND

Opioid use disorder (OUD) affects millions of Americans, but only a fraction receive treatment. Many patients with OUD are enrolled in Medicaid, but elements of different state Medicaid programs' drug benefit designs may impact patients' access to life-saving care.

OBJECTIVE

To describe medication for OUD (mOUD) use in Medicaid and examine the relationship between mOUD use and state drug benefit design plans.

DESIGN/SUBJECTS

Cross-sectional study using Medicaid State Drug Utilization Data from 2018 to quantify office-based mOUD and the Medicaid Behavioral Health Services Database to extract copay amounts and coverage limits for mOUD. We excluded states with <5% coverage and assessed for associations between copays or coverage limits and mOUD dispensing using simple linear regression.

MEASURES

Proportion of mOUD prescriptions relative to all prescriptions, opioid prescriptions, and the state-level prevalence of pain reliever use disorder and association between copays, coverage limits and these proportions.

RESULTS

There was substantial variability in mOUD use. Although state Medicaid drug benefit designs also varied, we found no significant relationship between copay requirements (yes/no), coverage limits (yes/no), copay amount ($0-$0.99 vs. $1 or more), and mOUD utilization measures.

CONCLUSIONS

Substantial state-level variation exists in mOUD use, but we did not find a significant association between copays or coverage limits and use in Medicaid. Further research is needed to assess other potential impacts of mOUD drug benefit design elements in Medicaid.

Payer strategies to ensure access to care for individuals with opioid use disorder during COVID-19

As the coronavirus disease 2019 (COVID-19) pandemic threatens to worsen the opioid crisis, payers must rapidly deploy policies to ensure care for individuals with opioid use disorder.

Factors Affecting Buprenorphine Utilization and Spending in Medicaid, 2002-2018

OBJECTIVE

Buprenorphine is an essential medication for the treatment of opioid use disorder (OUD), but studies show it has been underused over the last 2 decades. We sought to evaluate utilization of and spending on buprenorphine formulations in Medicaid and to evaluate the impact of key market and regulatory factors affecting availability of different formulations and generic versions.

METHODS

We first identified all buprenorphine formulations approved by the Food and Drug Administration for OUD using Drugs@FDA. We then used National Drug Codes to identify each drug in the Medicaid State Drug Utilization Data and extracted annual utilization rates and spending between 2002 and 2018 by drug and according to whether a brand-name or generic version was dispensed. We compared these trends to market and regulatory factors that affected competition, which we identified through searching the Federal Register, Westlaw, PubMed, and Google News.

RESULTS

Brand-name buprenorphine-naloxone sublingual tablet and film formulations (Suboxone) were dispensed 2.7 times more (n = 634 213 140) and reimbursed 4.4 times more (n = $4 440 556 473) than all other formulations combined (n = 237 769 689; $1 018 988 133). We identified numerous market and regulatory factors that contributed to an estimated 9-year delay in generic versions of the tablet formulation and 6-year delay for generic versions of the film formulation.

CONCLUSIONS

Brand-name buprenorphine formulations have been widely used in Medicaid, leading to substantial costs, in part because generic versions were delayed by multiple years owing to market and regulatory factors. Timely availability of low-cost generics could have helped encourage OUD treatment with buprenorphine during the height of the opioid crisis.

Economic Evaluation in Opioid Modeling: Systematic Review

OBJECTIVES

The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature.

METHODS

A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study.

RESULTS

The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs.

CONCLUSION

The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.

Cost and cost-effectiveness of interim methadone treatment and patient navigation initiated in jail

BACKGROUND

Individuals with opioid use disorder (OUD) who are released from pre-trial detention in jail have a high risk of opioid relapse. While several interventions for OUD initiated during incarceration have been studied, few have had an economic evaluation. As part of a three-group randomized trial, we estimated the cost and cost-effectiveness of a negative urine opioid test. Detainees were assigned to interim methadone (IM) in jail with continued methadone treatment post-release with and without 3 months of post-release patient navigation (PN) compared to an enhanced treatment-as-usual group.

METHODS

We implemented a micro-costing approach from the provider's perspective to estimate the cost per participant in jail and over the 12 months post-release from jail. Economic data included jail-based and community-based service utilization, self-reported healthcare utilization and justice system involvement, and administrative arrest records. Our outcome measure is the number of participants with a negative opioid urine test at their 12-month follow-up. We calculated incremental cost-effectiveness ratios (ICERs) for intervention costs only and costs from a societal perspective.

RESULTS

The average cost of providing patient navigation services per individual beginning in jail and continuing in the community was $283. We find that IM is dominated by ETAU and IM + PN. Per additional participant with a negative opioid urine test, the ICER for IM + PN including intervention costs only is $91 and $305 including societal costs.

CONCLUSIONS

IM + PN is almost certainly the cost-effective choice from both an intervention provider and societal perspective.

The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico

BACKGROUND

In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use.

