Expanding access to a treatment that combines medication and counseling for opioid addiction may generate significant cost savings while also saving many lives, according to a study by researchers at Stanford and the Veterans Health Administration.
Opioid use disorder (OUD) has become a public health crisis and is a significant cause of morbidity, death, lost productivity and excess costs to the criminal justice system. At least 2 million people in the United States have a substance use disorder related to prescription opioid pain medication.
“Opioid overdoses in the United states likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment,” the researchers write in their original investigation in JAMA Psychiatry.
The Centers for Disease Control and Prevention last December announced that more than 81,000 drug overdoses occurred in the United States in the 12 months ending in May 2020, the highest number of overdose deaths ever recorded in a 12-month period.
So a Stanford team of decision scientists with colleagues at the VA Palo Alto Health Care System developed a mathematical model to assess the cost-effectiveness of various interventions to treat opioid use disorder. They looked at the cost-effectiveness from two perspectives: the health-care sector and the criminal justice system.
Their model considered 26 different treatment combinations involving medication-assisted treatment such as oral buprenorphine or methadone and injectable, extended-release naltrexone, combined with a treatment such as psychotherapy and overdose education. They estimated the lifetime costs and quality-adjusted life years (QALYs) associated with the different treatment options and determined that medication-assisted treatment would prevent a substantial number of overdoses and result in approximately one additional quality-adjusted year of life for patients who receive this therapy.
“This treatment has very important benefits. It prevents overdose deaths, improves quality of life, and results in patients living longer — a very substantial benefit,” said Douglas K.Owens, director of Stanford Health Policy, a professor of medicine and a senior investigator at the VA Palo Alto Health Care System. Owens is also a senior fellow at the Freeman Spogli Institute for International Studies.
A few years ago, the team realized the opioid epidemic was threatening the hard-fought gains in the prevention and control of HIV and the hepatitis C virus. They launched a 10-year project with a MERIT award from the National Institute on Drug Abuse and with funding from the Department of Veterans Affairs to address the impact of opioids on the treatment of other diseases. Owens and Margaret Brandeau, PhD, professor of management science and engineering, have led this team of decision scientists for two decades.
“The U.S. opioid epidemic has decimated lives and families,” said Brandeau, who is co-senior author of the study with Owens. “And it has only gotten worse with COVID-19. Opioid use has increased while at the same time access to treatment has diminished.”
This cost-effectiveness analysis for opioid use disorder is the most recent study from their group tackling the opioid epidemic. Among the other authors of the study are Michael Fairley, a former PhD student in management science and engineering and first author of the study; Keith Humphreys, PhD, a professor of psychiatry and behavioral sciences; and Vilija R. Joyce, MS, associate director of the VA Health Economics Resource Center; Jeremy Goldhabert-Fiebert, PhD, an associate professor of medicine; and Steven M. Asch, MD, MPH, a professor of medicine and director of the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System. Other authors of the study are Mark Bounthavong, PharmD, PhD; Jodie Trafton, PhD; Ann Combs, MHA; and Elizabeth M. Oliva, PhD, with the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System.
There are over 2 million people in the U.S. with a substance use disorder related to prescription opioid pain medication. The researchers found that by providing medication-assisted treatment, combined with overdose education and naloxone and contingency management to everyone with opioid use disorder in the U.S., 41,000 lives over the next 5 years could be saved and $200 billion in health care and criminal justice costs over these individuals’ lifetimes.
For each treatment option, the researchers calculated the mean number of fatal and nonfatal overdoses and total deaths over five years for a simulated cohort of 100,000 individuals, reflective of individuals with OUD in the United States, and expected lifetime total costs and QALYs gained compared to no treatment.
Their projections found that total deaths decreased for all treatment options compared with no treatment at all. But when medication-assisted treatment was combined with contingency management, overdose education and the distribution of naloxone — a medicine that reverses opioid overdose — the number of deaths dropped by nearly 17% for methadone and 23.7% for buprenorphine and naltrexone. That treatment also led to an increase of 1.7 additional quality-adjusted years of life per person for all three forms of medication-assisted treatment.
In terms of the cost effectiveness for the health-care sector, the treatment of each patient using methadone would cost $16,000 per QALY gained. Treating patients with methadone, opioid education and naloxone costs $22,000 per QALY gained. "Both represent very good value by standards of cost effectiveness," Owens said.
The investigators then considered potential savings from criminal justice costs. Individuals with untreated OUD may be involved in the criminal justice system, and incur costs. These costs decrease significantly for individuals on treatment. When savings in criminal justice costs were included, all forms of medication assisted treatment (with buprenorphine, methadone or naltrexone) were cost-saving, with lifetime cost savings per patient on the order of $25,000 to $105,000.
“The health care system clearly has the capacity to provide this treatment, indeed the VA does so on a wide scale already, but stigma and poor insurance coverage have limited its adoption,” Humphreys said.
The researchers noted that policymakers and members of Congress have proposed expanding access to MAT and overdose education and naloxone distribution.
“Our results indicate that such a policy, especially if it included contingency management, would generate significant social cost savings and, more importantly, save numerous lives,” they concluded.