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Psychiatry Practice Research Review

Released: September 29, 2021

Opioid Use Disorder: Cost-effectiveness of Treatments

Fairley M, et al. JAMA Psychiatry. 2021;78:767-777.

Background
Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the United States, but many individuals with OUD do not have access to treatment. This study assessed the cost-effectiveness of OUD treatments and the association of these treatments with outcomes in the United States.

Methods
This model-based cost-effectiveness analysis included a US population with OUD.

Interventions included medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM).

Main outcomes and measures included fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs.

Results
In the absence of treatment, 42,717 overdoses (4132 fatal, 38,585 nonfatal) and 12,660 deaths were estimated to occur in a cohort of 100,000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range: 21.0%-31.4%). Estimated decrease in deaths were 6% in MAT with methadone, 13.9% in MAT with buprenorphine or naltrexone and 16.9% when MAT was combined with CM, OEND, and psychotherapy. MAT yielded discounted gains of 1.02-1.07 QALYs per person. When including only healthcare-sector costs, methadone cost $16,000/QALY gained compared with no treatment, followed by methadone with OEND ($22,000/QALY gained), then by buprenorphine with OEND and CM ($42,000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250,000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25,000-105,000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. An analysis using demographic and cost data for VHA patients yielded similar findings.

Conclusions
In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the United States likely reached a record high in 2020 because of COVID-19–related increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.

Clinical Commentary
The COVID-19 pandemic has resulted in an increase in OUD as well as destabilization of patients due to lack of in-person visits that have caused inadequate monitoring and drug screening. This study will likely serve as an eyeopener for all clinicians to the efficacy and cost-effectivity of MAT treatment in OUD. Although this is a retrospective study conducted in the context of the VHA system with limited generalizability to the civilian population, the findings are very relevant in lieu of the ongoing opioid addiction epidemic and increase in overdoses and related deaths.

Psychosocial services were offered independently and in conjunction with the preceding medications and included psychotherapy as well as a behavior change strategy known as CM. This study also included OEND, which are key components of OUD treatment but did not evaluate long-acting injectable preparation of buprenorphine as an option.

This study is the first to examine the effect and cost-effectiveness of specific forms of MAT (methadone, buprenorphine, or extended-release naltrexone) including combination strategies like CM and OEND. It is important to note that despite being a VHA study, approximately one half the sample was females.

Clinical Insights

  • Any form of consistent MAT works. Additional strategies go further as combinations have better outcomes and lower long-term costs. Very few medical interventions for less stigmatized conditions are cost saving when compared with no treatment. Methadone and buprenorphine generated the largest savings and health benefits.
  • In the absence of treatment, 12,660 deaths were estimated to occur in the cohort of 100,000 patients over 5 years.
  • Total overdoses decreased the most when MAT was combined with CM and psychotherapy. Least to most reductions in overdoses were with methadone (21% reduction), followed by buprenorphine (31.2% reduction), and followed by naltrexone (31.4% reduction).
  • OEND alone was associated with a slight increase in overdose due to its role in averting fatal overdose and the same individual is likely to overdose again.
  • There were cost increases that were least with methadone and most with buprenorphine with OEND, CM, and psychotherapy. When criminal justice costs are included, all treatments were cost saving compared with no treatment.

Summary
As a healthcare professional, I find the findings of this study robust and they highlight the need to change clinician mindsets so we can treat OUD as a disease state akin to diabetes. Those of us practicing psychiatry should strongly consider becoming certified to prescribe buprenorphine, as access to MAT is still difficult for patients. Note that there is also an overlap of mood disorders and chronic pain in this group of patients and mental health professionals are well positioned to provide treatment. Community mental health centers are ideal sites for large programs as they have multidisciplinary teams in place.

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