METHODS

PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision.

RESULTS

At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment.

CONCLUSION

Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.

Responses among substance abuse treatment providers to the opioid epidemic in the USA: Variations in buprenorphine and methadone treatment by geography, operational, and payment characteristics, 2007-16

Objective

To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers.

Methods

Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007–16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007–16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment.

Results

Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035).

Conclusions

Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs

AIMS

To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

DESIGN

HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

SETTING

Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

PARTICIPANTS

PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

INTERVENTIONS AND COMPARATOR

Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

MEASUREMENTS

Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

FINDINGS

For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

CONCLUSIONS

Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

Generic Drug Policy and Suboxone to Treat Opioid Use Disorder

Despite some improvements in access to evidence-based medications for opioid use disorder, treatment rates remain low at under a quarter of those with need. High costs for brand name products in these medication markets have limited the volume of drugs purchased, particularly through public health insurance and grant programs. Brand firm anti-competitive practices around the leading buprenorphine product Suboxone - including product hops, citizen petitions and Risk Evaluation and Mitigation Strategy abuses - helped to maintain high prices by extending brand exclusivity periods and hindering generic drug entry. Remedies to address costly anti-competitive activities include adoption of the proposed CREATES Act and modernization of the Hatch-Waxman Act by the Congress, and implementation of substantive modifications to the Food and Drug Administration citizen petition filing procedures. Given the persistence of these abuses, prescriptive changes are favorable to the procedural and clarifying steps thus far favored by the federal government. Extrapolating from the 37% price declines attributable to generic entry for buprenorphine tablets in 2011, our calculations suggest that implementing these remedies to facilitate generic competition with Suboxone film would have resulted in savings of approximately $703 million overall and $203 million to Medicaid in 2017.

Opioid agonist therapy during residential treatment of opioid use disorder: Cohort study on access and outcomes

OBJECTIVE

To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion.

DESIGN

Retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016.

MAIN OUTCOME MEASURES

Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models.

RESULTS

Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38).

CONCLUSION

This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT-the first-line treatment of opioid use disorder-while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.

Physicians as Mediators of Health Policy: Acceptance of Medicaid in the Context of Buprenorphine Treatment

Increasing numbers of individuals with opioid use disorder (OUD) are insured by Medicaid. Little is known about whether providers of buprenorphine, an evidence-based OUD pharmacotherapy, accept this type of payment. Data are scant regarding whether Medicaid acceptance varies by physician and state-level characteristics. To address these gaps, national survey data from 1174 buprenorphine-prescribing physicians (BPPs) and state characteristics were examined in a multi-level model of Medicaid acceptance. Only 52.0% of BPPs accepted Medicaid for buprenorphine-related office visits. Specialists in addiction and psychiatry were significantly less likely to accept Medicaid than other specialties, as were BPPs delivering buprenorphine in individual medical practice. Perceived adequacy of Medicaid reimbursement was positively associated with accepting Medicaid. Medicaid acceptance was not associated with states' implementation of the Medicaid expansion. Individuals who are covered by Medicaid may face barriers to accessing buprenorphine treatment, which has high public health significance given the ongoing opioid epidemic.

Clinical effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: a study protocol for a pragmatic cluster randomised trial

INTRODUCTION

Hepatitis C virus (HCV) infection affects 0.7% of the general population, and up to 40% of people prescribed opioid substitution therapy (OST) in Scotland. In conventional care, less than 10% of OST users are tested for HCV and less than 25% of these initiate treatment. Community pharmacists see this group frequently to provide OST supervision. This study examines whether a pharmacist-led 'test & treat' pathway increases cure rates for HCV.

METHODS AND ANALYSIS

This protocol describes a cluster-randomised trial where 60 community pharmacies provide either conventional or pharmacy-led care. All pharmacies offer dried blood spot testing (DBST) for HCV. Participants have attended the pharmacy for OST for 3 months; are positive for HCV genotype 1 or 3; are not co-infected with HIV and/or hepatitis B; have no decompensated liver disease; are not pregnant. For conventional care, pharmacists refer HCV-positive participants to a local centre for assessment. In the pharmacy-led arm, pharmacists assess participants themselves in the pharmacy. Drug prescribing is by nurse prescribers (conventional arm) or pharmacist prescribers (pharmacy-led arm). Treatment in both arms is delivered as daily modified directly observed therapy in a pharmacy. Primary trial outcome is number of sustained virological responses at 12 weeks after treatment completion. Secondary trial outcomes are number of tests taken; treatment uptake; completion; adherence; re-infection. An economic evaluation will assess potential cost-effectiveness. Qualitative research interviews with clients and health professionals assess acceptability of a pharmacist-led pathway.

