Costs of addressing heroin addiction in Malaysia and 32 comparable countries worldwide.

Abstract

Develop and apply new costing methodologies to estimate costs of opioid dependence treatment in countries worldwide.
Micro-costing methodology developed and data collected during randomized controlled trial (RCT) involving 126 patients (July 2003-May 2005) in Malaysia. Gross-costing methodology developed to estimate costs of treatment replication in 32 countries with data collected from publicly available sources.
Fixed, variable, and societal cost components of Malaysian RCT micro-costed and analytical framework created and employed for gross-costing in 32 countries selected by three criteria relative to Malaysia: major heroin problem, geographic proximity, and comparable gross domestic product (GDP) per capita.
Medication, and urine and blood testing accounted for the greatest percentage of total costs for both naltrexone (29-53 percent) and buprenorphine (33-72 percent) interventions. In 13 countries, buprenorphine treatment could be provided for under $2,000 per patient. For all countries except United Kingdom and Singapore, incremental costs per person were below $1,000 when comparing buprenorphine to naltrexone. An estimated 100 percent of opiate users in Cambodia and Lao People's Democratic Republic could be treated for $8 and $30 million, respectively.
Buprenorphine treatment can be provided at low cost in countries across the world. This study's new costing methodologies provide tools for health systems worldwide to determine the feasibility and cost of similar interventions.

Full text

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Electronic copy available at: http://ssrn.com/abstract=1698923
Costs of AddressingHeroin Addiction in
Malaysia and 32Comparable Countries
Worldwide
Jennifer PrahRuger, Marek Chawarski, Mahmud Mazlan, Craig
Luekens, Nora Ng, and Richard Schottenfeld
Objective. Develop and apply new costing methodologies to estimate costs of opioid
dependence treatment in countriesworldwide.
Data Sources/Study Setting. Micro-costing methodology developed and data col-
lected during randomized controlled trial (RCT) involving 126 patients (July 2003–
May 2005) in Malaysia. Gross-costing methodology developed to estimate costs of
treatment replication in 32 countries with data collected from publicly available
sources.
Study Design. Fixed, variable, and societal cost components of Malaysian RCT
micro-costed and analytical framework created and employed for gross-costing in 32
countries selected by three criteria relative to Malaysia: major heroin problem, geo-
graphicproximity, andcomparable grossdomestic product (GDP) percapita.
Principal Findings. Medication, and urine and blood testing accounted for the great-
estpercentageoftotalcostsforbothnaltrexone(29–53percent)andbuprenorphine(33
–72 percent) interventions. In 13 countries, buprenorphine treatment could be pro-
videdforunder$2,000perpatient.ForallcountriesexceptUnitedKingdomandSinga-
pore,incrementalcostsperpersonwerebelow $1,000whencomparing buprenorphine
to naltrexone. An estimated 100 percent of opiate users in Cambodia and Lao People’s
DemocraticRepubliccouldbetreatedfor$8and$30 million,respectively.
Conclusions. Buprenorphine treatment can be provided at low cost in countries
across the world. This study’s new costing methodologies provide tools for health sys-
tems worldwide todetermine the feasibility andcost ofsimilar interventions.
Key Words. Malaysia,micro-costing,gross-costing,herointreatment,international
comparison,healthsystems
There are an estimated 13–22 million opiate users globally, with more than
half residing in Asia (United Nations Office on Drugs and Crime [UNODC]
2010). Heroin use in Malaysia has reached significant levels, with 234,000
©Health ResearchandEducationalTrust
DOI: 10.1111/j.1475-6773.2011.01335.x
RESEARCH ARTICLE
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Electronic copy available at: http://ssrn.com/abstract=1698923
official heroin users or heroin-dependent individuals in the government regis-
try at the end of 2004; other estimates reachas high as 500,000 in a population
of roughly 24 million (2 percent) (Mazlan, Schottenfeld, and Chawarski
2006). Moreover, three quarters of all Malaysian HIV/AIDS cases stem from
injection drug use (Ministry of Health of Malaysia/World Health Organiza-
tion [WHO] 2004; WHO Representative Office of Malaysia 2006–2008). In
many countries, injection drug users (IDUs) have a 40 percent or higher HIV
prevalence rate (UNODC 2009). Treating and ending opioid depen-
dence, then, is an important public health aim in Malaysia and around the
world.
