Cost-Effectiveness of Long-Term Outpatient Buprenorphine-Naloxone Treatment for Opioid Dependence in Primary Care

Abstract

BACKGROUND: Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic. OBJECTIVE: We evaluated the cost-effectiveness of longterm office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment. DESIGN, SUBJECTS, AND INTERVENTION: A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-oflife weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated. MAIN MEASURES: Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually. KEY RESULTS: In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce qualityof-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction. CONCLUSIONS: Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.

Barriers to Medical Provider Support for Prescription Naloxone As Overdose Antidote for Lay Responders

“…Support from these providers is critical for expanding naloxone distribution to at-risk populations, who may not have any other point of contact for overdose prevention education or naloxone prescription. Previous work indicates that buprenorphine/naloxone treatment for opioid dependence is safe, feasible, and cost effective (Mintzer et al, 2007;Miotto et al, 2012;(Raisch, Fye, Boardman, & Sather, 2002;Schackman, Leff, Polsky, Moore, & Fiellin, 2012), with demonstrated capacity of prescribers to address addiction in the primary care setting. Incorporating overdose training and response into the medication assisted therapy conversation can build on these prior successes.…”

Short term health-related quality of life improvement during opioid agonist treatment

“…Information on the impact of repeated treatment attempts, and the durability of the impact of treatment on HRQoL, are critical to the accurate estimation of relative value for money of alternative substance use disorder treatment modalities, including medications. Uncertainty surrounding HRQoL valuations had an effect on the findings in at least one prior cost-effectiveness analysis for the treatment of opioid dependence (Schackman et al, 2012). Our objective was therefore to characterize short-term changes in HRQoL following enrollment into OAT across different modalities (detoxification, or tapered-dose treatment, maintenance, or time-unlimited treatment), medications (buprenorphine, methadone) and patient subgroups (heroin, PO dependence).…”

The Costs of Implementing Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care

“…The continuum of care for OAUD consisted of screening provided by medical assistants and brief interventions for at-risk individuals provided by medical providers, with either a six-session motivational interviewing/cognitive behavioral therapy-based psychotherapy or medicationassisted treatment for individuals with alcohol or opioid dependence. The research literature supports the effectiveness of treatment for OAUD (Department of Veterans Affairs, Department of Defense, 2015;Jonas et al, 2014;Kaner et al, 2007;Schackman et al, 2012;Smedslund et al, 2011). Intervention activities, described in detail elsewhere, included implementation meetings, provider trainings, development of treatment and procedure manuals, a pilot test, care coordination, and support for population-based care.…”