ETHICS AND DISSEMINATION

This protocol has been ethically approved by the East of Scotland Research Ethics Committee 2 (15/ES/0086) and complies with the Declaration of Helsinki and principles of Good Clinical Practice. Caldicott guardian approval was given on 16 December 2016 to allow NHS Tayside to pass information to the cluster community pharmacies about the HCV test status of patients that they are seeing to provide OST supervision. NHS R&D approvals have been obtained from each health board taking part in the study. Informed consent is obtained before study enrolment and only anonymised data are stored in a secured database, enabling an audit trail. Results will be submitted to international peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT02706223; Pre-results.

21st Century Cures for the Opioid Crisis: Promise, Impact, and Missed Opportunities

Signed into law in 2016, the landmark 21stCentury Cures Act is as complex as it is divisive. For some stakeholders, including patient groups and representatives of regulated industries, the Act represented a major leap forward in pharmaceutical innovation, human subjects protections, and numerous other provisions. For other observers, this legislation was characterized as a major rollback in important regulations, which would leave patients worse off and the payers holding the bag. The one element of the Act that was relatively uncontroversial covered a number of provisions related to addressing the opioid crisis.

This was by design. Provisions related to this issue were not part of the original legislation and were added to win over additional members of Congress who needed to be brought along to support the legislation. Many of the statute's provisions were intertwined with the Comprehensive Addiction Recovery Act (“CARA”) passed previously, but that legislation was stripped of much of its funding for opioid crisis response.

Healthcare utilization and costs associated with treatment for opioid dependence

OBJECTIVE

Opioid use disorder (OUD) can be managed with medication assisted therapy (MAT) (methadone [MET], buprenorphine [BUP], or extended-release naltrexone [XR-NTX]) or counseling alone (non-pharmacological therapy [NPT]). The objective of this study was to evaluate healthcare resource utilization and costs associated with XR-NTX compared with alternative treatments for opioid dependence.

METHODS

Adults with a diagnosis of opioid dependence who initiated treatment with XR-NTX, BUP, MET, or NPT between January 1, 2011 and December 31, 2014 were identified in the Truven Health MarketScan Commercial administrative claims database. Healthcare resource utilization, costs (inpatient [IP], emergency department [ED], outpatient [OP], and pharmacy) and adherence were evaluated for each cohort during 12-month baseline and follow-up periods.

RESULTS

A total of 29,235 patients were included in the analysis; 1,041, 20,566, 745, and 6,883 received XR-NTX, BUP, MET, and NPT, respectively. Patients in the XR-NTX cohort were significantly younger and had more comorbidities compared with the other cohorts. Patients in the XR-NTX group had the largest percentage decrease in IP and ED utilization and costs from baseline to follow-up. OP and pharmacy costs increased significantly from baseline to follow-up for all cohorts. Overall, there was no significant change in total healthcare costs for the XR-NTX group, whereas the costs increased significantly for other groups (BUP = +43%, MET = +47.7%, NPT = +38.8%).

CONCLUSIONS

Healthcare resource utilization and costs increased from baseline to follow-up in BUP, MET, and NPT patients, whereas patients receiving XR-NTX experienced no such increase. This analysis suggests there may be economic value in the use of XR-NTX for OUD.

State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder

OBJECTIVE

As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

METHODS

This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.

RESULTS

State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).

CONCLUSIONS

State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

Cost-effectiveness of emergency department-initiated treatment for opioid dependence

BACKGROUND AND AIMS

In a recent randomized trial, patients with opioid dependence receiving brief intervention, emergency department (ED)-initiated buprenorphine and ongoing follow-up in primary care with buprenorphine (buprenorphine) were twice as likely to be engaged in addiction treatment compared with referral to community-based treatment (referral) or brief intervention and referral (brief intervention). Our aim was to evaluate the relative cost-effectiveness of these three methods of intervening on opioid dependence in the ED.

DESIGN

Measured health-care use was converted to dollar values. We considered a health-care system perspective and constructed cost-effectiveness acceptability curves that indicate the probability each treatment is cost-effective under different thresholds of willingness-to-pay for outcomes studied.

SETTING

An urban ED in the United States.

PARTICIPANTS

Opioid-dependent patients aged 18 years or older.

MEASUREMENTS

Self-reported 30-day assessment data were used to construct cost-effectiveness acceptability curves for patient engagement in formal addiction treatment at 30 days and the number of days illicit opioid-free in the past week.

FINDINGS

Considering only health-care system costs, cost-effectiveness acceptability curves indicate that at all positive willingness-to-pay values, ED-initiated buprenorphine treatment was more cost-effective than brief intervention or referral. For example, at a willingness-to-pay threshold of $1000 for 30-day treatment engagement, we are 79% certain ED-initiated buprenorphine is most cost-effective compared with other studied treatments. Similar results were found for days illicit opioid-free in the past week. Results were robust to secondary analyses that included patients with missing cost data, included crime and patient time costs in the numerator, and to changes in unit price estimates.

CONCLUSION

In the United States, emergency department-initiated buprenorphine intervention for patients with opioid dependence provides high value compared with referral to community-based treatment or combined brief intervention and referral.

