Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

Abstract

ImportanceUS primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.ObjectiveTo estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.Design, Setting, and ParticipantsIn this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.Main Outcomes and MeasuresLife-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).ResultsThe simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.Conclusions and RelevanceThis modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Implementing harm reduction kits in an office-based addiction treatment program

“…We describe the successful implementation of a QI pilot program integrating kits in our OBAT clinic. Our program extends prior work in hospital settings domestically in the US [ 30 ] and internationally [ 23 , 24 ] and serves as a real-world example addressing calls for harm reduction integration in outpatient care [ 7 , 12 , 26 , 27 ]. Our findings, albeit limited to one-month post-implementation, highlight a significant unmet need for kits even among patients with access to long-term addiction treatment.…”

“…Numerous studies have demonstrated the significant positive impact of SSPs on patient and population-level outcomes [ 8 , 9 ]. SSPs, however, are not universally accessible in the US as a result of complex regional regulations [ 10 ] and so expanding these services to healthcare settings may increase access to harm reduction, be a cost-effective strategy [ 11 ], and improve clinical outcomes among PWUD [ 12 ].…”

Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction

“…Prior studies have focused on community-based harm reduction, and early studies are examining harm reduction in primary care . Our study builds on these findings, with patients and staff viewing hospitalization as an opportunity to offer overdose prevention education and harm reduction supplies, particularly for communities missed by existing access points .…”

Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs

“…One recent modeling analysis suggested that the average primary care physician would incur approximately $13 000 in excess costs (both direct and indirect) over a 5-year period if they were to incorporate harm reduction into their practice. Notably, this was associated with a 33% decrease in mortality rate and decreased costs of hospitalization [ 41 ]. Given the required investment, we believe that mechanisms to compensate this work are needed both to encourage the development of such programs and promote their sustainability.…”