No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Cost-Effectiveness of Extended Buprenorphine-Naloxone Treatment for Opioid-Dependent Youth: Data from a Randomized Trial
Abstract
The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine-naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth.
Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling.
152 patients aged 15-21 years.
Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12.
The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25,049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100,000 per QALY.
Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth.
... The validity of self-reported data on healthcare utilization is well established over recall periods similar to those in our study [46][47][48][49]. The NMOS form has been successfully used by our team in prior economic evaluation studies [40,[50][51][52][53], and is ideal for capturing the utilization of all relevant non-study resources for this project. ...
... The health-utility value produced by the EQ-5D-3L can range from − 0.594 to 1, where 0 represents death, 1 represents perfect health, and values below 0 represent health states perceived to be worse than death. The index value can then be used to calculate qualityadjusted life-years (QALYs), as our team, and others have done in similar studies [7,40,50,52]. ...
... The self-report method for collecting data on criminal activity has acceptable validity and reliability [58], including among individuals with a substance use disorder, and those on probation or parole [59,60]. The CLAF has been successfully used by our team in prior studies to value criminal activity and criminal justice resources from various perspectives [40,[50][51][52], and we recently developed recommendations on how to use different measures of criminal activity in economic evaluations [61]. ...
Background:
Persons with an opioid use disorder (OUD) who were incarcerated face many challenges to remaining abstinent; concomitantly, opioid-overdose is the leading cause of death among this population, with the initial weeks following release proving especially fatal. Extended-release naltrexone (XR-NTX) is the most widely-accepted, evidence-based OUD pharmacotherapy in criminal justice settings, and ensures approximately 30 days of protection from opioid overdose. The high cost of XR-NTX serves as a barrier to uptake by many prison/jail systems; however, the cost of the medication should not be viewed in isolation. Prison/jail healthcare budgets are ultimately determined by policymakers, and the benefits/cost-offsets associated with effective OUD treatment will directly and indirectly affect their overall budgets, and society as a whole.
Methods:
This protocol describes a study funded by the National Institute of Drug Abuse (NIDA) to: evaluate changes in healthcare utilization, health-related quality-of-life, and other resources associated with different strategies of XR-NTX delivery to persons with OUD being released from incarceration; and estimate the relative "value" of each strategy. Data from two ongoing, publicly-funded, randomized-controlled trials will be used to evaluate these questions. In Study A, (XR-NTX Before vs. After Reentry), participants are randomized to receive their first XR-NTX dose before release, or at a nearby program post-release. In Study B, (enhanced XR-NTX vs. XR-NTX), both arms receive XR-NTX prior to release; the enhanced arm receives mobile medical (place of residence) XR-NTX treatment post-release, and the XR-NTX arm receives referral to a community treatment program post-release. The economic data collection instruments required to evaluate outcomes of interest were incorporated into both studies from baseline. Moreover, because the same instruments are being used in both trials on comparable populations, we have the opportunity to not only assess differences in outcomes between study arms within each trial, but also to merge the data sets and test for differences across trials.
Discussion:
Initiating XR-NTX for OUD prior to release from incarceration may improve patient health and well-being, while also producing downstream cost-offsets. This study offers the unique opportunity to assess the effectiveness and cost-effectiveness of multiple strategies, according to different stakeholder perspectives.
... Further CTN associated economic evaluations were not published until 2010. Polsky et al. (2010) analyzed the cost-effectiveness of buprenorphine-naloxone treatment, versus brief detoxification treatment among youths (ages 15-25) with an opioid use disorder, alongside CTN-0010 "Buprenorphine/Naloxone-Facilitated Rehabilitation for Opioid Dependent Adolescents/Young Adults." The authors examined two measures of effectiveness. ...
... The second measure of effectiveness was the QALY, calculated from health-related quality-of-life scores measured periodically throughout the trial via the EuroQol 5-D (EQ-5D) (Balestroni & Bertolotti, 2012;Kind, 1996;Shaw, Johnson, & Coons, 2005). In contrast to the earlier CTN economic evaluations, Polsky et al. (2010) examined costs from multiple stakeholder perspectives (payer, healthcare system, and society) and administered the Substance Abuse Services Cost Analysis Program (SASCAP), a costing instrument for drug treatment services, to estimate costs of drug administration and counseling (Zarkin, Dunlap, & Homsi, 2004). The authors estimated that at a willingness-to-pay threshold of $100,000 per QALY, buprenorphine-naloxone had an 86% chance of being cost-effective compared to detoxification treatment for adolescents and emerging adults. ...
... nstrument for drug treatment services, to estimate costs of drug administration and counseling (Zarkin, Dunlap, & Homsi, 2004). The authors estimated that at a willingness-to-pay threshold of $100,000 per QALY, buprenorphine-naloxone had an 86% chance of being cost-effective compared to detoxification treatment for adolescents and emerging adults. Polsky et al's. (2010) study quality was rated a 10. ...
Economic evaluations provide evidence that informs stakeholders on how to efficiently allocate real and financial healthcare resources. The purpose of this study was to review and discuss the integration of economic evaluations into the National Drug Abuse Treatment Clinical Trials Network (CTN) since its inception, as well as expectations for the future of this relationship. A systematic review was performed on published and planned CTN economic evaluations in the CTN dissemination library and PubMed. The well-established Drummond checklist was used to evaluate the comprehensiveness and methodological rigor of published articles. One hundred thirty-eight ancillary, follow-up, or original protocols were reviewed, and 78 potentially relevant published articles were identified. A total number of 14 protocols included an economic evaluation. Of these, 6 protocols were completed, 2 were reported as active, and 6 were reported as in-development at the time of this review. Of the 78 published articles, 9 met the inclusion criteria. As gauged by the Drummond checklist, the quality of CTN published economic evaluations were found to improve over time, and recent published articles were identified as guides to cutting-edge economic research. As the CTN continues to grow and mature, it is imperative that high-quality economic evaluations are incorporated alongside trials in order to maximize the public health impact of the CTN.
... OUD has also escalated the spread of infectious diseases due to highrisk behaviors such as sharing injection materials. For example, hepatitis C increased from 2004 to 2014 (400% among [18][19][20][21][22][23][24][25][26][27][28][29] year-olds and 325% among 30 to 39 year-olds) and hepatitis B also increased (20,000 new cases in the US among persons who inject drugs) [4]. ...
... Nearly a quarter of the studies that could have been included ultimately had to be excluded because it was not possible to determine the effect of compared to another treatment on the outcomes of interest. These included: the outcome of being in treatment considered being in any treatment compared to no treatment at all [19][20][21][22]; the study compared buprenorphine (BUP) to BUP plus other treatments, such as an additional medication [23], or different types of counseling [15,24,25]; different lengths of BUP taper as the treatment groups [26][27][28][29][30]; and not reporting BUP data [31,32]. A detailed list of all studies excluded is provided in Table 1. ...
Background: Prior systematic reviews have compared the relative effectiveness of buprenorphine (BUP), methadone (MET) and other medications and treatments for opioid use disorder (OUD). The results suggest BUP is highly effective for reducing illicit opioid use and retaining people in treatment. The current review extends these
prior reviews by synthesizing research, which compares BUP and buprenorphine and naloxone (BUP/NX) to several treatments in addition to MET on several primary and secondary outcomes.
Method: Literature searches were conducted using nine databases. Articles were limited to quantitative reports of studies conducted with adult human subjects in an outpatient, non-residential treatment settings in the United States, in peer-reviewed journals between January 1, 2001 and May 31, 2017, and written in English. Search
strategies returned 1,981 articles, an additional eight articles were added through hand searching. Ninety-nine articles met inclusion criteria. After reading abstracts, 48 articles were excluded from the review. After reading the remaining 59 articles, another 36 were excluded. A total of 18 studies were included in the final analyses.
Results: MET was found to be superior to buprenorphine (BUP) in helping patients adhere to and remain in treatment, while BUP was superior to MET for achieving abstinence from opioids. BUP was found to be superior to behavioral treatment alone, extended release naltrexone (XR-NTX), an absence of any treatment, and placebo.
Given the range of study designs and quality, populations, and outcomes examined, a meta-analysis was not feasible. The heterogeneity of included studies, however, permitted close examination of both the benefits and barriers of medication treatment for OUD in a range of patient populations and clinical settings, as well as the identification of gaps in both the research and treatment of OUD across a body of available literature. Conclusion: Buprenorphine (BUP) is an effective treatment option for achieving abstinence from opioids, and with emerging treatment guidelines, may be easier to access than other forms of treatment. The review underscores
much of the available research utilized protocols that are inconsistent with current clinical practice guidelines. Further, flaws in research designs make it difficult for providers to determine the best medication treatment in order to improve outcomes. Future research is necessary to determine the effectiveness of BUP when administered according to the most current protocols.
... The mean annual cost was lowest for buprenorphine-naloxone (€2,875. 6 [69] analyzed the cost-effectiveness of BMT relative to detoxification in a 12-week clinical trial of US adolescents (15-21 years of age) with an opioid use disorder. The analyses were conducted from the perspectives of the payer, the provider and society. ...
... BMT was also compared to no treatment, [68] detoxification [69], and naltrexone. [67,70] As indicated in Table 6, the quality of these studies was good. ...
Background
The economic costs associated with opioid misuse are immense. Effective interventions for opioid use disorders are available; however, given the scarce resources faced by substance use treatment providers and payers of all kinds, evidence of effectiveness is not always sufficient to encourage adoption of a given therapy—nor should it be. Economic evaluations can provide evidence that will help stakeholders efficiently allocate their resources.
Objective
The purpose of this study was to review the literature on economic evaluations of opioid use disorder interventions.
Methods
We performed a systematic review of the major electronic databases from inception until August 2015. A sensitive approach was used to ensure a comprehensive list of relevant articles. Given the quality of the existing reviews, we narrowed our search to studies published since 2007. The Drummond checklist was used to evaluate and categorize economic evaluation studies according to their quality.
Results
A total of 98 articles were identified as potentially relevant to the current study. Of these 98 articles, half (n = 49) were included in this study. Six of the included articles were reviews. The remaining 43 articles reported economic evaluation studies of interventions for opioid use disorders. In general, the evidence on methadone maintenance therapy (MMT) supports previous findings that MMT is an economically advantageous opioid use disorder therapy. The economic literature comparing MMT with other opioid use disorder pharmacotherapies is limited, as is the literature on other forms of therapy.
Conclusion
With the possible exception of MMT, additional high-quality economic evaluations are needed in order to assess the relative value of existing opioid use disorder interventions.
... Several recent studies have shown that suboxone is a medically and cost effective treatment for heroin addiction [15][16][17]. Suboxone has seen consistent market growth over the years. For instance, in 2002 approximately 12,000 prescriptions were issued and this number rose to 300,000 in 2006 [18]. ...
... Although relapse rates increased over time for both groups, adolescents who were in the 14-day detoxification group relapsed sooner and with greater severity than the 12-week group. The 12-week Suboxone group also had lower percentages of opioidpositive urine samples at follow-up visits than the detoxification group and this was attributed to Suboxone patients who enrolled in longerterm treatments [15]. ...
... Administrative records and self-reported data allow us to calculate the average cost of the intervention, reflecting treatment-related labor, supply, administrative, and space requirements. A standardized form details use of non-study medical resources [35,36]. The Client Status Review and EuroQol 5D measure self-reported health-related quality-of-life (HRQOL) [37][38][39]. ...
Objectives:
Detoxification clinics manage acute intoxication and withdrawal from alcohol and other drugs. At discharge, patients are referred to treatment, yet many are readmitted to detoxification, creating a "revolving door" of discharges and admissions. This pattern disproportionately affects some groups such as Alaska Native and American Indian (AN/AI) people. The primary goals of this study are to: 1) test the effectiveness of a patient navigation intervention to increase rates of transition to alcohol treatment following detoxification, and 2) prevent readmission to detoxification within 12-months. The secondary goal is a cost-effectiveness and cost-benefit evaluation of patient navigation.