Naltrexone has been approved by the U.S. Food and Drug Adminis-
tration for treating opioid dependence since 1984 (Schottenfeld, Chawarski,
and Mazlan 2008), and buprenorphine with counseling has proven effective
in treating opioid dependence and addiction as well as reducing HIV risk
behavior (Barnett, Zaric, and Brandeau 2001; Chawarski, Mazlan, and
Schottenfeld 2008). The cost of providing opioid maintenance treatment
and concurrent group and individual therapy, however, can be a major con-
cern, especially for governments that send arrested drug users to mandatory
drug treatment centers, such as Cambodia, China, Indonesia, Lao People’s
Democratic Republic (PDR), Malaysia, Myanmar, Thailand, and Vietnam
(WHO 2009). This study develops and applies novel costing methodologies
to estimate the cost of opioid dependence treatment in countries around the
world.
We conducted a cost study of buprenorphine and naltrexone mainte-
nance treatment with counseling for opiate addiction in a three-arm random-
ized controlled trial (RCT) in Malaysia. The interventions have demonstrated
efficacy in improving abstinence and retention, and reducing relapse (Schot-
tenfeld, Chawarski, and Mazlan 2008). Grounded in economic theory, we
developed a micro-costing methodology, a bottom-up approach to data col-
lection that produces precise estimates by directly accounting for the units and
costs of each input consumed by participants in a given intervention. Micro-
Address correspondence to Jennifer Prah Ruger, Ph.D., Yale School of Public Health, Health Pol-
icy and Administration, 60 College Street, P.O. Box 208034, New Haven, CT 06520; e-mail:
jennifer.ruger@yale.edu. Marek Chawarski, Ph.D., and Richard Schottenfeld, M.D., are with the
Department of Psychiatry, Yale School of Medicine, New Haven, CT. Mahmud Mazlan, M.D., is
with the Substance Abuse Center, Muar Johor, Malaysia. Craig Luekens, M.Div., and Nora Ng,
Ph.D., are with Yale School of Public Health, Health Policy and Administration, New Haven, CT.
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costing is often used to study a given intervention in a particular setting, with
the“implicitassumption”that the“mix ofinputs andthequalityoftheproduct
or service will generalize to the next application of the approach in a new set-
ting” (Goldet al.1996, p.189).
Based upon this micro-costing methodology, we created an analytical
framework and methodology for extrapolating our results through gross-cost-
ing to estimate the costs of treatment replication in 32 othercountries, selected
based on their heroin problem, geographical proximity, or comparable gross
domestic product (GDP) per capita to Malaysia. Compared to micro-costing,
gross-costing is top down; rather than measuring costs directly, this method
uses more general cost data, such as national average wages or reimbursement
rates (Gold et al. 1996). Gross-costing is simpler and less expensive to under-
take than micro-costing, but it may lack sensitivity and precision. It is an
appropriate costing method when a high degree of precision is not necessary
or not possible, or when researchers can expect large differences in costs
(McBride and Hessel 2008), which we do when estimating treatment replica-
tion costs in 32 countriesspanning widely different levels of development.
To our knowledge, this type of multipart study has yet to be done and
offers promise as a new way to take advantage of the precision and accuracy
gained from micro-costing for health system analysis and for extrapolation
through gross-costing on a global scale.
METHODS
Intervention Overview
Details of the Malaysian RCT can be found in Schottenfeld, Chawarski, and
Mazlan (2008). Briefly, 126 patients were enrolled between July 2003 and
May 2005, all completing a 14-day detoxification protocol before being ran-
domly assigned to placebo (N = 39), naltrexone (N = 43), or buprenorphine
(N = 44) treatment. Patients were given one 8-mg tablet of buprenorphine (or
matching placebo) or one 50-mg tablet of naltrexone (or placebo) each day for
the first week, and two tablets of the same doses every Monday and Wednes-
day and three tablets every Friday in subsequent weeks, adjusting for craving
and withdrawal symptoms. Each patient also received weekly 45-minute man-
ual-guided individual and group counseling at an outpatient clinic in Muar,
Malaysia.
The mean age of study participants ranged from 36 in the buprenor-
phine arm to 38 in the naltrexone arm. About two-thirds of participants in
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each arm were of Malay ethnic origin. Very few attained a high-school level
of education or above (a low of 5 percent in the buprenorphine arm and a
high of 13 percent in the placebo arm), and between a third to a half of the
participants in each arm were unemployed. The mean number of years of
lifetime heroin use was approximately 15, and the average participant used
heroin almost daily in the past 30 days. At least 75 percent of participants
had injected drugs at some point, and between 37 and 46 percent were cur-
rent IDUs. Participants who were HIV positive accounted for 26 percent of
the buprenorphine arm, 26 percent of the naltrexone arm, and 13 percent
of the placebo arm.
