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PharmacoEconomics

, Volume 23, Issue 1, pp 77–91 | Cite as

A randomised trial of the cost effectiveness of buprenorphine as an alternative to methadone maintenance treatment for heroin dependence in a primary care setting

  • Anthony H. HarrisEmail author
  • Elena Gospodarevskaya
  • Alison J. Ritter
Original Research Article

Abstract

Background and aim: 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.

Study design and methods: 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 ($A).

Results: 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 $A17 736 (95% CI −$A2981, $A38 364) with methadone and $A11 916 (95% CI $A7697, $A16 135) with buprenorphine; costs excluding crime were $A4513 (95% CI $A3495, $A5531) and $A5651 (95% CI $A4202, $A7100). 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 $A39 404 if crime is excluded, but buprenorphine is dominant if crime is included.

Conclusions: 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%.

Keywords

Heroin Buprenorphine Incremental Cost Effectiveness Ratio Methadone Maintenance Treatment Heroin Dependence 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

This research was supported by a grant from the Victorian Government, Community Support Fund. Buprenorphine was supplied free of charge to the study by Reckitt Benckiser. The third author has received an educational grant from Reckitt Benckiser.

References

  1. 1.
    Ward DC, Mattick RP, Hall W. Key issues in methadone maintenance treatment. Sydney: New South Wales University Press, 1992Google Scholar
  2. 2.
    Johnson RE, Chutuape MA, Strain EC, et al. A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence. N Engl J Med 2000; 343 (18): 1290–7PubMedCrossRefGoogle Scholar
  3. 3.
    Johnson RE, Eissenberg T, Stitzer ML, et al. A placebo controlled clinical trial of buprenorphine as a treatment for opioid dependence. Drug Alcohol Depend 1995; 40 (1): 17–25PubMedCrossRefGoogle Scholar
  4. 4.
    Johnson RE, Fudala PJ. Development of buprenorphine for treatment of opioid dependence. NIDA Res Monogr 1992; 121: 120–41PubMedGoogle Scholar
  5. 5.
    Strain EC, Stitzer ML, Liebson IA, et al. Comparison of buprenorphine and methadone in the treatment of opioid dependence. Am J Psychiatry 1994; 151 (7): 1025–30PubMedGoogle Scholar
  6. 6.
    Strain EC, Stitzer ML, Liebson IA, et al. Buprenorphine versus methadone in the treatment of opioid-dependent cocaine users. Psychopharmacology (Berl) 1994; 116 (4): 401–6CrossRefGoogle Scholar
  7. 7.
    Ling W, Charuvastra C, Collins JF, et al. Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial. Addiction 1998; 93 (4): 475–86PubMedCrossRefGoogle Scholar
  8. 8.
    Schottenfeld RS, Pakes JR, Kosten TR. Prognostic factors in Buprenorphine- versus methadone-maintained patients. J Nerv Ment Dis 1998; 186 (1): 35–43PubMedCrossRefGoogle Scholar
  9. 9.
    Ling W, Wesson DR, Charuvastra C, et al. A controlled trial comparing buprenorphine and methadone maintenance in opioid dependence. Arch Gen Psychiatry 1996; 53 (5): 401–7PubMedCrossRefGoogle Scholar
  10. 10.
    Fischer G, Gombas W, Eder H, et al. Buprenorphine versus methadone maintenance for the treatment of opioid dependence. Addiction 1999; 94 (9): 1337–47PubMedCrossRefGoogle Scholar
  11. 11.
    Mattick RP, Kimber J, Breen C, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database SystRev 2004; (3) article no.: CD002207.pub2. DOI: 10.1002/14651858. CD002207.pub2.Google Scholar
  12. 12.
    O’Connor PG, Carroll KM, Shi JM, et al. Three methods of opioid detoxification in a primary care setting: a randomized trial. Ann Intern Med 1997; 127 (7): 526–30PubMedGoogle Scholar
  13. 13.
    Rosenheck R, Kosten T. Buprenorphine for opiate addiction: potential economic impact. Drug Alcohol Depend 2001; 63 (3): 253–62PubMedCrossRefGoogle Scholar
  14. 14.
    Barnett PG, Zaric GS, Brandeau ML. The cost effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States. Addiction 2001; 96 (7): 1267–78PubMedCrossRefGoogle Scholar
  15. 15.
    Lintzeris N, Ritter A, Panjari M, et al. Implementing buprenorphine treatment in community settings in Australia: experiences from the buprenorphine implementation trial. Am J Addictions 2004; 13 Suppl. 1: S29–41CrossRefGoogle Scholar
  16. 16.
    Department of Health and Community Services. Victorian methadone program. Guidelines for providers. Melbourne: Victorian Government Department of Health and Community Services, 1995Google Scholar
  17. 17.
    Digiusto E, Seres V, Bibb, et al. Concordance between urinalysis results and self-reported drug use by applicants for methadone maintenance in Australia. Addict Behav 1996; 21 (3): 319–29PubMedCrossRefGoogle Scholar