Study design:
This randomized controlled comparative effectiveness trial plans to recruit 440 patients (∼70% AN/AI) admitted to alcohol detoxification. We collaborated with Fairbanks Native Association (FNA) to select an appropriate intervention, control condition, and other study-related decisions. Here, we describe intervention development, study design, challenges encountered during implementation, and collaborative processes to identify solutions.
Methods:
Participants are equally randomized to the control (one motivational interviewing session) or intervention (one motivational interviewing session plus up to four weeks of patient navigation). The primary outcomes are successful transition to alcohol treatment within 30-days after discharge and detoxification readmission within 12-months. The secondary outcome is health-related quality of life.
Conclusion:
Patient navigation is successful in other settings and for other health conditions. It may assist in overcoming barriers to successful transition to substance use treatment and may augment interventions, such as motivational interviewing, that are less resource-intensive but may not be optimally effective by themselves.
Clinicaltrialsgov identifier:
NCT03737864.
... abscess) [43,44]. Time free from opioids was added as a covariate to the analytical model, as prior studies have shown effective treatment for OUD resulting in time free from opioids, to be associated with improved HRQoL [21,22,45]. As in Jalali et al. [33], the weeks free from opioids variable was calculated as a combination of urinalysis and self-report of opioid use; missing urinalysis (measured weekly) or urinalysis that was refused were counted as positive with the exception where XR-NTX was administered within the past 28 days [46]. ...
Background\Objectives
Concomitant with low rates of pharmacotherapy for incarcerated individuals with OUD, there is a high rate of opioid overdose following re-entry into the community. Our research objective was to develop a better understanding of the factors that influence health-related quality-of-life (HRQoL) among this population during the high-risk transition period from incarceration to community. Few studies have assessed health-related quality-of-life (HRQoL) among individuals with OUD who are involved with the criminal-legal system, let alone over the period directly surrounding release from incarceration.
Methods
Secondary longitudinal analysis of data from a clinical trial where participants were randomized 1:1 to pre-release extended-release naltrexone (XR-NTX) + referral to community XR-NTX, vs. referral only. We conducted individual, multivariable regressions of EQ-5D domains (mobility, pain/discomfort, anxiety/depression; usual activities and self-care were excluded due to insufficient variation in scores), and the overall preference/utility score. HRQoL data were subset to timepoints immediately before release (baseline) and 12 weeks post-release; treatment groups were collapsed across condition. Multiple imputation by chained equations was conducted to handle missing 3-month data in the dependent variables and covariates, ad hoc.
Results
Greater severity in the psychiatric composite score was associated with substantially lower HRQoL, across all measures, following release from incarceration. Greater severity in the medical composite score was associated with lower pain/discomfort-related HRQoL.
Conclusions
Our findings highlight the importance of ensuring individuals with OUD are linked not only to MOUD, but also treatment for their comorbid conditions upon release from incarceration.
... 33 This value is then used to calculate QALYs. [34][35][36][37][38] The secondary measure of effectiveness for the economic evaluation will be Opioid-Free Years, which will be operationalized as the predicted proportion of the year that the participant was not using opioids. ...
Introduction
A marked increase in hospitalizations for severe, injection-related infections (SIRI) has been associated with the opioid epidemic. Outpatient parenteral antibiotic therapy (OPAT) is typically not offered to persons with opioid use disorder (OUD) and SIRI, though increasing evidence suggests it may be feasible and safe. This study evaluates the efficacy and cost-effectiveness of an integrated care model combining Buprenorphine treatment of OUD with OPAT for SIRI (B-OPAT) compared with treatment as usual on key OUD, infectious disease, and health economic outcomes. B-OPAT expands and incorporates key elements of established clinical models, including inpatient initiation of buprenorphine for OUD, inpatient infectious disease consultation for SIRI, office-based treatment of OUD, and OPAT, and includes more frequent clinical outpatient visits than standard OPAT. A qualitative evaluation is included to contextualize effectiveness outcomes and identify barriers and facilitators to intervention adoption and implementation.
Methods
B-OPAT is a single-site, randomized, parallel-group, superiority trial recruiting 90 adult inpatients hospitalized with OUD and SIRI who require at least 2 weeks of intravenous (IV) antibiotic therapy. After screening, eligible participants are randomized 1:1 to either discharge once medically stable to an integrated outpatient treatment care model combining Buprenorphine and OPAT (B-OPAT) or to Treatment As Usual (TAU). The primary outcome measure is the proportion of urine samples negative for illicit opioids in the 12 weeks after discharge from the hospital. Key secondary OUD outcomes include self-reported number of days of illicit opioid abstinence and 12-week retention in buprenorphine treatment. The infection outcomes are completion of recommended IV antibiotic therapy, peripherally inserted central catheter (PICC) complications, and readmission related to primary SIRI.
Conclusions
The B-OPAT study will help address the important question of whether it is clinically effective and cost-effective to discharge persons with OUD and SIRI to an integrated outpatient care model combining OUD treatment with OPAT relative to TAU (Clinicaltrials.gov Identifier: NCT04677114).
... As in prior studies by the Murphy team Murphy et al., 2019;Murphy et al., 2017;Neumann et al., 2014;Polsky et al., 2010), the Non-study Medical and Other Services (NMOS) form elicit self-reported information on health care resource utilization, and out-of-J o u r n a l P r e -p r o o f Journal Pre-proof pocket health care, pharmaceutical, and travel costs; we collected self-reported nonstudy medication use using a concomitant medication questionnaire; participants also self-reported state transfers (e.g., unemployment benefits, welfare), criminal activities, hours worked, and wages received based on the Addiction Severity Index (ASI) assessment (McLellan et al., 1992). Supplemental Appendix A contains the Impact Inventory (Peter J. Neumann, 2016), which lists the resources relevant to each stakeholder, and Table B1 in Supplemental Appendix B lists all unit costs, according to the stakeholder's perspective. ...
Introduction
Opioid use disorder (OUD) is highly prevalent among incarcerated populations, and the risk of fatal overdose following release from prison is substantial. Despite efficacy, few correctional facilities provide evidence-based addiction treatment. Extended-release injectable naltrexone (XR-NTX) administered prior to release from incarceration may improve health and economic outcomes.
Methods
We conducted an economic evaluation alongside a randomized controlled trial testing the effectiveness of XR-NTX before release from prison (n = 38) vs. XR-NTX referral after release (n = 48) of incarcerated participants with OUD, both groups continuing treatment at a community addiction treatment center. The incremental cost-effectiveness ratio (ICER) assessed the cost-effectiveness of XR-NTX before release compared to referral after release for three stakeholder perspectives at 12- and 24-week periods: state policymaker, health care sector, and societal. Effectiveness measures included quality-adjusted life-years (QALYs) and abstinent years from opioids. In addition, we categorized resources as OUD-related and non-OUD-related medical care, state transfers payments, and other societal costs (productivity, criminal justice resources, etc.).
Results
Results showed an association between XR-NTX and greater OUD-related costs and total costs from the state policymaker perspective. QALYs gained were positive but statistically insignificant between arms; however, results showed XR-NTX had an estimated 15.5 more days of opioid abstinence over 24 weeks and statistically significant at a 95 % confidence level based on the distribution of bootstrapped samples. We found that estimated ICERs to be > $500,000 per QALY for all stakeholder perspectives. For the abstinent-year effectiveness measure, we found XR-NTX before release to be cost-effective at a 95 % confidence level for willingness-to-pay values >$49,000 per abstinent-year, across all perspectives.
Conclusions
XR-NTX administered to persons who are incarcerated with OUD before release may provide value for stakeholders and bridge a well-known treatment gap for this vulnerable population. Lower than expected participant engagement and missing data limit our results, and study outcomes may be sensitive to methods that address missing data if replicated.
... Previous cost-effectiveness research of SUD related evidence-based interventions include costeffectiveness studies of medications for opioid use disorder, [17][18][19][20][21][22] psychosocial treatment modalities, 23,24 and a variety of harm reduction strategies. 25,26 Previous cost-effectiveness work in this field has established precedence for modeling societal and health systems costs, and for estimating utility (usually operationalized as a quantitative measure of quality of life) among those with SUD and those in recovery; however, there remains a paucity of cost-effectiveness research on recovery support services, especially those that are long-term or ongoing, such as is the case with CRPs. ...
Objective:
To conduct a preliminary cost-effectiveness analysis of collegiate recovery programs in the United States and to create a tailorable cost-effectiveness calculator based on the preliminary cost-effectiveness model.
Methods:
Cost-effectiveness was assessed with a base case, one-way sensitivity analyses, and probabilistic sensitivity analyses for the societal and health systems (institutions of higher education) perspectives, comparing CRPs to treatment as usual. Models were estimated using secondary data sources. A cost-effectiveness calculator was constructed using the models developed for the cost-effectiveness analysis.
Results:
CRPs were found to be cost-effective across all models. Institutional and societal models were robust to changes in parameters.
Conclusions:
CRPs are a cost-effective intervention and are cost-saving under certain conditions. A free online calculator developed form this analysis is available to estimate program-specific cost-effectiveness.
... Self-report on criminal activity has acceptable validity and reliability [34], even among individuals with a substance use disorder, including those on probation or parole [35,36]. The Criminal and Legal Activities Form has been successfully used to value criminal activity and criminal justice resources [37][38][39][40], and in economic evaluations [41]. ...
Background
Despite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety.
Methods
We will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness.
Discussion
Our study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.
... The use of health services was measured with a modified Medical Services Utilization Form. 33 For the last 6 months, participants estimated the number of visits made to their primary care clinic, emergency room, and urgent care, and reported overnight stays in hospital or long-term care (e.g., assisted living facility, nursing home). ...
Background
By 2030, the number of US adults age ≥65 will exceed 70 million. Their quality of life has been declared a national priority by the US government.
Objective
Assess effects of an eHealth intervention for older adults on quality of life, independence, and related outcomes.
Design
Multi-site, 2-arm (1:1), non-blinded randomized clinical trial. Recruitment November 2013 to May 2015; data collection through November 2016.
Setting
Three Wisconsin communities (urban, suburban, and rural).
Participants
Purposive community-based sample, 390 adults age ≥65 with health challenges. Exclusions: long-term care, inability to get out of bed/chair unassisted.
Intervention
Access (vs. no access) to interactive website (ElderTree) designed to improve quality of life, social connection, and independence.
Measures
Primary outcome: quality of life (PROMIS Global Health). Secondary: independence (Instrumental Activities of Daily Living); social support (MOS Social Support); depression (Patient Health Questionnaire-8); falls prevention (Falls Behavioral Scale). Moderation: healthcare use (Medical Services Utilization). Both groups completed all measures at baseline, 6, and 12 months.
Results
Three hundred ten participants (79%) completed the 12-month survey. There were no main effects of ElderTree over time. Moderation analyses indicated that among participants with high primary care use, ElderTree (vs. control) led to better trajectories for mental quality of life (OR=0.32, 95% CI 0.10–0.54, P =0.005), social support received (OR=0.17, 95% CI 0.05–0.29, P =0.007), social support provided (OR=0.29, 95% CI 0.13–0.45, P <0.001), and depression (OR= −0.20, 95% CI −0.39 to −0.01, P =0.034). Supplemental analyses suggested ElderTree may be more effective among people with multiple (vs. 0 or 1) chronic conditions.
Limitations
Once randomized, participants were not blind to the condition; self-reports may be subject to memory bias.
Conclusion
Interventions like ET may help improve quality of life and socio-emotional outcomes among older adults with more illness burden. Our next study focuses on this population.