Expanding co-payment for methadone maintenance services in Vietnam: the importance of addressing health and socioeconomic inequalities

BACKGROUND

Ensuring high enrollment while mobilizing resources through co-payment services is critical to the success of the methadone maintenance treatment (MMT) program in Vietnam. This study assessed the willingness of patients to pay (WTP) for different MMT services delivery models and determined its associated factors.

METHODS

A facility based survey was conducted among 1016 MMT patients (98.7% male, 42% aged 35 or less, and 67% living with spouse) in five MMT clinics in Hanoi and Nam Dinh province in 2013. Socioeconomic, HIV and health status, history of drug use and rehabilitation, and MMT experience were interviewed. WTP was assessed using contingent valuation method, including a set of double-bounded binary questions and a follow-up open-ended question. Point and interval data models were used to estimate maximum willingness to pay.

RESULTS

95.5% patients were willing to pay for MMT at the monthly mean price of US$ 32 (95%CI = 28-35). Higher WTP was associated with higher level of educational attainment, higher income, male sex, and had high expenses on opiates prior to MMT. Patients who reported having any problem in Pain/ Discomfort, and who did not have outpatient care last year were willing to pay less for MMT than others.

CONCLUSION

High level of WTP supports the co-payment policies as a strategy to mobilize resources for the MMT program in Vietnam. However, it is necessary to ensure equalities across patient groups by acknowledging socioeconomic status of different settings and providing financial supports for disadvantaged patients with severe health status.

Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study

AIMS

This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year.

METHODS

Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection.

RESULTS

Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use.

LIMITATIONS

The model's 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured.

CONCLUSIONS

OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK's willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.

Opioid Use Disorder and Pregnancy

Over-prescription of opioid pain medications and increases in heroin use have contributed to the sharp rise in opioid-related hospitalizations and overdose deaths among young adults in the United States, including pregnant women. This has imposed substantial direct and indirect costs to our nation's health care system. Effective treatment with methadone and buprenorphine is available, but significant barriers to care may restrict access for many. Improved screening tools and expanded access to treatments for substance use disorders are keys to addressing the epidemic of opioid use disorder.

Implementation of methadone therapy for opioid use disorder in Russia - a modeled cost-effectiveness analysis

BACKGROUND

Opioid agonist therapy using methadone, an effective treatment of opioid use disorders (OUD) for people who inject drugs (PWID), is recommended by the World Health Organization as essential to curtail the growing HIV epidemic. Yet, despite increasing prevalence of OUD and HIV, methadone therapy has not yet been implemented in Russia. The aim of this modeling study was to estimate the cost-effectiveness of methadone therapy for Russian adults with a diagnosed OUD.

METHODS/DESIGN

We modeled the projected program implementation costs and estimated disability-adjusted life years (DALYs) averted over a 10-year period, associated with the provision of methadone therapy for a hypothetical, unreplenished cohort of Russian adults with an OUD (n = 249,000), in comparison to the current therapies at existing addiction treatment facilities. Our model compared four distinct scenarios of treatment coverage in the cohort ranging from 3.1 to 55%.

RESULTS

Providing methadone therapy to as few as 3.1% of adults with an OUD amounted to an estimated almost 50,000 DALYs averted over 10 years at a cost of just over USD 17 million. Further expanding service coverage to 55% resulted in an estimated almost 900,000 DALYs averted, at a cost of about USD 308 million.

CONCLUSION

Our study indicated that implementing opioid agonist therapy with methadone to treat OUD at existing facilities in Russia is highly cost-effective.

Office-Based Buprenorphine Versus Clinic-Based Methadone: A Cost-Effectiveness Analysis

The objective of this analysis was to compare the cost-effectiveness of clinic-based methadone maintenance therapy (MMT) and office-based buprenorphine maintenance therapy (BMT) from the perspective of third-party payers in the United States. The authors used a Markov cost-effectiveness model. A hypothetical cohort of 1000 adult, opioid-dependent patients was modeled over a 1-year time horizon. Patients were allowed to transition between the health states of in opioid dependence treatment and either abusing or not abusing opioids, or to have dropped out of treatment. Probabilities were derived from randomized clinical trials comparing methadone and buprenorphine. Costs included drug and administration, clinic visits, and therapy sessions. Effectiveness outcomes examined were (1) retention in the treatment program and (2) opioid abuse-free weeks. For retention in treatment at 1 year, MMT was more costly ($4,613 vs. $4,155) and more effective (20.3% vs. 15.9%) than BMT, resulting in an incremental cost-effectiveness ratio (ICER) of $10,437 per additional patient retained in treatment. MMT was also more effective than BMT in terms of opioid abuse-free weeks (9.2 vs. 9.1 weeks), resulting in an ICER of $8,515 per opioid abuse-free week gained. One-way sensitivity analyses found costs per week of MMT to have the largest impact on the retention-in-treatment outcome, whereas the probability of dropping out with MMT had the greatest impact on opioid abuse-free weeks. The authors conclude that MMT is cost-effective compared with BMT for the treatment of patients with opioid dependence. However, the treatment of substance abuse is complex, and decision makers should also consider individual patient characteristics when making coverage decisions.