Micro-Costing Methodology
Based on the recommendations of the Panel on Cost-Effectiveness in Health
and Medicine (Gold et al. 1996), we developed a micro-costing methodology
and conducted cost analyses of all three treatment arms by identifying, mea-
suring, and valuing resources used from a provider and societal perspective.
Our methodology was based on previous studies (Ruger et al. 2009; Ruger,
Ben Abdallah, and Cottler 2010). Data were collected from the investigators,
staff, and project records on the number and type of resources used and unit
costs. Total costs and cost per participant by arm as well as incremental costs
—the additional cost per participant compared to the next least costly inter-
vention—were calculated. Costs accrued solely for research purposes, such as
recruitment, mouthwash used to mask slight taste differences in medication,
RCT management and oversight, and activities to record data that would not
be used in a clinical setting, were excluded. We categorized costs according to
fixed, variable,and societal costs (Table 1).
Fixed costs, which do not necessarily change with the number of par-
ticipants, included costs for buildings and facilities, detoxification, training,
and quality assurance. We conservatively estimated conference calls and
tape reviews with nurses, psychiatrist, and/or investigators as approxima-
tions for the quality assurance that would take place in a typical clinical
setting. For example, we included one half of the time in weekly confer-
ence calls because half of the time was spent addressing research-specific
issues. Variable costs, which vary by the number of participants, included
costs for materials and testing, medications, and personnel for therapy and
administration of tests and medications. Costs of finding and recruiting
study participants and maintaining their participation were excluded.
While the RCT received its buprenorphine supply free of charge, for this
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Table 1: Micro-CostingComponents by CostCategory
FixedCostsVariableCosts Societal Costs
Buildingandfacilities
Clinic overhead(rent,
utilities, maintenance)
Detoxification
Detoxification
Buprenorphine during
detoxification;14 mg/patient
Naltrexoneduringdetoxification;
87.5 mg/patient
Psychiatristtimefor
physicalexam
Training
Trainingmanuals(10total)
Nurse trainer(individualand
grouptherapytraining)
Nurse trainee(individualtherapy
training; fivenurses)
Nurse trainee(grouptherapy
training; fivenurses)
Qualityassurance
Monthlyconference(25total,
1 houreach)
Nurse counselors (threenurses,
forperiodI)
Nurse counselors (fivenurses,
forperiodII)
Advisor(co-investigator)
Monthlytapereview(25total,
1 houreach)
Nurse counselors (threenurses,
forperiodI)
Nurse counselors (fivenurses,
forperiodII)
Psychiatrist
Weekly conferencecalls(109total;
1 houreach,1/2 clinical)
Advisor(investigator)
Advisor(co-investigator)
Advisor(psychiatrist)
Research assistants(4total)
Materialsandtestingcosts
Therapymaterials
Individual therapy
(40pages/patient)
Testingmaterials
Gloves(2/bloodand
2/liver)
Wipes(2/bloodand2/liver)
Testing
Urine,1-panel
EKG
X-ray
Blood(FBC,bloodsugar,
renal,liver,VDRL/TPHA,
HepB/C,HIV;2/patient)
Additionalliver tests
Nursetimetoadministertests
Urine(5 minutes/test)
EKG(10 minutes/test)
X-ray(10 minutes/test)
Blood(10 minutes/test)
Additionalliver tests
(10 minutes/test)
Personnelcosts
Individual therapy(19/week,
nurseonly)
Nursetimefor therapysession
(45 minutes/session)
Nursetimefor adminand
scheduling(10 minutes/
session)
Grouptherapy(19/week
perarm;109 weekstotal;
psychiatrist/nurse)
Psychiatristtimefor therapy
session(45 minutes/session)
Psychiatristtimefor admin
(15 minutes/session)
Nurse timefor therapysession
(45 minutes/session)
Nurse timefor admin
(10 minutes/session)
Participant’stime
Detoxification
Timein detoxcenter
(2 weeks)
Physicalexam
(30 minutes/patient)
Traveltimefor
detox(20 minutes/
patient)
Travelcosts
(motorcycle)
Tests
Urine(5 minutes/test)
EKG(10 minutes/test)
X-ray(10 minutes/test)
X-raywaitingtime
(1 hour/test)
Blood(10 minutes/test)
Additional liver tests
(10 minutes/test)
Therapysession
Individual therapy
Grouptherapy
Family therapy
Timefor medication
Timefor dosage
andtesting
(15 minutes/visit)
Travel
Travel time(20
minutes/visit)
Travel cost
(motorcycle)
Travel time,X-ray(10
minutes/visit)
continued
International Costs of AddressingHeroinAddiction5