Trial Registration
ClinicalTrials.gov ; registration ID number: NCT02128789
... The literature has primarily examined the feasibility and efficacy of buprenorphine/naloxone among youth. OAT with buprenorphine has been found to be effective among youth with OUD (Marsch et al., 2005;Polsky et al., 2010). Concerning detoxification, longer taper periods seem to be desirable (Marsch et al., 2016). ...
Aim
First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high‐risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population.
Methods
A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high‐risk opioid use among youth. After full‐text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews.
Results
Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost‐effectiveness for opioid agonist treatment than abstinence‐based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories.
Conclusions
From the limited findings, there is no evidence to deny youth with high‐risk opioid use the same treatment options available to adults. A combination of pharmacological and youth‐specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.
... It provides information that will enable evaluation of alcohol-related negative consequences (driving impaired, riding with impaired driver, injuries, arrests, tardiness, days absent from school or work). Items from this assessment are from the Non-Study Medical Services Form [57,58]. Examples of questions asked in the BED include, "Have you been a driver of a car involved in a crash after drinking or being intoxicated (past 6 months)?," with response options as, no, almost, yes-once, yes-more than once, and if yes is initially answered, additional questions about who were the passengers in the car (family members, close friends, coworkers, some other person, a minor) is asked; "In the past 30 days, how many full or part days have you missed work because of your own health problems or illness, a family member's health problem or illness, because of a legal problem, or other problem?," with response options as, how many were full-days, and how many were part-days. ...
The described first-of-a-kind ED-RCT, has been intentionally designed to address alcohol-related health disparities in adult U.S. Latino ED patients using AB-CASI. In this trial, we will test the efficacy of the AB-CASI intervention against a SC condition and compare alcohol consumption, negative health behaviors and consequences, and 30-day treatment engagement. Moreover, we will explore variations in intervention outcomes between Latino subpopulations. This study harnesses bilingual digital health tool providing a tablet-delivered brief negotiation interview (BNI). The intervention is conducted in a busy clinical setting that offers unique and important access to this vulnerable population that can benefit from directed disease prevention and health promotion efforts to close alcohol-related disparity gaps. Of particular note, this trial provides the opportunity to expand the evidence that well-known ED-SBIRT barriers (e.g., practitioner time burden, cost of intervention personnel, maintaining intervention fidelity, providing intervention in other languages) can be effectively surmounted. This could potentially reinvigorate and bolster prevention efforts to further advance national ED activities and programs addressing AUDs and ED-SBIRT practice known to currently lag behind national guidelines [
74
• Cunningham R.M.
• Harrison S.R.
• McKay M.P.
• Mello M.J.
• Sochor M.
• Shandro J.R.
• Walton M.A.
• D’onofrio G.D.
National survey of emergency department alcohol screening and intervention practices.Ann. Emerg. Med. 2010; 55: 556-562
• Abstract
• Full Text
• Full Text PDF
• PubMed
• Scopus (75)
• Google Scholar
].
... Healthcare service utilization will be captured using medical records, and through self-report using the Nonstudy Medical and Other Services (NMOS) form. The NMOS has been used extensively in previous research with similar populations [67][68][69][70]. Two measures of effectiveness will be included in the cost-effectiveness analysis. ...
Background
North America is facing an unprecedented public health crisis of opioid-related morbidity and mortality, increasingly as a result of the introduction of illicitly manufactured fentanyl into the street drug market. Although the treatment of opioid use disorder (OUD) is a key element in the response to the opioid overdose epidemic, currently available pharmacotherapies (e.g., methadone, buprenorphine) may not be acceptable to or effective in all patients. Available evidence suggests that slow-release oral morphine (SROM) has similar efficacy rates as methadone with respect to promoting abstinence, and with improvements in a number of patient-reported outcomes among persons using heroin. However, little is known about the relative effectiveness and acceptability of SROM compared to methadone in the context of fentanyl use. This study aims to address this research gap.
Methods
pRESTO is a 24-week, open-label, two arm, non-inferiority, randomized controlled trial comparing SROM versus methadone for the treatment of OUD. Participants will be 298 clinically stable, non-pregnant adults with OUD, recruited from outpatient clinics in Vancouver, Canada, where the majority of the illicit opioids are contaminated with fentanyl. The primary outcome is suppression of illicit opioid use, measured by bi-weekly urine drug screens. Secondary outcomes include: treatment retention, medication safety, overdose events, treatment satisfaction, psychological functioning, changes in drug-related problems, changes in quality of life, opioid cravings, other substance use, and cost-effectiveness.
Discussion
pRESTO will be among the first studies to evaluate treatment options for individuals primarily using synthetic street opioids, providing important evidence to guide treatment strategies for this population.
... All utilities were derived from the existing literature or, when that was lacking, by consensus of the authors (Table 4). [40][41][42][43][44][45][46] We assumed that an incremental costeffectiveness ratio of $100,000 per QALY defined cost effectiveness, which means that any cost greater than $100,000 for an additional QALY would indicate that a given strategy would not be cost effective. 47 When reporting strategies, they are described as dominant, in that the strategy is both cost saving and more effective than the other strategies, or cost effective, in that the strategy does not incur greater than $100,000 Unauthorized reproduction of this article is prohibited. ...
Objective:
To estimate whether methadone, buprenorphine, or detoxification treatment is the most cost-effective approach to the management of opioid use disorder (OUD) during pregnancy.
Methods:
We created a decision analytic model that compared the cost effectiveness (eg, the marginal cost of the strategy in U.S. dollars divided by the marginal effectiveness of the strategy, measured in quality-adjusted life-years [QALYs]) of initiation of methadone, buprenorphine, or detoxification in treatment of OUD during pregnancy. Probabilities, costs, and utilities were estimated from the existing literature. Incremental cost-effective ratios for each strategy were calculated, and a ratio of $100,000 per QALY was used to define cost effectiveness. One-way sensitivity analyses and a Monte Carlo probabilistic sensitivity analysis were performed.
Results:
Under base assumptions, initiation of buprenorphine was more effective at a lower cost than either methadone or detoxification and thus was the dominant strategy. Buprenorphine was no longer cost effective if the cost of methadone was 8% less than the base-case estimate ($1,646/month) or if the overall costs of detoxification were 121% less than the base-case estimate for the detoxification cost multiplier, which was used to increase the values of both inpatient and outpatient management of detoxification by a factor of 2. Monte Carlo analyses revealed that buprenorphine was the cost-effective strategy in 70.5% of the simulations. Direct comparison of buprenorphine with methadone demonstrated that buprenorphine was below the incremental cost-effective ratio in 95.1% of simulations; direct comparison between buprenorphine and detoxification demonstrated that buprenorphine was below the incremental cost-effective ratio in 45% of simulations.
Conclusion:
Under most circumstances, we estimate that buprenorphine is the cost-effective strategy when compared with either methadone or detoxification as treatment for OUD during pregnancy. Nonetheless, the fact that buprenorphine was not the cost-effective strategy in almost one out of three of simulations suggests that the robustness of our model may be limited and that further evaluation of the cost-effective approach to the management of OUD during pregnancy is needed.
... The extant literature has primarily examined the feasibility and efficacy of buprenorphine/naloxone among youth, including a recent randomized controlled trial which found that longer duration (i.e., 56 days) of buprenorphine/naloxone was more effective in preventing relapse among youth compared with a shorter duration (i.e., 28 days) of therapy (6). In addition to improving treatment outcomes, buprenorphine/ naloxone has also been found to be a cost-effective treatment for youth with OUD (7). From youth's perspective, buprenorphine/naloxone was perceived to be more effective than methadone for reducing cravings and eliminating withdrawal symptoms, and it was also perceived to be a less-stigmatizing medication than methadone (8). ...
The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth (adolescents and young adults age 15-25) in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with opioid use disorder, and there is an urgent need to expand evidence-based care for treatment of opioid use disorder among this population. Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. In this article, we outline the current dilemmas and questions regarding the use of medication-assisted treatment among youth with opioid use disorder and propose some potential solutions based on the current evidence.
... Did the presentation and discussion of study results include all issues of concern to users? use, 76-89 did not include a comparator, 90,91 were not explicitly focused on mental health outcomes, 92,93 pre-dated 1997, [94][95][96][97] examined individual treatments for full-threshold disorders, [98][99][100][101][102][103][104][105][106][107][108][109][110][111][112][113][114][115] were evidence reviews, [116][117][118][119][120][121][122][123][124][125][126] were not peer-reviewed 120,[127][128][129] or were primarily focused on matt ers relating to system fi nancing. 77,130 To integrate the fi ndings from our review of included studies with the themes identifi ed in our briefer review of excluded studies and preference studies, we prepared a list of att ributes of youth mental health care that may be acceptable to young people and potentially cost-eff ective (Box 5). ...
Objective:
To identify attributes of youth mental health care for which there is evidence of potential cost-effectiveness.
Study design:
We performed a literature review of economic evaluations that examined both costs and outcomes for attributes of youth mental health care other than pharmacological or individual psychological therapies for full-threshold disorders.
Data sources:
We searched the United Kingdom National Health Service Economic Evaluations Database for evaluations published to the end of 2014; and MEDLINE, Google Scholar and the citation lists of relevant publications for peer-reviewed studies published in English since 1997.
Data synthesis:
Forty economic evaluations met inclusion criteria. Psychosis was the mental disorder with the most developed economic evidence base, with good evidence of cost-effectiveness for first-episode psychosis services. There was a developing cost-effectiveness evidence base for other disorders. The most common attributes of the interventions examined in the included studies were the location of services, engagement and support of families, assessment, prevention, early intervention, group delivery format and information provision. We used our findings to formulate a list of attributes of youth mental health care that may be acceptable to young people and potentially cost-effective.
Conclusion:
There is at least suggestive cost-effectiveness evidence for a range of attributes of youth mental health care. Further economic research is needed to substantiate most cost-effectiveness findings and to improve targeting of care among young people. Future economic evaluations should examine costs from both societal and health care perspectives and incorporate evidence regarding young people's preferences.
... Pharmacotherapy for addiction has evolved significantly over the past decade (Franck & Jayaram-Lindstrom, 2013;Hall et al., 2014;Riksheim, Gossop, & Clausen, 2014), with more types of medications and methods of administration available. Demonstrated effectiveness and cost-effectiveness have made addiction pharmacotherapy an evidencebased practice Gastfriend, 2011;Maisel, Blodgett, Wilbourne, Humphreys, & Finney, 2013;Polsky et al., 2010;Rosner et al., 2010;Schackman, Leff, Polsky, Moore, & Fiellin, 2012;Thomas et al., 2014). Newer medications address craving, moving beyond limiting withdrawal symptoms or reducing the "high" from substance use. ...
Background:
An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).
Methods:
Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.
Results:
Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.
Conclusions:
Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating that they value addiction pharmacotherapy as an evidence-based practice.
... The surge in opioid abuse has been attributed to factors including the social acceptance of medications, the aggressive culture of pharmaceutical advertising, and the increasing availability of prescription analgesics Daubresse et al, 2013). Subsequently, concerns have been raised over drug prescribing patterns (Compton and Volkow, 2006), the social and economic costs of opioid addiction (Connock et al, 2007;McCarty et al, 2010;Polsky et al, 2010;Schackman et al, 2012), as well as the safety (Maremmani and Gerra, 2010), availability (Bonhomme et al, 2012;Nosyk et al, 2013;Novick et al, 2015) and expansion of current treatment options, mainly methadone (METH) and buprenorphine (BUP) replacement (Bonhomme et al, 2012;Kraus et al, 2011;Wesson and Smith, 2010). ...