Characteristics and treatment patterns of US commercially insured and Medicaid patients with opioid dependence or abuse

OBJECTIVE

To identify the demographic and clinical characteristics of commercially insured and Medicaid patients with a diagnosis of opioid dependence or abuse and to describe the pharmacological and nonpharmacological treatments received by these patients.

DESIGN

This was a retrospective observational study using de-identified administrative claims data.

SETTING

The analysis included commercially insured and Medicaid patient data extracted from the Truven Health MarketScan® Commercial and Medicaid Databases.

PATIENTS

Patients with a diagnosis of opioid dependence or abuse from 2008 to 2014 (earliest diagnosis = index date) and a minimum of 6 months of pre-index and postindex continuous enrollment in the database.

MAIN OUTCOME MEASURE(S)

Baseline demographic and clinical characteristics, medication-assisted treatment (MAT), and treatment other than MAT received following diagnosis, and the clinical practice setting in which patients received any opioid dependence-related care were reported.

RESULTS

Data from commercially insured (N = 103,768) and Medicaid (N = 50,552) patients were analyzed. Common comorbid conditions included chronic pain (48.6 percent Commercial, 56.8 percent Medicaid), depressive disorder (24.0 percent Commercial, 32.8 percent Medicaid), and other substance abuse disorders (13.3 percent Commercial, 23.7 percent Medicaid). Nearly one third of both Commercial (31.6 percent) and Medicaid (33.6 percent) patients did not have any claims for psychosocial therapy or MAT during the follow-up period. Only 24.3 percent of Commercial patients and 20.4 percent of Medicaid patients had evidence of claims for both MAT and psychosocial treatment anytime following diagnosis.

CONCLUSIONS

The results suggest that there are opportunities to improve care through comprehensive and coordinated treatment for opioid dependence/abuse. Policies aimed at improving treatment access may be warranted.

Economic Evaluations of Opioid Use Disorder Interventions

BACKGROUND

The economic costs associated with opioid misuse are immense. Effective interventions for opioid use disorders are available; however, given the scarce resources faced by substance use treatment providers and payers of all kinds, evidence of effectiveness is not always sufficient to encourage adoption of a given therapy-nor should it be. Economic evaluations can provide evidence that will help stakeholders efficiently allocate their resources.

OBJECTIVE

The purpose of this study was to review the literature on economic evaluations of opioid use disorder interventions.

METHODS

We performed a systematic review of the major electronic databases from inception until August 2015. A sensitive approach was used to ensure a comprehensive list of relevant articles. Given the quality of the existing reviews, we narrowed our search to studies published since 2007. The Drummond checklist was used to evaluate and categorize economic evaluation studies according to their quality.

RESULTS

A total of 98 articles were identified as potentially relevant to the current study. Of these 98 articles, half (n = 49) were included in this study. Six of the included articles were reviews. The remaining 43 articles reported economic evaluation studies of interventions for opioid use disorders. In general, the evidence on methadone maintenance therapy (MMT) supports previous findings that MMT is an economically advantageous opioid use disorder therapy. The economic literature comparing MMT with other opioid use disorder pharmacotherapies is limited, as is the literature on other forms of therapy.

CONCLUSION

With the possible exception of MMT, additional high-quality economic evaluations are needed in order to assess the relative value of existing opioid use disorder interventions.

Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial

BACKGROUND

Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs.

METHODS

This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215.

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.

Risk Factors for Relapse and Higher Costs Among Medicaid Members with Opioid Dependence or Abuse: Opioid Agonists, Comorbidities, and Treatment History

Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods. We used Medicaid claims for 52,278 Massachusetts Medicaid beneficiaries with a diagnosis of opioid abuse or dependence between 2004 and 2010 to study associations between use of methadone, buprenorphine or other behavioral health treatment without OAT, and time to relapse and total healthcare expenditures. Cox Proportional Hazards ratios for patients treated with either methadone or buprenorphine showed approximately 50% lower risk of relapse than behavioral treatment without OAT. Expenditures per month were from $153 to $233 lower for OAT episodes compared to other behavioral treatment. Co-occurring alcohol abuse/dependence quadrupled the risk of relapse, other non-opioid abuse/dependence doubled the relapse risk and severe mental illness added 80% greater risk compared to those without each of those disorders. Longer current treatment episodes were associated with lower risk of relapse. Relapse risk increased as prior treatment exposure increased but prior treatment was associated with slightly lower total healthcare expenditures. These findings suggest that the effectiveness of OAT that has been demonstrated in clinical trials persists at the population level in a less controlled setting and that OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction. Co-occurring other substance use and mental illness exert strong influences on cost and risk of relapse, suggesting that individuals with these conditions need more comprehensive treatment.

