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

Abstract

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 3 methods of intervening on opioid dependence in the ED. Design Measured healthcare 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 USA. Participants Opioid-dependent patients 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 percent 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.

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

“…It can substantially reduce the risk of mortality and facilitate long-term recovery. [1][2][3][4][5][6] Studies show that patients who receive buprenorphine have reduced emergency department (ED) and inpatient use compared with those who do not receive OUD medications, [7][8][9] that longer time taking buprenorphine is associated with reduced ED use, [10][11][12][13] and that expansion of the number of institutions and clinicians providing buprenorphine in a region is associated with reduced ED and inpatient use. 14 Federal and state governments are focused on improving access to OUD medications by training more professionals to prescribe them; expanding the delivery of OUD treatment in specialty addiction programs, hospitals, community health centers, and criminal justice settings; and encouraging coverage of OUD medications in Medicaid, Medicare, and private insurance programs.…”

Routes of non-traditional entry into buprenorphine treatment programs

“…Busch and colleagues (2017) examined the costeffectiveness of ED-initiated buprenorphine in a subset of patients (n = 244) after completion of a 30-day assessment [26]. Cost measures included utilization of healthcare and treatment resources, labor costs of medical practitioners involved in treatment, drug costs, costs associated with crime, and patient time costs.…”

“…We found only two articles that utilized community-based outreach: one using flyers distributed and posted throughout the community [29], and the other utilizing a mobile healthcare van linked to needle exchange [30]. An additional study [26] and its secondary analyses [27,28], is considered outreach because patients, while hospitalized for other health problems, were actively engaged in buprenorphine treatment. Hospital-based outreach represents an ideal environment because not only can they be an effective site of screening, they can also initiate treatment without delay.…”

How Emergency Physicians Approach Refusal of Observation after Naloxone Resuscitation

“…Initiating MAT can make patients more comfortable while in the ED, thereby prolonging the amount of time they are willing to be observed and, most importantly, increasing their willingness to participate in subsequent treatment (43,44), However, effectively providing MAT is contingent on institutional engagement, which allows treatment started within the ED to be sustained after a patient's index visit. In light of the fact that our interviewees reported a significant lack of institutional assistance for treating post-naloxone patients, this represents a potential hurdle to more widespread adoption of this strategy.…”