Methadone and buprenorphine are currently the most common pharmacological treatments for opioid dependence. Interestingly, the clinical response to these drugs appears to be sex-specific. That is, females exhibit superior therapeutic efficacy, defined as extended periods of abstinence and longer time to relapse, compared to males. However, the underlying metabolic effects of opioid withdrawal and replacement have not been examined. Therefore, using (18)FDG and microPET, we measured differences in regional brain glucose metabolism in males and females following morphine withdrawal and subsequent methadone or buprenorphine replacement. In both males and females, spontaneous opioid withdrawal altered glucose metabolism in regions associated with reward and drug dependence. Specifically, metabolic increases in the thalamus, as well as metabolic decreases in insular cortex and the periaqueductal grey were noted. However, compared to males, females exhibited increased metabolism in the preoptic area, primary motor cortex, and the amygdala, and decreased metabolism in the caudate/putamen and medial geniculate nucleus. Methadone and buprenorphine initially abolished these changes uniformly, but subsequently produced their own regional metabolic alterations that varied by treatment and sex. Compared to sex-matched control animals undergoing spontaneous opioid withdrawal, male animals treated with methadone exhibited increased caudate/putamen metabolism, whereas buprenorphine produced increased ventral striatum and motor cortex metabolism in females, and increased ventral striatum and somatosensory cortex metabolism in males. Notably, when treatment effects were compared between sexes, methadone-treated females showed increased cingulate cortex metabolism, while buprenorphine-treated females showed decreased metabolism in cingulate cortex and increased metabolism in the globus pallidus. Perhaps the initial similarities in males and females underlie early therapeutic efficacy, while these post-treatment sex differences contribute to clinical treatment failure more commonly experienced by the former.Neuropsychopharmacology accepted article preview online, 10 April 2017. doi:10.1038/npp.2017.69.
... Measuring HRQoL in opioid use disorder treatment programs represents an opportunity to consider outcomes that are more patient-centered and more relevant to overall health than abstinence alone, and to expand the definition of treatment benefits. Some clinical trials of opioid use disorder therapies measure HRQoL outcomes, and in particular QALYs, so that economic outcomes can be compared to those from studies of other health conditions (Byford et al., 2013;Campbell et al., 2012;Nosyk et al., 2011;Polsky et al., 2010). Measurement of these patient-centered and economic outcomes in "real world" program settings is also needed to support greater adoption of evidence-based services. ...
Background and aims:
The recent opioid epidemic has prompted renewed interest in opioid use disorder treatment, but there is little evidence regarding health-related quality-of-life (HRQoL) outcomes in treatment programs. Measuring HRQoL represents an opportunity to consider outcomes of opioid use disorder treatment that are more patient-centered and more relevant to overall health than abstinence alone. We conducted a systematic literature review to explore the extent to which the collection of HRQoL by opioid treatment programs is documented in the treatment program literature.
Materials and methods:
We searched PubMed, Embase PsycINFO and Web of Science for papers published between 1965 and 2015 that reported HRQoL outcome measures from substance abuse treatment programs.
Results:
Of the 3014 unduplicated articles initially identified for screening, 99 articles met criteria for further review. Of those articles, 7 were unavailable in English; therefore 92 articles were reviewed. Of these articles, 44 included any quality-of-life measure, 17 of which included validated HRQoL measures, and 10 supported derivation of quality-adjusted life year utility weights. The most frequently used validated measure was the Addiction Severity Index (ASI). Non-U.S. and more recent studies were more likely to include a measure of HRQoL.
Conclusions:
HRQoL measures are rarely used as outcomes in opioid treatment programs. The field should incorporate HRQoL measures as standard practice, especially measures that can be used to derive utility weights, such as the SF-12 or EQ-5D. These instruments provide policy makers with evidence on the impact of programs on patients' lives and with data to quantify the value of investing in opioid use disorder treatments.
... A price increase of 10% globally would cost $12-313USD per disability-adjusted life year (DALY) saved. In low and middle income countries this would be $3-70USD/DALY saved, in high income countries, $83-2771USD/DALY saved 459 Buprenorphine-naloxone maintenance treatment is cost effective in treating opioid dependent young people: the incremental cost-effectiveness ratio was $1376 per QALY and $308 per opioid-free year 327 . ...
We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision—which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.
... Medical services that were tracked included residential rehabilitation, hospital detoxification, hospital non-detoxification, medical office, emergency department (ED) and psychiatrist visits, and post-intervention counseling hours. The unit costs for residential ($511), detox ($672), hospital non-detox ($1,247), medical office ($127) and ED ($504) visits were obtained from the 2003 MEDSTAT MarketScan database and are based on mean out-of-pocket expenditures and reimbursements for beneficiaries with SUDs between the ages of 12 and 25 (Polsky et al., 2010). The cost of a psychiatrist visit was based on the BLS' estimated mean annual salary for a psychiatrist ($182,660) (Bureau of Labor Statistics, 2014), and 30.2% benefit rate, resulting in a total annual compensation estimate of $261,691 ($126/hour). ...
Background:
Few studies have examined the cost of medication for opioid use disorder (MOUD) with counseling for the adolescent and young adult population. This study calculated the health care utilization and cost of MOUD treatment, other substance use disorder treatment, and general health care for adolescents and young adults receiving treatment for opioid use disorder.
Methods:
The study randomized youth ages 15 to 21 (N = 288) equally into the two study conditions: extended-release naltrexone (XR-NTX) or treatment as usual (TAU). While participants committed to treatment based on randomization the study observed considerable nonadherence to both randomized conditions. Instead of using the randomly assigned study conditions, we present descriptive costs by the type of MOUD treatment received: XR-NTX only, buprenorphine only, any other combination of MOUD treatments, and no MOUD. Health care use was aggregated over the 6-month period for each participant, and we calculated average/participant utilization for each treatment group. To determine participant costs, we multiplied the unit costs of health care services obtained from the literature by the reported amount of health care utilization for each participant. We then calculated the mean, standard error, median and IQR for MOUD costs, other substance use disorder treatment costs and general healthcare cost from the health care sector perspective.
Results:
On average, participants in the XR-NTX only group received 2.6 doses of XR-NTX (equivalent to approximately 78 days of treatment). The buprenorphine only group had an average of 97 days of buprenorphine treatment. The XR-NTX only group had higher/patient costs compared to participants in the buprenorphine only group ($10,491 vs. $8765) and higher XR-NTX utilization would further increase costs. Participants in the any other MOUD combination group had the highest total costs ($14,627) while participants in the no MOUD group at the lowest ($3453).
Discussion:
Our cost analysis calculates the real-world cost of MOUD treatment and, while not generalizable, provides policy makers an estimate of costs for adolescents and young adults. We found that participants in the XR-NTX only group received fewer days of medication compared to the buprenorphine only group, but their medication costs were higher due to the cost of XR-NTX injections. While the buprenorphine only group had the highest number of days of medication utilization of all the groups, the average number of days of medication utilization was considerably shorter than the six-month treatment period.
Introduction:
The economic burden of substance use disorder (SUD) is significant, comprising costs of health care and social services, criminal justice resources, loss of productivity, and premature mortality. This study assembles and synthesizes two decades of evidence describing the benefits of SUD treatment across five main outcome domains; 1) health care utilization; 2) self-reported criminal activity by offense type; 3) criminal justice involvement collected from administrative records or self-reported; 4) productivity assessed through working hours or wages earned; and 5) social services (e.g., a day spent in transitional housing).
Methods:
This review included studies if they reported the monetary value of the intervention outcomes, most commonly through a cost-benefit or cost-effectiveness framework. The search included studies from 2003 to the present day as of this writing (up to October 15, 2021). Summary cost estimates were adjusted using the US Consumer Price Index (CPI) to reflect the 12-month benefits per client in USD 2021. We followed the PRISMA methodology for study selection and assessed quality using the Checklist for Health Economic Evaluation Reporting Standards (CHEERS).
Results:
The databases yielded 729 studies after removing duplicates, and we ultimately selected 12 for review. Studies varied widely regarding analytical approaches, time horizons, outcome domains, and other methodological factors. Among the ten studies that found positive economic benefits, reductions in criminal activity or criminal justice costs represented the largest or second largest component of these benefits (range $621 to $193,440 per client).
Conclusions:
Consistent with previous findings, a reduction in criminal activity costs is driven by the relatively high societal cost per criminal offense, notably for violent crimes, such as aggravated assault and rape/sexual assault. Accepting the economic rationale for increased investment in SUD interventions will require recognizing that more benefits accrue to individuals by avoiding being victims of a crime than to governments through budget offsets resulting from savings in non-SUD program expenses. Future studies should explore individually tailored interventions to optimize care management, which may yield unexpected economic benefits to services utilization, and criminal activity data to estimate economic benefits across a broad range of interventions.
Importance:
Alcohol use disorders have a high disease burden among US Latino groups. In this population, health disparities persist, and high-risk drinking has been increasing. Effective bilingual and culturally adapted brief interventions are needed to identify and reduce disease burden.
Objective:
To compare the effectiveness of an automated bilingual computerized alcohol screening and intervention (AB-CASI) digital health tool with standard care for the reduction of alcohol consumption among US adult Latino emergency department (ED) patients with unhealthy drinking.
Design, setting, and participants:
This bilingual unblinded parallel-group randomized clinical trial evaluated the effectiveness of AB-CASI vs standard care among 840 self-identified adult Latino ED patients with unhealthy drinking (representing the full spectrum of unhealthy drinking). The study was conducted from October 29, 2014, to May 1, 2020, at the ED of a large urban community tertiary care center in the northeastern US that was verified as a level II trauma center by the American College of Surgeons. Data were analyzed from May 14, 2020, to November 24, 2020.
Intervention:
Patients randomized to the intervention group received AB-CASI, which included alcohol screening and a structured interactive brief negotiated interview in their preferred language (English or Spanish) while in the ED. Patients randomized to the standard care group received standard emergency medical care, including an informational sheet with recommended primary care follow-up.
Main outcomes and measures:
The primary outcome was the self-reported number of binge drinking episodes within the last 28 days, assessed by the timeline followback method at 12 months after randomization.
Results:
Among 840 self-identified adult Latino ED patients (mean [SD] age, 36.2 [11.2] years; 433 [51.5%] male; and 697 [83.0%] of Puerto Rican descent), 418 were randomized to the AB-CASI group and 422 to the standard care group. A total of 443 patients (52.7%) chose Spanish as their preferred language at enrollment. At 12 months, the number of binge drinking episodes within the last 28 days was significantly lower in those receiving AB-CASI (3.2; 95% CI, 2.7-3.8) vs standard care (4.0; 95% CI, 3.4-4.7; relative difference [RD], 0.79; 95% CI, 0.64-0.99). Alcohol-related adverse health behaviors and consequences were similar between groups. The effect of AB-CASI was modified by age; at 12 months, the relative reduction in the number of binge drinking episodes within the last 28 days in the AB-CASI vs standard care group was 30% in participants older than 25 years (RD, 0.70; 95% CI, 0.54-0.89) compared with an increase of 40% in participants 25 years or younger (RD, 1.40; 95% CI, 0.85-2.31; P = .01 for interaction).
Conclusions and relevance:
In this study, US adult Latino ED patients who received AB-CASI had a significant reduction in the number of binge drinking episodes within the last 28 days at 12 months after randomization. These findings suggest that AB-CASI is a viable brief intervention that overcomes known procedural barriers to ED screening, brief intervention, and referral to treatment and directly addresses alcohol-related health disparities.
Trial registration:
ClinicalTrials.gov Identifier: NCT02247388.