Barriers to Telephone Quitline Use Among Methadone-Maintained Smokers

INTRODUCTION

Drug users have high rates of tobacco use and tobacco-related disease. Telephone quitlines promote smoking cessation, but their reach among drug users is unknown. We thus aimed to assess utilization of and barriers to telephone quitlines among methadone-maintained smokers.

METHODS

Subjects were opioid-dependent smokers in Bronx, New York, methadone treatment programs who were enrolled in a clinical trial of varenicline. All subjects were offered referral to a free, proactive quitline. We examined quitline records, surveyed barriers to quitline use, and queried reasons for declining referral.

RESULTS

Of the 112 subjects enrolled, 47% were male, 54% were Hispanic, and 28% were Black. All subjects were offered referral, and 25 (22% of study participants) utilized the quitline. Quitline utilizers (vs. nonutilizers) were significantly more likely to have landline phone service (72 vs. 42%, p = .01), interest in quitline participation (92 vs. 62%, p < .01), and willingness to receive calls (96 vs. 76%, p = .02). Nonutilizers were significantly more likely to report cell phone service lapse (38 vs. 14%, p = .04), and difficulty charging cell phones (19 vs. 0%, p = .02). Reasons for quitline refusal included: (a) skepticism of quitline efficacy; (b) aversion to telephone communication; (c) competing life demands (e.g., drug treatment, shelter); and (d) problems with cell phone service or minutes.

CONCLUSIONS

Despite several limitations to quitline access among methadone-maintained smokers, routine quitline referral was associated with 22% utilization. To expand provision of smoking cessation treatment to opioid-dependent smokers, interventions to promote routine quitline referral in substance abuse treatment programs warrant investigation.

Cost-Effectiveness of Injectable Extended-Release Naltrexone Compared With Methadone Maintenance and Buprenorphine Maintenance Treatment for Opioid Dependence

BACKGROUND

The aim of this study was to estimate the cost-effectiveness of injectable extended-release naltrexone (XR-NTX) compared with methadone maintenance and buprenorphine maintenance treatment (MMT and BMT, respectively) for adult males enrolled in treatment for opioid dependence in the United States from the perspective of state-level addiction treatment payers.

METHODS

A Markov model with daily time cycles was used to estimate the incremental cost per opioid-free day in a simulated cohort of adult males aged 18-65 over a 6-month period from the state health program perspective.

RESULTS

XR-NTX is predicted to be more effective and more costly than methadone or buprenorphine in our target population, with an incremental cost per opioid-free day gained relative to the next-most effective treatment (MMT) of $72. The cost-effectiveness of XR-NTX relative to MMT was driven by its effectiveness in deterring opioid use while receiving treatment.

CONCLUSIONS

XR-NTX is a cost-effective medication for treating opioid dependence if state addiction treatment payers are willing to pay at least $72 per opioid-free day.

Police bribery and access to methadone maintenance therapy within the context of drug policy reform in Tijuana, Mexico

AIMS

In 2009, Mexico passed legislation to decriminalize drug possession and improve access to addiction treatment. We undertook research to assess the implementation of the reform among a cohort of people who inject drugs (PWID) in Tijuana. This study specifically sought to determine whether discretionary policing practices like extortion impact access to methadone maintenance therapy (MMT) in Tijuana, a city characterized by high levels of drug-related harms.

METHODS

Generalized estimating equation analyses were used to construct longitudinal confounding models to determine the association between paying a police bribe and MMT enrolment among PWID in Tijuana enrolled in a prospective cohort study. Outcome of interest was MMT enrolment in the past six months. Data on police interactions and MMT enrolment were also obtained.

RESULTS

Between October, 2011 and September, 2013, 637 participants provided 1825 observations, with 143 (7.8%) reports of MMT enrolment during the study period. In a final confounding model, recently reporting being forced to pay a bribe to police was significantly associated with an increased likelihood of accessing MMT (adjusted odds ratio=1.69, 95% confidence interval: 1.02-2.81, p=0.043). However, in 56 (39.2%) cases, MMT enrolment ceased within six months. The majority of participant responses cited the fact that MMT was too expensive (69.1%).

DISCUSSION

Levels of MMT access were low. PWID who experienced police extortion were more likely to access MMT at baseline, though this association decreased during the study period. Coupled with the costs of MMT, this may compromise MMT retention among PWID.

