Cost-Effectiveness of Buprenorphine and Naltrexone Treatments for Heroin Dependence in Malaysia

Abstract

AimsTo aid public health policymaking, we studied the cost-effectiveness of buprenorphine, naltrexone, and placebo interventions for heroin dependence in Malaysia.DesignWe estimated the cost-effectiveness ratios of three treatments for heroin dependence. We used a microcosting methodology to determine fixed, variable, and societal costs of each intervention. Cost data were collected from investigators, staff, and project records on the number and type of resources used and unit costs; societal costs for participants’ time were estimated using Malaysia’s minimum wage. Costs were estimated from a provider and societal perspective and reported in 2004 US dollars.SettingMuar, Malaysia.Participants126 patients enrolled in a randomized, double-blind, placebo-controlled clinical trial in Malaysia (2003–2005) receiving counseling and buprenorphine, naltrexone, or placebo for treatment of heroin dependence.MeasurementsPrimary outcome measures included days in treatment, maximum consecutive days of heroin abstinence, days to first heroin use, and days to heroin relapse. Secondary outcome measures included treatment retention, injection drug use, illicit opiate use, AIDS Risk Inventory total score, and drug risk and sex risk subscores.FindingsBuprenorphine was more effective and more costly than naltrexone for all primary and most secondary outcomes. Incremental cost-effectiveness ratios were below $50 for primary outcomes, mostly below $350 for secondary outcomes. Naltrexone was dominated by placebo for all secondary outcomes at almost all endpoints. Incremental treatment costs were driven mainly by medication costs, especially the price of buprenorphine.ConclusionsBuprenorphine appears to be a cost-effective alternative to naltrexone that might enhance economic productivity and reduce drug use over a longer term.

Economic Evaluations of Opioid Use Disorder Interventions

“…Schackman et al[68] and Polsky et al[69] both estimated cost-per-QALY point estimates that fell within the aforementioned range of acceptable U.S. values for cost-effectiveness[61]; however, Schackman et al only found the therapy to have a 64% chance of being considered cost-effective at a willingness-to-pay threshold of $100,000, while Polsky et al's estimates revealed an 86% chance at the same threshold value. Jackson et al[67] estimated an ICER of $72 [∼2014 USD] per opioid-free day relative to MMT, and Ruger et al[70] estimated ICER values below $50 for a host of primary outcomes, including abstinence; however, as mentioned above, we are unable to assess the general level of acceptance for cost-effectiveness for these estimates.…”

“…Ruger et al[70] conducted a CEA of a randomized, double-blind, placebo-controlled clinical trial in Malaysia testing the effectiveness of BMT relative to naltrexone for the treatment of heroin dependence. Study participants were detoxified heroin-dependent patients from an outpatient research clinic and detoxification program.…”

“…[67, 70] As indicated in Table 6, the quality of these studies was good . In general the results from these studies favored BMT.…”

Retention in medication-assisted treatment for opiate dependence: A systematic review

“…25 When all patients received counseling, receipt of buprenorphine rather than placebo or naltrexone was again associated with a higher 6-month retention rate. 26 Among patients who were HIV+, those receiving buprenorphine within the HIV clinic rather than a referral to an opioid treatment program were more likely to be in MAT at 12 months. 27 Thus, as expected, receipt of naltrexone or buprenorphine was associated with better retention in MAT than placebo or no medication.…”

Attitudes toward medication-assisted treatment among fishermen in Kuantan, Malaysia, who inject drugs

“…Fishermen described trying to limit the amount of methadone they are taking on the boat so that it lasts, but they could be receiving inadequate dosage to curb their cravings. A comparison of cost effectiveness of buprenorphine, naltrexone, and placebo for heroin dependence in Malaysia found that buprenorphine was more costly but more effective than the other treatments (Ruger, Chawarski, Mazlan, Ng, & Schottenfeld, 2012). According to the data presented here, fishermen carry such negative attitudes toward buprenorphine that either methadone or extended-release naltrexone might be better options for fishermen with opioid dependence, given their occupation and risk environment.…”