Prospective economic evaluations conducted alongside clinical trials have become an increasingly popular approach in evaluating the cost-effectiveness of a public health initiative or treatment intervention. These types of economic studies provide improved internal validity and accuracy of cost and effectiveness estimates of health interventions and have the advantage of jointly observing health and economics outcomes of trial participants compared to simulation or decision-analytic models. However, missing data due to incomplete response or patient attrition, and sampling uncertainty are common concerns in econometric analysis of clinical trials. Missing data is a particular problem for comparative effectiveness trials of substance use disorder interventions. Methods such as multiple imputation and inverse probability weighting are two widely-recommend methods to address missing data bias, and the nonparametric bootstrap is recommended to address uncertainty in predicted mean cost and effectiveness between trial interventions. While these methods have been studied extensively by themselves, little is known on how to appropriately combine them, and the potential pitfalls and advantages of different approaches. We provide a timely review of statistical methods employed by 29 economic evaluations of substance use disorders intervention identified from 4 prior-published systematic reviews and a targeted search of the literature. We evaluate how each study addressed missing data bias, whether the recommended nonparametric bootstrap was employed, how these two methods were combined, and conclude with recommendations for future research.
Background:
Opioid use disorder (OUD), including opioid misuse, abuse, and overdose, has evolved into a national crisis with a lasting effect on society, individuals, and health care systems. Although an office-based treatment of Suboxone combined with counseling is a viable option for individuals with OUD and has been shown to reduce utilization of medical services, the relapse rate among those individuals remains high. There is a need to investigate factors associated with relapse to tailor treatment programs in an effort to prevent relapse. This study aimed to examine factors associated with relapse in individuals with OUD receiving Suboxone.
Methods:
A convenience sample was recruited from an outpatient Suboxone facility located in a rural county of New York. Measures included urine drug testing obtained through the medical record, patterns of time to relapse as measured by the Time to Relapse Questionnaire, pain intensity, and a demographic questionnaire. Descriptive statistics, independent t test, and chi-square statistics were utilized for data analysis.
Results:
Forty-six patients participated in the study. Length of time in a Suboxone program, scores in sudden and long delay relapse, and the type of treatment program were statistically associated with relapse.
Conclusion:
This study provided insight regarding factors contributing to relapse and different time-to-relapse styles that could be incorporated into clinical practice to help prevent relapse.
Introduction
Persons with opioid use disorder (OUD) are prone to frequent relapse following brief inpatient medically managed withdrawal. This longitudinal, naturalistic study examines associations among illicit opioid use, use of medication for opioid use disorder (MOUD), and one’s confidence in the ability to resist drug use in the face of negative emotions (i.e., negative affect–associated drug refusal self-efficacy).
Method
Participants were 220 adults with OUD who recently completed a short-term inpatient program and the study followed for 6 months. At baseline, participants reported demographics, illicit opioid use, recent engagement with MOUD, and negative affect–associated drug refusal self-efficacy. At follow-up (1 week and 1-, 3-, and 6-months following discharge), participants reported illicit opioid use and MOUD.
Results
Participants averaged 30.7 years of age, 63.2% were male, and 84.1% were white. Both illicit opioid use and rates of MOUD increased during the 6-month follow-up period, although only 34.1% received MOUD. At baseline, participants reported less than 50% self-confidence to resist using opioids during negative emotional states. Baseline negative affect–associated drug refusal self-efficacy inversely predicted illicit opioid use (p=.01) at follow-up but was not associated with follow-up MOUD.
Conclusion
Among persons with OUD, lower confidence to resist using opioids in negative emotional states predicts greater use of illicit opioids in the months following medically managed withdrawal, even with receipt of MOUD.
We apply a mixed-payer economy model to study the effects of changes in the generosity of children’s public health insurance programs – measured by Medicaid and Children’s Health Insurance Program income thresholds – on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997 to 2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children’s public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.
We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.
Although recent spikes in overdose deaths are largely attributable to heroin and fentanyl, prescription opioids still account for a significant percentage of overdose deaths. Additionally, overdose deaths are not a problem solely for adults; roughly 8% of all overdose deaths occur in persons aged 15 to 24. In addition to identifying factors that increase risk for misuse and negative outcomes among adolescents, research must examine the causal mechanisms that link these factors to increased risk. Finally, the extant research must serve as the foundation for prevention/intervention strategies and identify treatments that are effective among adolescents with opioid use disorders.
Opioid use disorder (OUD) is a national crisis. Health care must achieve greater success than it has to date in helping opioid users achieve recovery. Integration of comprehensive primary care with treatment for OUD has the potential to increase care access among the substance-using population, improve outcomes, and reduce costs. However, little is known about the effectiveness of such care models. The Comprehensive Care Practice (CCP), a primary care practice located in Maryland, implemented a care model that blends buprenorphine treatment for OUD with attention to primary care needs. This study evaluates the model by comparing patients with OUD treated in CCP and other Maryland facilities in a large state Medicaid program. Compared to the non-CCP patient group (n = 867), the CCP group (n = 131) had a higher 6-month buprenorphine treatment retention rate (79% vs. 61%, adjusted average marginal effect (AME) = 0.17, P < 0.001). CCP patients also had fewer hospital stays in the 12-month follow-up period (0.22 vs. 0.41, AME = -0.17, P = 0.005), and lower total cost (US$10,942 vs. $13,097, AME = -$4554, P < 0.001) and hospital stay cost (US$1448 vs. $4265, AME = -$2609, P = 0.001), but higher buprenorphine pharmacy cost (US$3867 vs. $2781, AME = $987, P < 0.001). Other measures, including emergency department utilization and cost, substance abuse cost, and non-buprenorphine pharmacy cost, were not statistically different between the 2 groups. Results suggested that patients, as well as the health care system, can benefit from an integrated model of buprenorphine treatment and primary care for OUD with better treatment retention, fewer hospital stays, and lower costs.
Background
Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.
Methods
Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk.
Results
During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40).
Discussion
These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings.
Trial registration number
NCT0178830; Results.
Background:
Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations.
Objective:
To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities.
Design:
Model-based cost-effectiveness analysis.
Data sources:
Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature.
Target population:
Persons initially presenting for publicly funded treatment of opioid use disorder.
Time horizon:
Lifetime.
Perspective:
Societal.
Intervention:
Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal).
Outcome measures:
Discounted quality-adjusted life-years (QALYs) and discounted costs.
Results of base-case analysis:
Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion.
Results of sensitivity analysis:
99.6% of the 2000 simulations resulted in lower costs and more QALYs.
Limitation:
Nonrandomized delivery of OAT or medically managed withdrawal.
Conclusion:
The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care.
Primary funding source:
National Institute on Drug Abuse.
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 three methods of intervening on opioid dependence in the ED.
Design:
Measured health-care 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 United States.
Participants:
Opioid-dependent patients aged 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% 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.
Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.
From the late 1960s to the mid-1990s, the basic drug-crime policy challenge was to manage social harms associated with the heroin and cocaine epidemics. As they ebbed, the crime-drug policy challenges changed. Alcohol receives greater attention as the leading criminogenic substance. Efforts are under way to improve and expand substance use disorder (SUD) treatment for criminally active populations. Model nontreatment interventions seek to monitor and deter use among individuals whose use endangers others. Two key issues are the continuing high rate of alcohol-related crime and violence and opportunities to expand SUD treatment for criminally active populations under the Affordable Care Act (ACA). Alcohol taxes, regulation of alcohol venues, and model programs such as Dakota 24/7 are promising paths to reduced alcohol-related crime. Problem-solving courts can be made more pertinent to the broad range of drug-involved offenders. Existing treatment systems face many challenges in providing mental and behavioral health services mandated under the ACA. Properly implemented, ACA offers many opportunities to prevent offending through provision of appropriate services.
Background and aims:
Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol® ) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use disorder. The cost of XR-NTX may be a significant barrier to adoption. Thus, it is important to account for improved quality of life and downstream cost-offsets. Our aims were to (1) estimate the incremental cost per quality-adjusted life-year (QALY) gained for XR-NTX versus treatment as usual (TAU) and evaluate it relative to generally accepted value thresholds; and (2) estimate the incremental cost per additional year of opioid abstinence.
Design:
Economic evaluation of the aforementioned trial from the taxpayer perspective. Participants were randomized to 25 weeks of XR-NTX injections or TAU; follow-up occurred at 52 and 78 weeks.
Setting:
Five study sites in the US Northeast corridor.
Participants:
A total of 308 participants were randomized to XR-NTX (n = 153) or TAU (n = 155).
Measurements:
Incremental costs relative to incremental economic and clinical effectiveness measures, QALYs and abstinent years, respectively.
Findings:
The 25-week cost per QALY and abstinent-year figures were $162 150 and $46 329, respectively. The 78-week figures were $76 400/QALY and $16 371/abstinent year. At 25 weeks, we can be 10% certain that XR-NTX is cost-effective at a value threshold of $100 000/QALY and 62% certain at $200 000/QALY. At 78 weeks, the cost-effectiveness probabilities are 59% at $100 000/QALY and 76% at $200 000/QALY. We can be 95% confident that the intervention would be considered 'good value' at $90 000/abstinent year at 25 weeks and $500/abstinent year at 78 weeks.
Conclusions:
While extended-release naltrexone appears to be effective in increasing both quality-adjusted life-years (QALYs) and abstinence, it does not appear to be cost-effective using generally accepted value thresholds for QALYs, due to the high price of the injection.
Background:
Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of substitution treatment.
Objectives:
To assess the effects of buprenorphine versus tapered doses of methadone, alpha2-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine regimens for managing opioid withdrawal, in terms of the intensity of the withdrawal syndrome experienced, duration and completion of treatment, and adverse effects.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2016), MEDLINE (1946 to December week 1, 2016), Embase (to 22 December 2016), PsycINFO (1806 to December week 3, 2016), and the Web of Science (to 22 December 2016) and handsearched the reference lists of articles.
Selection criteria:
Randomised controlled trials of interventions using buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2-adrenergic agonists (clonidine or lofexidine), symptomatic medications or placebo, and different buprenorphine-based regimens.
Data collection and analysis:
We used standard methodological procedures expected by Cochrane.
Main results:
We included 27 studies involving 3048 participants. The main comparators were clonidine or lofexidine (14 studies). Six studies compared buprenorphine versus methadone, and seven compared different rates of buprenorphine dose reduction. We assessed 12 studies as being at high risk of bias in at least one of seven domains of methodological quality. Six of these studies compared buprenorphine with clonidine or lofexidine and two with methadone; the other four studies compared different rates of buprenorphine dose reduction.For the comparison of buprenorphine and methadone in tapered doses, meta-analysis was not possible for the outcomes of intensity of withdrawal or adverse effects. However, information reported by the individual studies was suggestive of buprenorphine and methadone having similar capacity to ameliorate opioid withdrawal, without clinically significant adverse effects. The meta-analyses that were possible support a conclusion of no difference between buprenorphine and methadone in terms of average treatment duration (mean difference (MD) 1.30 days, 95% confidence interval (CI) -8.11 to 10.72; N = 82; studies = 2; low quality) or treatment completion rates (risk ratio (RR) 1.04, 95% CI 0.91 to 1.20; N = 457; studies = 5; moderate quality).Relative to clonidine or lofexidine, buprenorphine was associated with a lower average withdrawal score (indicating less severe withdrawal) during the treatment episode, with an effect size that is considered to be small to moderate (standardised mean difference (SMD) -0.43, 95% CI -0.58 to -0.28; N = 902; studies = 7; moderate quality). Patients receiving buprenorphine stayed in treatment for longer, with an effect size that is considered to be large (SMD 0.92, 95% CI 0.57 to 1.27; N = 558; studies = 5; moderate quality) and were more likely to complete withdrawal treatment (RR 1.59, 95% CI 1.23 to 2.06; N = 1264; studies = 12; moderate quality). At the same time there was no significant difference in the incidence of adverse effects, but dropout due to adverse effects may be more likely with clonidine (RR 0.20, 95% CI 0.04 to 1.15; N = 134; studies = 3; low quality). The difference in treatment completion rates translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 6), indicating that for every four people treated with buprenorphine, we can expect that one additional person will complete treatment than with clonidine or lofexidine.For studies comparing different rates of reduction of the buprenorphine dose, meta-analysis was possible only for treatment completion, with separate analyses for inpatient and outpatient settings. The results were diverse, and we assessed the quality of evidence as being very low. It remains very uncertain what effect the rate of dose taper has on treatment outcome.