The reductions in monetary cost and gains in productivity with methadone maintenance treatment: one year follow-up

While methadone maintenance treatment (MMT) is beneficial for heroin dependence, there is little information regarding the reductions in monetary cost and gains in productivity following MMT. The aim of this study was to evaluate the changes in the monetary cost of heroin addiction and productivity after one year of MMT. Twenty-nine participants from an MMT clinic were included. The monetary cost, productivity, quality of life (QOL) and mental health status were assessed at both baseline and one year follow-up. The average annual total cost was approximately US$26,485 (1.43 GDP per capita in 2010) at baseline, and decreased by 59.3% to US$10,784 (0.58 GDP) at follow-up. The mean number of months of unemployment dropped from 6.03 to 2.79, the mean income increased to exceed the basic salary, but only reached 45.3% of the national average monthly earnings. The participants׳ mental health improved, but their QOL scores did not increase significantly. After one year of MMT, the monetary cost of heroin addiction fell, both the productivity and mental health of the participants׳ improved, but limited gains were seen with regard to their QOL.

A pharmaceutical industry perspective on the economics of treatments for alcohol and opioid use disorders

Individuals with alcohol and/or drug use disorders often fail to receive care, or evidence-based care, yet the literature shows health economic benefits. Comparative effectiveness research is emerging that examines approved approaches in terms of real, total healthcare cost/utilization. Comprehensive retrospective insurance claims analyses are few but tend to be nationally distributed and large. The emerging pattern is that, while treatment in general is cost effective, specific therapeutics can yield different health economic outcomes. Cost/utilization data consistently show greater savings with pharmacotherapies (despite their costs) versus psychosocial treatment alone. All FDA-approved addiction pharmacotherapies (oral naltrexone, extended-release naltrexone, acamprosate, disulfiram, buprenorphine, buprenorphine/naloxone, and methadone) are intended for use in conjunction with psychosocial management, not as stand-alone therapeutics; hence, pharmacotherapy costs must offer benefits in addition to abstinence alone or psychological therapy. Patient persistence is problematic, and (despite its cost) extended-release pharmacotherapy may be associated with lower or no greater total healthcare cost, mostly due to reduced hospitalization. The reviewed studies use rigorous case-mix adjustment to balance treatment cohorts but lack the randomization that clinical trials use to protect against confounding. Unlike trials, however, these studies can offer generalizability to diverse populations, providers, and payment models--and are of particular salience to payers.

Public opinion of drug treatment policy: exploring the public's attitudes, knowledge, experience and willingness to pay for drug treatment strategies

BACKGROUND

Research evidence is strong for opiate replacement treatment (ORT). However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between, attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. This is relevant in the current policy arena in which a major shift from harm reduction to, rehabilitation is underway.

METHODS

A cross sectional postal questionnaire survey in Scotland was conducted where the drug, treatment strategy has changed from harm-reduction to recovery-based. A random sample (N=3000), of the general public, >18 years, and on the electoral register was used. The questionnaire was largely structured with tick box format but included two open questions for qualitative responses. Valuation was measured using the economic willingness-to-pay (WTP) method.

RESULTS

The response rate was 38.1% (1067/2803). Less than 10% had personal experience of drug, misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p<0.001), better knowledge of drugs (p=0.001) and higher income (those earning >£50,000 per, annum compared to <£15K; p=0.01). Over half of respondents were not willing to pay anything for drug treatment indicating they did not value these treatments at all. Respondents were willing-to-pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated many strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit.

CONCLUSIONS

There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

[Health economic evaluation for the extension clinics of methadone maintenance treatment]

OBJECTIVE

To discuss the cost, cost-effectiveness, and cost-utility of the extension methadone maintenance treatment (MMT) clinics and provide the evidences of the strategy of scaling up the extension MMT clinics.

METHODS

A study was conducted in Dehong prefecture, Yunnan province, including Mang, Ruili city, Longchuan, Yingjiang, Lianghe county. 117 newly enrolling heroin addict patients in 17 extension MMT clinics were recruited as subjects from December 2010 to February 2011. An interview was conducted by the trained interviewers for the quality of life score of patients, and the cost of drug use was calculated. Table of outpatient costs of methadone maintenance treatment clinic of Dehong prefecture in Yunnan was used for collecting and calculating the fixed cost, operating cost of the clinics, and the unit cost and incremental cost of the patients from 2008 to 2010. Cost-effectiveness and cost-utility of the extension clinics were analyzed by using the Markov model.

RESULTS

The total spending of extension clinics for 2008, 2009, and 2010 on average was ¥57 294, ¥80 752 and ¥74 739 respectively, or about ¥4379 annually per patient. The cost of averting one HIV infection was ¥316 509; the cost of averting one acquired immune deficiency syndrome (AIDS) patients was ¥508 676; and the cost of averting one death was ¥152 330. The cost of obtaining one life year (LY) was ¥3696 and the cost of obtaining one quality adjusted life year (QALY) was ¥9014. Comparing with drug users, the incremental cost utility ratio (ICUR) of the patients of the extension MMT clinics were -7074 yuan/QALY and -7162 yuan/LY.

CONCLUSION

The extension MMT clinic service is lower in cost, and better in cost-effectiveness and cost-utility.

