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

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ABSTRACT

BACKGROUND

Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic.

OBJECTIVE

We evaluated the cost-effectiveness of long-term office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment.

DESIGN, SUBJECTS, AND INTERVENTION

A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-of-life weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated.

MAIN MEASURES

Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually.

KEY RESULTS

In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce quality-of-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction.

CONCLUSIONS

Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.

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Acknowledgements

This research was supported in part by the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program grants nos. 63625 and 55396. The Robert Wood Johnson Foundation had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. This study was also supported by the National Institute on Drug Abuse K01 DA01719 (Dr. Schackman), R01 DA017221 (Dr. Polsky), K01 DA022398 (Dr. Moore), and R01 DA0009803 (Dr. Fiellin).

Portions of earlier versions of this paper were presented at the 2009 Addiction Health Services Research Conference, the 2009 Society for Medical Decision Making Annual Meeting, and the 2009 Substance Abuse and Mental Health Services Administration/National Institute on Drug Abuse Buprenorphine Summit.

We would like to thank Dr. George Woody and the National Institute on Drug Abuse Clinical Trials Network (CTN) for the use of summary results from CTN-0010, “Buprenorphine/Naloxone (Bup/Nx) Facilitated Rehabilitation for Heroin Addicted Adolescents/Young Adults” (NCT 00078130). We acknowledge the members of the Using Modeling to Inform Public Health (UMPH!) seminar at Yale University School of Medicine and the students in Industrial and Systems Engineering 191 at the University of Wisconsin-Madison for their valuable comments.

Conflicts of interest

Dr. Polsky has been a consultant to GlaxoSmithKline, Precision Economics (project funded by Pfizer), and SDIHealth (project funded by Amgen). Dr. Fiellin has received honoraria for serving on an external advisory board monitoring diversion and abuse of buprenorphine from Pinney Associates and Paragon Rx.

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Authors and Affiliations

  1. Department of Public Health, Weill Cornell Medical College, 402 East 67th Street, New York, NY, 10065, USA

    Bruce R. Schackman PhD & Jared A. Leff MS

  2. Division of Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Daniel Polsky PhD

  3. Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA

    Brent A. Moore PhD

  4. Department of Medicine, Yale University School of Medicine, New Haven, CT, USA

    David A. Fiellin MD

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  1. Bruce R. Schackman PhD
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  2. Jared A. Leff MS
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  5. David A. Fiellin MD
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Correspondence to Bruce R. Schackman PhD.

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Schackman, B.R., Leff, J.A., Polsky, D. et al. Cost-Effectiveness of Long-Term Outpatient Buprenorphine-Naloxone Treatment for Opioid Dependence in Primary Care. J GEN INTERN MED 27, 669–676 (2012). https://doi.org/10.1007/s11606-011-1962-8

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