  18. 18.
    Hawthorne G, Richardson J, Osbome R. The Australian Quality of Life (AQoL) instrument: a psychometric measure of health related quality of life. Qual Life Res 1999; 8: 209–24PubMedCrossRefGoogle Scholar
  19. 19.
    Schedule of pharmaceutical benefits for approved pharmacists and medical practitioners, Australian Government, Department of Health and Aged Care. Canberra: Australian Government Publishing Service, 1999 AugGoogle Scholar
  20. 20.
    Caswell A, editor. MIMS Australia. Sydney (NSW): MediMedia Australia Pty Ltd, A Vivendi Universal Publishing Company, 1999 JunGoogle Scholar
  21. 21.
    Medicare Benefits Schedule, Australian government, Department of Health and Aged Care, Canberra, ACT. 1999 Nov [online]. Available from URL: http://www7.health.gov.au/pubs/mbs/nov99s.htm [Accessed 2004 Dec 6]Google Scholar
  22. 22.
    Victorian Acute Health Cost Weights Study 1998–1999. Published by Acute Health Division, Victorian government Department of Human Services, 1999 Melbourne, Victoria, Aus tralia [online]. Previously available from URL: http://www.dhs.vic.gov.au/ahs/pub.htm [Accessed 2000 Feb 15]Google Scholar
  23. 23.
    Australian Psychological Society’s recommended fee schedule [online]. Available from URL: http://www.psychsociety.com.au/member/fr_member.htm [Accessed 1999 Jun 71Google Scholar
  24. 24.
    Royal Auto, RACV members magazine. Victoria: Royal Automobile Club of Victoria, 2000 JunGoogle Scholar
  25. 25.
    VicTrip Information Centre [online]. Previously available from URL: http://www.victrip.com.au/fares zones [Accessed 1999 Jul 15]. Now available from URL: http://www.metlinkmelboume.com.au [Accessed 1999 Jul 15]Google Scholar
  26. 26.
    Allen Consulting Group Pty Ltd and Cox JB. Centre of Policy Studies Economic impact of city link: transurban project. Consultancy report to the Melbourne City Link Authority, 1996 AprGoogle Scholar
  27. 27.
    John Walker. Estimates of the costs of crime in Australia: trends and issues [paper no. 39]. Canberra (ACT): Australian Institute of Criminology, 1992 AugGoogle Scholar
  28. 28.
    John Walker. Estimates of the costs of crime in Australia in 1996: trends and issues [paper no. 72]. Canberra (ACT): Australian Institute of Criminology, 1997 AugGoogle Scholar
  29. 29.
    Potas I, Vining A, Wilson P. Young people and crime: costs and prevention. Australian Institute of Criminology, Canberra, ACT, Australia; 1990 ISBN 0 642 15538 0 [online]. Available from URL: http://www.aic.gov.au/publications/young-people [Accessed 2004 Dec 13]Google Scholar
  30. 30.
    Victorian Police Service Annual Crime Statistics Report, 1996/97. Melbourne (VIC): Victorian Police Service, 1997Google Scholar
  31. 31.
    Briggs AH, Wonderling DE, Mooney CZ. Pulling cost-effectiveness up by bootstraps: a non parametric approach to confidence interval estimation. Health Econ 1997; 6: 327–40PubMedCrossRefGoogle Scholar
  32. 32.
    Briggs AIL Fenn P. Confidence intervals or surfaces: uncertainty on the cost effectiveness plane. Health Econ 1998; 7 (8): 723–40PubMedCrossRefGoogle Scholar
  33. 33.
    Stinnet AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998; 18 (2 Suppl.): S68–80CrossRefGoogle Scholar
  34. 34.
    O’Brien BJ, Gertsen K, Willan AR, et al. Is there a kink in consumers’ threshold value for cost-effectiveness in health care? Health Econ 2002; 11 (2): 175–80PubMedCrossRefGoogle Scholar
  35. 35.
    George B, Harris A, Mitchell A. Cost-effectiveness analysis and the consistency of decision making. Pharmacoeconomics 2001; 19 (11): 1103–9PubMedCrossRefGoogle Scholar
  36. 36.
    Van Hout BA, Al MJ, Gordon GS, et al. Costs, effects and CIE ratios alongside a clinical trial. Health Econ 1994; 3: 309–19PubMedCrossRefGoogle Scholar
  37. 37.
    Briggs AIL A Bayesian approach to stochastic cost-effectiveness analysis. Health Econ 1999; 8: 257–61PubMedCrossRefGoogle Scholar
  38. 38.
    Briggs A, Clark T, Wolsenholme J, et al. Missing … presumed at random: cost analysis of incomplete data. Health Econ 2003; 12 (5): 377–92PubMedCrossRefGoogle Scholar
  39. 39.
    Zhou XH, Gao S. Confidence intervals for the log-normal mean. Stat Med 1997; 16: 783–90PubMedCrossRefGoogle Scholar
  40. 40.
    Doran CM, Shanahan M, Mattick RP, et al. Buprenorphine versus methadone maintenance: a cost-effectiveness analysis. Drug Alcohol Depend 2003; 71 (3): 295–302PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  • Anthony H. Harris
    • 1
    Email author
  • Elena Gospodarevskaya
    • 1
  • Alison J. Ritter
    • 2
  1. 1.Centre for Health Program EvaluationMonash UniversityMelbourneAustralia
  2. 2.Turning Point Alcohol & Drug CentreMelbourneAustralia

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