Authors' conclusions:
Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion.Buprenorphine and methadone appear to be equally effective, but data are limited. It remains possible that the pattern of withdrawal experienced may differ and that withdrawal symptoms may resolve more quickly with buprenorphine.It is not possible to draw any conclusions from the available evidence on the relative effectiveness of different rates of tapering the buprenorphine dose. The divergent findings of studies included in this review suggest that there may be multiple factors affecting the response to the rate of dose taper. One such factor could be whether or not the initial treatment plan includes a transition to subsequent relapse prevention treatment with naltrexone. Indeed, the use of buprenorphine to support transition to naltrexone treatment is an aspect worthy of further research.Most participants in the studies included in this review were male. None of the studies reported outcomes on the basis of sex, preventing any exploration of differences related to this variable. Consideration of sex as a factor influencing response to withdrawal treatment would be relevant research for selecting the most appropriate type of intervention for each individual.
O Projeto Diretrizes, iniciativa da Associação Médica Brasileira, tem por objetivo conciliar informações da área médica a fim de padronizar condutas que auxiliem o raciocínio e a tomada de decisão do médico. As informações contidas neste projeto devem ser submetidas à avaliação e à crítica do médico, responsável pela conduta a ser seguida, frente à realidade e ao estado clínico de cada paciente.
The term drug is not employed in the International Classification of Diseases, 10th revision (ICD-10) classification (World Health Organisation 1996), which refers instead to groups of psychotropic substances, the ingestion of which - usually on a regular and medically inappropriate basis - can lead to mental disorders and behavioral abnormalities: alcohol, opioids, cannabinoids, sedatives or hypnotics, cocaine, other psychostimulants (including caffeine), hallucinogens, tobacco, and volatile solvents. Disorders arising from alcohol abuse are not discussed here, but in Chap. 10. It is difficult to accommodate so-called party drugs in these categories, so they will be discussed in a separate section.
Patients with a history of abuse/misuse of pain and psychotic medications are at high risk for suicide. Novel drug delivery and formulation approaches have been explored to reduce the potential of drug abuse/misuse and to improve patient compliance. This chapter reviews the design and mechanism of five successful products in the opioid and anti-psychotic categories. Embeda® is an extended release capsule containing morphine pellets with a sequestered core of naltrexone; naltrexone acts as an aversive agent and is released only when the product is crushed. Remoxy® is an extended release oxycodone capsule with a highly viscous liquid fill content which is resistant to most common methods of tampering. Suboxone® is a sublingual tablet or film strip of buprenorphine with naloxone as an aversive agent; naloxone has poor sublingual/oral bioavailability and does not exert its activity unless the product is abused by the injectable route. Risperidal® Consta®, is a biweekly intramuscular injection of risperidone based on a biodegradable polymer microsphere technology. Invega® Sustenna® is a once-monthly intramuscular injection of paliperidone based on the water insoluble prodrug approach. The review of these five new drug products showcases the novel formulation tools and technologies available to deter drug abuse/misuse in patients who are at high risk of suicide.
Associação Médica Brasileira O Projeto Diretrizes, iniciativa da Associação Médica Brasileira, tem por objetivo conciliar informações da área médica a fim de padronizar condutas que auxiliem o raciocínio e a tomada de decisão do médico. As informações contidas neste projeto devem ser submetidas à avaliação e à crítica do médico, responsável pela conduta a ser seguida, frente à realidade e ao estado clínico de cada paciente.
Background:
A large number of interventions are available for the treatment of addiction. Professionals need to know about the effectiveness and cost-effectiveness of interventions so they can prioritise appropriate interventions for the treatment of addiction.
Aim:
To provide an overview of the scientific literature on the cost-effectiveness of addiction treatment for alcohol- and drug-abusers.
Method:
We searched the databases Medline and Centre for Reviews and Dissemination. To be relevant for our study, articles had to focus on interventions in the health-care setting, have a Western context and have a health-related outcome measure such as quality adjusted life years (QALY). Twenty-nine studies met our inclusion criteria: 15 for alcohol and 14 for drugs.
Results:
The studies on alcohol addiction related mainly to brief interventions. They proved to be cost-saving or had a favourable incremental cost-effectiveness ratio (ICER), remaining below the threshold of € 20,000 per QALY. The studies on drug addiction all involved pharmacotherapeutic interventions. In the case of 10 out of 14 interventions, the ICER was less than € 20,000 per QALY.
Conclusion:
Almost all of the interventions studied were cost-saving or cost-effective. Many studies consider only health-care costs. Additional research, for instance using a social cost-benefit analysis, could provide more details about the costs of addiction and about the impact that an intervention could have in these/the costs.
The objective of this review was to evaluate the use of all direct and indirect methods used to estimate health utilities in both children and adolescents. Utilities measured pre- and post-intervention are combined with the time over which health states are experienced to calculate quality-adjusted life years (QALYs). Cost-utility analyses (CUAs) estimate the cost-effectiveness of health technologies based on their costs and benefits using QALYs as a measure of benefit. The accurate measurement of QALYs is dependent on using appropriate methods to elicit health utilities.
We sought studies that measured health utilities directly from patients or their proxies. We did not exclude those studies that also included adults in the analysis, but excluded those studies focused only on adults.
We evaluated 90 studies from a total of 1,780 selected from the databases. 47 (52%) studies were CUAs incorporated into randomised clinical trials; 23 (26%) were health-state utility assessments; 8 (9%) validated methods and 12 (13%) compared existing or new methods. 22 unique direct or indirect calculation methods were used a total of 137 times. Direct calculation through standard gamble, time trade-off and visual analogue scale was used 32 times. The EuroQol EQ-5D was the most frequently-used single method, selected for 41 studies. 15 of the methods used were generic methods and the remaining 7 were disease-specific. 48 of the 90 studies (53%) used some form of proxy, with 26 (29%) using proxies exclusively to estimate health utilities.
Several child- and adolescent-specific methods are still being developed and validated, leaving many studies using methods that have not been designed or validated for use in children or adolescents. Several studies failed to justify using proxy respondents rather than administering the methods directly to the patients. Only two studies examined missing responses to the methods administered with respect to the patients' ages.
The usual treatment for opioid-addicted youth is detoxification and counseling. Extended medication-assisted therapy may be more helpful.
To evaluate the efficacy of continuing buprenorphine-naloxone for 12 weeks vs detoxification for opioid-addicted youth.
Clinical trial at 6 community programs from July 2003 to December 2006 including 152 patients aged 15 to 21 years who were randomized to 12 weeks of buprenorphine-naloxone or a 14-day taper (detox).
Patients in the 12-week buprenorphine-naloxone group were prescribed up to 24 mg per day for 9 weeks and then tapered to week 12; patients in the detox group were prescribed up to 14 mg per day and then tapered to day 14. All were offered weekly individual and group counseling.
Opioid-positive urine test result at weeks 4, 8, and 12.
The number of patients younger than 18 years was too small to analyze separately, but overall, patients in the detox group had higher proportions of opioid-positive urine test results at weeks 4 and 8 but not at week 12 (chi(2)(2) = 4.93, P = .09). At week 4, 59 detox patients had positive results (61%; 95% confidence interval [CI] = 47%-75%) vs 58 12-week buprenorphine-naloxone patients (26%; 95% CI = 14%-38%). At week 8, 53 detox patients had positive results (54%; 95% CI = 38%-70%) vs 52 12-week buprenorphine-naloxone patients (23%; 95% CI = 11%-35%). At week 12, 53 detox patients had positive results (51%; 95% CI = 35%-67%) vs 49 12-week buprenorphine-naloxone patients (43%; 95% CI = 29%-57%). By week 12, 16 of 78 detox patients (20.5%) remained in treatment vs 52 of 74 12-week buprenorphine-naloxone patients (70%; chi(2)(1) = 32.90, P < .001). During weeks 1 through 12, patients in the 12-week buprenorphine-naloxone group reported less opioid use (chi(2)(1) = 18.45, P < .001), less injecting (chi(2)(1) = 6.00, P = .01), and less nonstudy addiction treatment (chi(2)(1) = 25.82, P < .001). High levels of opioid use occurred in both groups at follow-up. Four of 83 patients who tested negative for hepatitis C at baseline were positive for hepatitis C at week 12.
Continuing treatment with buprenorphine-naloxone improved outcome compared with short-term detoxification. Further research is necessary to assess the efficacy and safety of longer-term treatment with buprenorphine for young individuals with opioid dependence.
clinicaltrials.gov Identifier: NCT00078130.
Juvenile drug court (JDC) programs have expanded rapidly over the past 20 years and are an increasingly popular option for rehabilitating juvenile offenders with substance use problems. Given the high cost of crime to society, an important economic question is whether and to what extent JDC programs reduce criminal activity among juvenile offenders. To address this question, the present study added an economic cost analysis to an ongoing randomized trial of JDC conducted in Charleston, South Carolina. Four treatment conditions were included in the parent study: Family Court with usual community-based treatment (FC, the comparison group), Drug Court with usual community-based treatment (DC), DC with Multisystemic Therapy (DC/MST), and DC/MST enhanced with Contingency Management (DC/MST/CM). The economic study estimated the cost of criminal activity for nine specific crimes at baseline (pretreatment) and 4 and 12 months thereafter. A number of methodological challenges were encountered, suggesting that it may be more difficult to economically quantify frequency and type of criminal activity for adolescents than for adults. The present paper addresses methodological approaches and challenges, and proposes guidelines for future economic evaluations of adolescent substance abuse and crime prevention programs.
The use of information on inflation, pharmacoeconomics, generic competition, new drug entities, site-specific drug-use patterns, legislation, and the changing health care environment in the projection of drug expenditures is discussed.
Drug price inflation has declined from 6.9% in 1991 to 2.1% for part of 1995. Much of the decline is attributable to deep discounts given by manufacturers to managed care institutions. Some marketing specialists are predicting that drug manufacturers will begin to scale back discounts. Pharmaceutical industry analysts project that overall price increase for pharmaceuticals in the next 12-24 months will average 2.8% (range, 0-6%). Pharmacists need to be able to understand and critically evaluate pharmacoeconomic research, particularly studies conducted by the pharmaceutical industry. Savings due to increases in generic product selection may be offset to some degree by extensions of patent expiration dates under the General .Agreement on Tariffs and Trade (GATT). Drug budget projections should include a complete review of new drugs and biotechnology agents pending FDA approval, drugs pending approval for new indications, and common unlabeled uses of expensive existing agents. Various methods are available for tracking drug-use patterns in specific practice settings. When resources are limited, pharmacy managers maselect to target only high-cost drugs; a proactive approach, such as projecting costs and developing guidelines for costly agents before their market release and before consideration by the pharmacy and therajreutics committee. is advantageous. Relevant legislative activities in 1995 included reform proposals for Medicare, Medicaid, and FDA; the Federal Acquisition Streamlining Act; and GATT. Disease management and other approaches to pharmacy benefits have increased opportunities for cooperative arrangements between drug companies and health care providers that may have major effects on drug marketing and pricing.
Combining information on inflation, pharmacoeconomics, generics, new drugs, practicesite drug-use patterns, federal legislation, and the changing health care environment is necessary for accurate projections of drug expenditures.