[Costs-analysis of methadone program in the autonomous community La Rioja, Spain]

BACKGROUND

Methadone programs have been organized in each Spanish region in a specific way. In spite of the regional interests to manage those programs in a more efficient way, so far the costs of the programs are unknown. As a previous step, it would be desirable to understand the activities related to these programs as well as their respective costs. This article aims to calculate the cost of the Methadone program in the autonomous community of La Rioja, and to understand those parameters which generate a greater cost to this programme.

METHODS

The study followed a similar structure as the research recently applied to the region of Murcia. The reference year for the study of the annual costs of the Methadone program was 2010. Data were obtained from different registries of several institutions involved in the regional program. Costs were classified according to different stages and dispensation centres which participated in this programme.

RESULTS

Data analysis, for a concentration of 2 mg/ml of methadone, showed an approximate annual cost of 165.759 euros. Taking the total number of patients into consideration the individual cost was 412,34 euros.

CONCLUSIONS

Dispensation is the stage which caused the largest cost to the programme, the highest per patient cost corresponded to the centre with less patients due to the fact that fixed costs are shared by a smaller group of persons; the biggest global cost of the programme came from Logroño's center but its average cost is lower.

[Reimbursement of opiate substitution drugs to militaries in 2007]

INTRODUCTION

The use of psychoactive drugs by militaries is not compatible with the analytical skills and self-control required by their jobs. Military physicians take this problem into consideration by organising systematic drugs screening in the French forces. However, for technical reasons, opiates are not concerned by this screening with the agreement of the people concerned. The estimated number of militaries who use an opiate substitute may be an approach of heroin consumption in the French forces. This study describes buprenorphine and methadone reimbursements made during 2007 by the national military healthcare centre to French militaries.

MATERIAL AND METHOD

Each French soldier is affiliated to a special health insurance. The national military healthcare centre has in its information system, all the data concerning drug reimbursement made to French military personnel. This is a retrospective study of buprenorphine and methadone reimbursements made during 2007 by the military healthcare centre, to militaries from the three sectors of the French forces, and from the gendarmerie and joint forces. Only one reimbursement of one of these two drugs during this period allowed the patient to be included in our study. Daily drug dose and treatment steadiness profile have been calculated according to the criteria of the French monitoring centre for drugs and drug addiction. The criteria of the National guidelines against frauds have been used to identify misuse of these drugs. Doctors' shopping behaviour has also been studied. Finally, the nature of the prescriber and the consumption of other drugs in combination with opiate substitute have been analysed.

RESULTS

One hundred and eighty-one military consumers of opiate substitute drugs (167 men and 14 women) participated. This sample included people from the three sectors of the French forces as well as from the gendarmerie and from the joint forces. The average age of the consumers was 26.6 years (20-42 years). The average length of service was 6.1 years (maximum 22 years service). One hundred and fifty-nine militaries had been delivered buprenorphine, 15 had been delivered methadone and seven had been delivered both. The prevalence of opiate substitute drug consumption by the militaries (52 per 100,000) is lower than in general population. According to the criteria of the National Healthcare Insurance, this population is not affected by abuse or fraud behaviour. Doctors' shopping behaviour is unusual. Opiate substitutes are prescribed by general physicians in 88% of issues. Only one prescriber was a military physician. An analysis of reimbursement of some drugs associated with opiate substitute has been made. The sampled military consume more psychoactive drugs (anxiolytics, antidepressants, hypnotics) than the French population under opiate substitution.

CONCLUSION

In our observation, the military physician is almost always excluded the process of substitution. His/her different responsibilities of care, but also in determining the working aptitude, lead to dissimulation behaviour by the militaries. The difficulty for military physicians is to identify such consumption. They have to evaluate the capacity to work through a physical and psychological examination.

Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: a mathematical modeling study

BACKGROUND

Indonesia faces an HIV epidemic that is in rapid transition. Injecting drug users (IDUs) are among the most heavily affected risk populations, with estimated prevalence of HIV reaching 50% or more in most parts of the country. Although Indonesia started opening methadone clinics in 2003, coverage remains low.

METHODS

We used the Asian Epidemic Model and Resource Needs Model to evaluate the long-term population-level preventive impact of expanding Methadone Maintenance Therapy (MMT) in West Java (43 million people). We compared intervention costs and the number of incident HIV cases in the intervention scenario with current practice to establish the cost per infection averted by expanding MMT. An extensive sensitivity analysis was performed on costs and epidemiological input, as well as on the cost-effectiveness calculation itself.

RESULTS

Our analysis shows that expanding MMT from 5% coverage now to 40% coverage in 2019 would avert approximately 2400 HIV infections, at a cost of approximately US$7000 per HIV infection averted. Sensitivity analyses demonstrate that the use of alternative assumptions does not change the study conclusions.

CONCLUSION

Our analyses suggest that expanding MMT is cost-effective, and support government policies to make MMT widely available as an integrated component of HIV/AIDS control in West Java.

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.