In the course of developing a standardised, non-disease-specific instrument for describing and valuing health states (based on the items in Table 1), the EuroQol Group (whose members are listed In the Appendix) conducted postal surveys in England, The Netherlands and Sweden which indicate a striking similarity in the relative valuations attached to 14 different health states (see Table 3). The data were collected using a visual analogue scale similar to a thermometer (see Table 2). The EuroQol Instrument Is Intended to complement other quality-of-life measures and to facilitate the collection of a common data set for reference purposes. Others interested in participating in the extension of this work are invited to contact the EuroQol Group.
Aims. To determine the cost‐effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States, particularly its effect on the HIV epidemic.
Design. We developed a dynamic model to capture the effects of adding buprenorphine maintenance to the current opiate dependence treatment system. We evaluated incremental costs, including all health‐care costs, and incremental effectiveness, measured as quality‐adjusted life years (QALYs) of survival. We considered communities with HIV prevalence among injection drug users of 5% and 40%. Because no price has been set in the United States for a dose of buprenorphine, we considered three prices per dose: $5, $15, and $30.
Findings. If buprenorphine increases the number of individuals in maintenance treatment by 10%, but does not affect the number of individuals receiving methadone maintenance, the cost‐effectiveness ratios for buprenorphine maintenance therapy are less than $45 000 per QALY gained for all prices, in both the low‐prevalence and high‐prevalence communities. If the same number of individuals enter buprenorphine maintenance (10% of the number currently in methadone), but half are injection drug users newly entering maintenance and half are individuals who switched from methadone to buprenorphine, the cost‐effectiveness ratios in both communities are less than $45 000 per QALY gained for the $5 and $15 prices, and greater than $65 000 per QALY gained for the $30 price.
Conclusions. At a price of $5 or less per dose, buprenorphine maintenance is cost‐effective under all scenarios we considered. At $15 per dose, it is cost‐effective if its adoption does not lead to a net decline in methadone use, or if a medium to high value is assigned to the years of life lived by injection drug users and those in maintenance therapy. At $30 per dose, buprenorphine will be cost‐effective only under the most optimistic modeling assumptions.
It is becoming increasingly important to examine the relationship between the outcomes of a clinical trial and the costs of the medical therapy under study. The results of such analysis can affect reimbursement decisions for new medical technologies, for example drugs, devices or diagnostics; aid companies seeking to make claims about the cost-effectiveness of their product; allow early consideration of the economic value of therapies, which may be important to improving initial adoption decisions; or address the requirements of regulatory bodies. Economic evaluation in clinical trials uses a consistent set of data collected within the trial, or by projection from this data, and avoids having to incorporate unrelated (and potentially inconsistent) data from many different sources. This book provides a practical guide to conducting economic evaluation in ongoing clinical trials. It covers issues and techniques related to the collection of both cost and outcome data, as well as a framework for reporting and interpreting economic reports from clinical trials. This is illustrated by detailed supporting examples and exercises, designed to teach the reader how to apply this model. These exercises are supported with datasets, programmes and solutions made available online. ABOUT THE SERIES - series editors Alastair Gray and Andrew Briggs Economic evaluation of health intervention is a growing specialist field, and this series of practical handbooks tackles, in depth, topics superficially addressed in more geinconsistent economics books. Each volume includes illustrative material, case histories and worked examples to encourage the reader to apply the methods discussed, with supporting material provided online. This series is aimed at health economists in academia, the pharmaceutical industry and the health sector, those on advanced health economics courses, and health researchers in associated fields.
To determine whether drug abuse treatment services are cost-effective, policy makers need accurate estimates of the cost of treatment services. The objective of our analysis was to develop a new method for estimating the costs of specific drug treatment services and to apply that method to 170 methadone treatment clinics that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project.Our method extends previous research by including both indirect labor and nonlabor resources in service cost estimates. We found that service cost estimates that included indirect labor and nonlabor resources were two to three times higher than those that only included direct labor costs. Service costs ranged from $8 per patient per week for ongoing medical services to $106 for a session of initial patient assessment and treatment planning. Over all services, indirect labor and nonlabor costs combined accounted for between 41 and 69% of the estimated total service costs. We conclude that studies that only include direct labor costs are seriously underestimating the true costs of providing treatment services. Our services cost estimation method is applicable not only to the cost estimation of other drug treatment modalities but also to the cost estimation of other health care services.
This paper surveys the recent literature on the causal relationship between education and earnings. I focus on four areas of work: theoretical and econometric advances in modelling the causal effect of education in the presence of heterogeneous returns to schooling; recent studies that use institutional aspects of the education system to form instrumental variables estimates of the return to schooling; recent studies of the earnings and schooling of twins; and recent attempts to explicitly model sources of heterogeneity in the returns to education. Consistent with earlier surveys of the literature, I conclude that the average (or average marginal) return to education is not much below the estimate that emerges from a standard human capital earnings function fit by OLS. Evidence from the latest studies of identical twins suggests a small upward “ability” bias — on the order of 10%. A consistent finding among studies using instrumental variables based on institutional changes in the education system is that the estimated returns to schooling are 20–40% above the corresponding OLS estimates. Part of the explanation for this finding may be that marginal returns to schooling for certain subgroups — particularly relatively disadvantaged groups with low education outcomes — are higher than the average marginal returns to education in the population as a whole.
Abstract Objectives. This paper describes the methodology for estimating the present value of lifetime earnings (PVLE) for the year 2000. Methods. Estimation takes into account life expectancy by gender and age group, percent of people in the labor force or keeping house, current pattern of earnings at successive ages, an imputed value for household production, and the discount rate. Results. At a discount rate of 3 percent, males and females aged 20-24 have the highest PVLE — $1,517,045 and $1,085,188 respectively. Lifetime earnings for men are higher than for women. Higher discount rates yield lower values at all ages. Conclusions. The present value of lifetime earnings yields useful estimates of the valueof life. These estimates are conservative compared with other approaches.
Estimating the cost to society of individual crimes is essential to the economic evaluation of many social programs, such as substance abuse treatment and community policing. A review of the crime-costing literature reveals multiple sources, including published articles and government reports, which collectively represent the alternative approaches for estimating the economic losses associated with criminal activity. Many of these sources are based upon data that are more than 10 years old, indicating a need for updated figures. This study presents a comprehensive methodology for calculating the cost to society of various criminal acts. Tangible and intangible losses are estimated using the most current data available. The selected approach, which incorporates both the cost-of-illness and the jury compensation methods, yields cost estimates for more than a dozen major crime categories, including several categories not found in previous studies. Updated crime cost estimates can help government agencies and other organizations execute more prudent policy evaluations, particularly benefit-cost analyses of substance abuse treatment or other interventions that reduce crime.
The use of heroin in Australia results in disproportionate harm. Although the evidence suggests that a relatively low proportion of the population aged 14 years and over have ever used (1.4%) heroin or have used it in the past 12 months (0.2%), heroin use remains a significant cause of death, injury, illness and social harm. Research demonstrates that being in treatment leads to less heroin use, lowered mortality rates and reduced crime. Pharmacotherapy treatment in Australia involves methadone and buprenorphine. Trial data used by Doran and colleagues are used in the current analysis to extend the original analysis of methadone versus low-dose buprenorphine to include high-dose buprenorphine and the buprenorphine-naloxone combination in the maintenance of heroin dependence. Adopting a provider perspective suggests that the observed difference between the cost-effectiveness of methadone and the other treatments was not statistically significant, indicating that high-dose buprenorphine and the buprenorphine/naloxone combination can provide a viable alternative to methadone in the treatment of heroin dependence. Wider treatment choices provide greater potential to recruit a larger proportion of regular dependent users and retain them in treatment for longer. The forthcoming introduction of buprenorphine/naloxone to Australia provides an exciting opportunity to enhance the treatment of heroin dependence in this country.
To assess the clinical characteristics of adolescents with DSM-IV opioid use disorder (OUD) and compare them to adolescents with cannabis/alcohol use disorders.
94 adolescents (ages 14-18 years) with a current OUD and 74 adolescents with a current non-OUD cannabis/alcohol use disorders were recruited from admissions, predominantly residential, to a substance abuse treatment program in Baltimore, ML. Participants were assessed cross-sectionally using standardized interviews and self-reports. Chi-square, t-tests and ANCOVA (adjusting for age, gender and treatment setting, race and residence) were performed to determine group differences on demographic, substance use, psychiatric and HIV-risk behaviors; logistic regression analyses, both unadjusted and adjusted for the above five factors were conducted to assess the strength of associations.
The OUD group was more likely to be Caucasian, to have dropped out of school and to live in the suburbs (trend). They also had greater substance use severity with higher proportion of current sedative and multiple substance use disorders (SUD). There were generally no differences in rates of criminal behaviors. Both groups had high rates of current psychiatric disorders (83% vs. 78%, n.s.) but the OUD adolescents reported higher depressive symptoms, mostly in the moderate range. Injection drug use (IDU) and needle sharing was almost exclusive to the OUD group, while both groups reported similar high rates of risky sexual behaviors.
While there were similarities between the two groups, OUD adolescents evidenced greater impairment in academic, substance use, depressive symptom and IDU-related HIV-risk areas. Findings suggest poorer long-term prognosis and highlight the need for specialized interventions for treatment-seeking OUD adolescents.
The use of information on inflation, pharmacoeconomics, generic competition, new drug entities, site-specific drug-use patterns, legislation, and the changing health care environment in the projection of drug expenditures is discussed. Drug price inflation has declined from 6.9% in 1991 to 2.1% for part of 1995. Much of the decline is attributable to deep discounts given by manufacturers to managed care institutions. Some marketing specialists are predicting that drug manufacturers will begin to scale back discounts. Pharmaceutical industry analysts project that overall price increase for pharmaceuticals in the next 12-24 months will average 2.8% (range, 0-6%). Pharmacists need to be able to understand and critically evaluate pharmacoeconomic research, particularly studies conducted by the pharmaceutical industry. Savings due to increases in generic product selection may be offset to some degree by extensions of patent expiration dates under the General Agreement on Tariffs and Trade (GATT). Drug budget projections should include a complete review of new drugs and biotechnology agents pending FDA approval, drugs pending approval for new indications, and common unlabeled uses of expensive existing agents. Various methods are available for tracking drug-use patterns in specific practice settings. When resources are limited, pharmacy managers may elect to target only high-cost drugs; a proactive approach, such as projecting costs and developing guidelines for costly agents before their market release and before consideration by the pharmacy and therapeutics committee, is advantageous. Relevant legislative activities in 1995 included reform proposals for Medicare, Medicaid, and FDA; the Federal Acquisition Streamlining Act; and GATT. Disease management and other approaches to pharmacy benefits have increased opportunities for cooperative arrangements between drug companies and health care providers that may have major effects on drug marketing and pricing. Combining information on inflation, pharmacoeconomics, generics, new drugs, practice-site drug-use patterns, federal legislation, and the changing health care environment is necessary for accurate projections of drug expenditures.
It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these.
In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a "tariff" of EuroQol values from this data.
A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level.
The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.
Cost-benefit analysis (CBA) provides a clear decision rule: undertake an intervention if the monetary value of its benefits exceed its costs. However, due to a reluctance to characterize health benefits in monetary terms, users of cost-utility and cost-effectiveness analyses must rely on arbitrary standards (e.g., < $50,000 per QALY) to deem a program "cost-effective." Moreover, there is no consensus regarding the appropriate dollar value per QALY gained upon which to base resource allocation decisions. To address this, the authors determined the value of a QALY as implied by the value-of-life literature and compared this value with arbitrary thresholds for cost-effectiveness that have come into common use. A literature search identified 42 estimates of the value of life that were appropriate for inclusion. These estimates were classified by method: human capital (HK), contingent valuation (CV), revealed preference/job risk (RP-JR) and revealed preference/non-occupational safety (RP-S), and by U.S. or non-U.S. origin. After converting these value-of-life estimates to 1997 U.S. dollars, the life expectancy of the study population, age-specific QALY weights, and a 3% real discount rate were used to calculate the implied value of a QALY. An ordinary least-squares regression of the value of a QALY on study type and national origin explained 28.4% of the variance across studies. Most of the explained variance was attributable to study type; national origin did not significantly affect the values. Median values by study type were $24,777 (HK estimates), $93,402 (RP-S estimates), $161,305 (CV estimates), and $428,286 (RP-JR estimates). With the exception of HK, these far exceed the "rules of thumb" that are frequently used to determine whether an intervention produces an acceptable increase in health benefits in exchange for incremental expenditures.
To determine the cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States, particularly its effect on the HIV epidemic.
We developed a dynamic model to capture the effects of adding buprenorphine maintenance to the current opiate dependence treatment system. We evaluated incremental costs, including all health-care costs, and incremental effectiveness, measured as quality-adjusted life years (QALYs) of survival. We considered communities with HIV prevalence among injection drug users of 5% and 40%. Because no price has been set in the United States for a dose of buprenorphine, we considered three prices per dose: $5, $15, and $30.
If buprenorphine increases the number of individuals in maintenance treatment by 10%, but does not affect the number of individuals receiving methadone maintenance, the cost-effectiveness ratios for buprenorphine maintenance therapy are less than $45 000 per QALY gained for all prices, in both the low-prevalence and high-prevalence communities. If the same number of individuals enter buprenorphine maintenance (10% of the number currently in methadone), but half are injection drug users newly entering maintenance and half are individuals who switched from methadone to buprenorphine, the cost-effectiveness ratios in both communities are less than $45 000 per QALY gained for the $5 and $15 prices, and greater than $65 000 per QALY gained for the $30 price.
At a price of $5 or less per dose, buprenorphine maintenance is cost-effective under all scenarios we considered. At $15 per dose, it is cost-effective if its adoption does not lead to a net decline in methadone use, or if a medium to high value is assigned to the years of life lived by injection drug users and those in maintenance therapy. At $30 per dose, buprenorphine will be cost-effective only under the most optimistic modeling assumptions.
The accumulation of medical cost over time for each subject is an increasing stochastic process defined up to the instant of death. The stochastic structure of this process is complex. In most applications, the process can only be observed at a limited number of time points. Furthermore, the process is subject to right censoring so that it is unobservable after the censoring time. These special features of the medical cost data, especially the presence of death and censoring, pose major challenges in the construction of plausible statistical models and the development of the corresponding inference procedures. In this paper, we propose several classes of regression models which formulate the effects of possibly time-dependent covariates on the marginal mean of cost accumulation in the presence of death or on the conditional means of cost accumulation given specific survival patterns. We then develop estimating equations for these models by combining the approach of generalized estimating equations for longitudinal data with the inverse probability of censoring weighting technique. The resultant estimators are shown to be consistent and asymptotically normal with simple variance estimators. Simulation studies indicate that the proposed inference procedures behave well in practical situations. An application to data taken from a large cancer study reveals that the Medicare enrollees who are diagnosed with less aggressive ovarian cancer tend to accumulate medical cost at lower rates than those with more aggressive disease, but tend to have higher lifetime costs because they live longer.
This paper deals with the problem of linear regression for medical cost data when some study subjects are not followed for the full duration of interest so that their total costs are unknown. Standard survival analysis techniques are ill-suited to this type of censoring. The familiar normal equations for the least-squares estimation are modified in several ways to properly account for the incompleteness of the data. The resulting estimators are shown to be consistent and asymptotically normal with easily estimated variance-covariance matrices. The proposed methodology can be used when the cost database contains only the total costs for those with complete follow-up. More efficient estimators are available when the cost data are recorded in multiple time intervals. A study on the medical cost for ovarian cancer is presented.
This article presents the cost-effectiveness results of a randomised controlled trial conducted in two Australian cities. The trial was designed to assess the safety, efficacy and cost-effectiveness of buprenorphine versus methadone in the management of opioid dependence. The trial utilised a flexible dosing regime that was tailored to the clinical need of the patients, with high maximum doses, using the marketed formulation, under double-blind conditions. A total of 405 subjects were randomised to a treatment at one of three specialist outpatient drug treatment centres in Adelaide and Sydney, Australia. The perspective of the cost-effectiveness analysis was that of the service provider and included costs relevant to the provision of treatment. The primary outcome measure used in the economic analysis was change in heroin-free days from baseline to the sixth month of treatment. Treatment with methadone was found to be both less expensive and more effective than treatment with buprenorphine, which suggests methadone dominates buprenorphine. However, statistical testing found that the observed difference between the cost-effectiveness of methadone and buprenorphine treatments was not statistically significant. The results of this study provide useful policy information on the costs and outcomes associated with the use of methadone and buprenorphine and indicate that buprenorphine provides a viable alternative to methadone in the treatment of opioid dependence.
Buprenorphine offers an alternative to methadone in the treatment of heroin dependence, and has the advantage of allowing alternate-day dosing. This study is the first to examine the cost effectiveness of buprenorphine as maintenance treatment for heroin dependence in a primary care setting using economic and clinical data collected within a randomised trial.
The study was a randomised, open-label, 12-month trial of 139 heroin-dependent patients in a community setting receiving individualised treatment regimens of buprenorphine or methadone. Those who were currently on a methadone program (n = 57; continuing therapy subgroup) were analysed separately from new treatment recipients (n = 82; initial therapy subgroup). The study took a broad societal perspective and included health, crime and personal costs. Data on resource use and outcomes were a combination of clinical records and self report at interview. The main outcomes were incremental cost per additional day free of heroin use and per QALY. An analysis of uncertainty calculated the likelihood of net benefits for a range of acceptable money values of outcomes. All costs were in 1999 Australian dollars (DollarA).
The estimated mean number of heroin-free days did not differ significantly between those randomised to methadone (225 [95% CI 91, 266]), or buprenorphine (222 [95% CI 194, 250]) over the year of the trial. Buprenorphine was associated with an average 0.03 greater QALYs over 52 weeks (not significant). The total cost was DollarA 17,736 (95% CI -DollarA 2981, DollarA 38,364) with methadone and DollarA 11,916 (95% CI DollarA 7697, DollarA 16,135) with buprenorphine; costs excluding crime were DollarA 4513 (95% CI DollarA 3495, DollarA 5531) and DollarA 5651 (95% CI DollarA 4202, DollarA 7100). With additional heroin-free days as the outcome, and crime costs included buprenorphine has a lower cost but less heroin-free days. If crime costs are excluded buprenorphine has a higher cost and worse outcome than methadone. With additional QALYs as the outcome, the cost effectiveness of buprenorphine is DollarA 39,404 if crime is excluded, but buprenorphine is dominant if crime is included.
The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance in this particular setting. Although some of the results suggest that methadone may have a cost advantage, it is difficult to infer from the trial data that offering buprenorphine as an alternative would have a significant effect on total costs or outcomes. The point estimates of costs and outcomes suggest that buprenorphine may have an advantage in those initiating therapy. The confidence intervals were wide, however, and the likelihood of net benefits from substituting one treatment for another was close to 50%.
To describe a framework that can be used to determine optimal spending on substance abuse treatment in the United States.
Selective review of the literature on spending for substance abuse treatment combined with an economic analysis of how to determine when spending is optimal, defining optimal spending as that which minimizes the social costs of substance use disorders.
In 1997, only $11.9 billion of the $294 billion estimated social costs of substance abuse was spent on treatment. The discrepancy between the high indirect costs of illness relative to the level of spending on treatment of addictive disorders leads many to believe that the United States spends too little on treatment. In this paper, we argue that information on the social costs of substance abuse disorders and the level of spending on treatment is insufficient to determine whether current spending is optimal. We develop a framework that could be used to determine optimal spending on substance abuse treatment in the United States. We develop this framework in four steps. First, we provide background on the unique financial and delivery features of substance abuse treatment. Secondly, we outline the points raised by advocates of expanded substance abuse treatment: substance abuse has high social costs, yet few people receive the many effective treatments available partly because of financial barriers to treatment. Thirdly, we provide a framework that can be used to judge the additional benefits of alternative levels and types of spending on substance abuse treatment. Finally, we discuss the distinction between the potential impact of spending on substance abuse treatment and its actual impact, using productivity as an example of one significant portion of the costs of substance abuse.
To determine optimal spending on substance abuse treatment, research should describe who receives treatment, the quality of treatment received, and how treatments relate to outcomes that comprise a large share of the economic burden of substance abuse.
The prevalence of heroin and other opioid use has markedly increased among adolescents in the last decade; however, virtually no research has been conducted to identify effective treatments for this population.
To evaluate the relative efficacy of 2 pharmacotherapies, the partial opioid agonist buprenorphine hydrochloride and the centrally active alpha(2)-adrenergic blocker clonidine hydrochloride, in the detoxification of opioid-dependent adolescents.
A double-blind, double-dummy, parallel-groups randomized controlled trial conducted in a university-based research clinic from October 2001 to December 2003. Patients were a volunteer sample of 36 adolescents who met DSM-IV criteria for opioid dependence (ages 13-18 years eligible).
Participants were randomly assigned to a 28-day, outpatient, medication-assisted withdrawal treatment with either buprenorphine or clonidine. Both medications were provided along with thrice weekly behavioral counseling and incentives contingent on opiate abstinence. Postdetoxification, all participants were offered the opportunity for continued treatment with the opiate antagonist, naltrexone hydrochloride.
Treatment retention, opiate abstinence, and human immunodeficiency virus risk behavior, along with measures of withdrawal and medication effects.
A significantly greater percentage of adolescents who received buprenorphine were retained in treatment (72%) relative to those who received clonidine (39%) (P<.05). For those in the buprenorphine group, a significantly higher percentage of scheduled urine test results were opiate negative (64% vs 32%; P = .01). Participants in both groups reported relief of withdrawal symptoms and drug-related human immunodeficiency virus risk behavior. Those in the buprenorphine condition generally reported more positive effects of the medication. No evidence of opioid intoxication or psychomotor impairment was observed. Sixty-one percent of participants in the buprenorphine condition and 5% of those in the clonidine group initiated treatment with naltrexone.
Combining buprenorphine with behavioral interventions is significantly more efficacious in the treatment of opioid-dependent adolescents relative to combining clonidine and behavioral interventions.
To examine costs and monetary benefits associated with substance abuse treatment.
Primary and administrative data on client outcomes and agency costs from 43 substance abuse treatment providers in 13 counties in California during 2000-2001.
Using a social planner perspective, the estimated direct cost of treatment was compared with the associated monetary benefits, including the client's costs of medical care, mental health services, criminal activity, earnings, and (from the government's perspective) transfer program payments. The cost of the client's substance abuse treatment episode was estimated by multiplying the number of days that the client spent in each treatment modality by the estimated average per diem cost of that modality. Monetary benefits associated with treatment were estimated using a pre-posttreatment admission study design, i.e., each client served as his or her own control.
Treatment cost data were collected from providers using the Drug Abuse Treatment Cost Analysis Program instrument. For the main sample of 2,567 clients, information on medical hospitalizations, emergency room visits, earnings, and transfer payments was obtained from baseline and 9-month follow-up interviews, and linked to information on inpatient and outpatient mental health services use and criminal activity from administrative databases. Sensitivity analyses examined administrative data outcomes for a larger cohort (N=6,545) and longer time period (1 year).
On average, substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487, representing a greater than 7:1 ratio of benefits to costs. These benefits were primarily because of reduced costs of crime and increased employment earnings.
Even without considering the direct value to clients of improved health and quality of life, allocating taxpayer dollars to substance abuse treatment may be a wise investment.
EuroQol a new facility for the measure-ment of health related quality of life
- The Euroqol
- Group
The EuroQol Group. EuroQol a new facility for the measure-ment of health related quality of life. Health Policy 1990; 16: 199–208.