In the JournalsPerspective

Immediate access to opioid agonist treatment could save billions

Unlimited, immediate access to opioid agonist treatment with methadone for patients with opioid use disorder offers drastic cost savings and greater health benefits compared with the standard of care, according to a study published in Annals of Internal Medicine.

Limited access to opioid agonist treatment with either methadone or buprenorphine is a major impediment to reducing the societal burden of the current prescription opioid and heroin use epidemic,” Emanuel Krebs, MA, from British Columbia Centre for Excellence in HIV/AIDS, Canada, and colleagues wrote.

“Only one in five of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015,” they added.

Krebs and colleagues conducted a model-based cost-effectiveness analysis to investigate the benefits and costs of immediate access to opioid agonist treatment with methadone for all patients presenting at California’s publicly funded treatment facilities with opioid use disorder compared with the observed standard of care. The standard of care included time-limited medically supervised withdrawal and comprised 54.3% of those with opioid use disorder.

The researchers identified data on drug treatment and criminal justice system engagement for California from 2006 to 2010 using linked population-level administrative databases. They compared these data with health benefits that were measured with accumulated quality-adjusted life-years and lifetime costs for patients starting opioid use disorder treatment in 2014 using a computer model.

The model estimated that unlimited, immediate access to opioid agonist treatment could save up to $3.8 billion over the lifetimes of the patients in this cohort. In addition, the researchers found that patients receiving immediate opioid agonist treatment saved a total lifetime cost of $78,257 per person and raised QALYs by 0.42 per person, compared with observed standard of care.

These findings were robust according to sensitivity analyses, which revealed that 99.6% of 2,000 simulations demonstrated lower costs and more QALYs with immediate opioid agonist treatment.

“Immediate access to [opioid agonist treatment] for patients presenting for opioid use disorder treatment is more effective and less costly than the observed standard of care in publicly funded treatment facilities in California, and the model-projected savings can inform strategic investments for public health policy,” Krebs and colleagues concluded.

“Our findings further underline the need for widespread and unencumbered access to evidence-based treatment of opioid use disorder to reduce the burden to society of the current prescription opioid and heroin use epidemic,” they added.

In an accompanying editorial, Jeanette M. Tetrault, MD, and David A. Fiellin, MD, both from the Yale University School of Medicine, wrote that these data further validate the efficacy of opioid agonist treatment and prove that health care resources should focus less on medically managed withdrawal and more on outpatient opioid agonist treatment.

“Threats to health care funding may have lasting consequences, especially if lawmakers do not heed the most science-based and policy applicable data as decisions are being made,” they warned. – by Alaina Tedesco

Disclosure: Krebs and Tetrault report no relevant financial disclosures. Fiellin reports being a consultant to the American Academy of Addiction Psychiatry for service related to the HHS’s Substance Abuse and Mental Health Services Administration funded Providers’ Clinical Support System (PCSS) for Opioid Therapy and PCSS for Medication Assisted Treatment. Please see study for all other authors’ relevant financial disclosures.

Unlimited, immediate access to opioid agonist treatment with methadone for patients with opioid use disorder offers drastic cost savings and greater health benefits compared with the standard of care, according to a study published in Annals of Internal Medicine.

Limited access to opioid agonist treatment with either methadone or buprenorphine is a major impediment to reducing the societal burden of the current prescription opioid and heroin use epidemic,” Emanuel Krebs, MA, from British Columbia Centre for Excellence in HIV/AIDS, Canada, and colleagues wrote.

“Only one in five of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015,” they added.

Krebs and colleagues conducted a model-based cost-effectiveness analysis to investigate the benefits and costs of immediate access to opioid agonist treatment with methadone for all patients presenting at California’s publicly funded treatment facilities with opioid use disorder compared with the observed standard of care. The standard of care included time-limited medically supervised withdrawal and comprised 54.3% of those with opioid use disorder.

The researchers identified data on drug treatment and criminal justice system engagement for California from 2006 to 2010 using linked population-level administrative databases. They compared these data with health benefits that were measured with accumulated quality-adjusted life-years and lifetime costs for patients starting opioid use disorder treatment in 2014 using a computer model.

The model estimated that unlimited, immediate access to opioid agonist treatment could save up to $3.8 billion over the lifetimes of the patients in this cohort. In addition, the researchers found that patients receiving immediate opioid agonist treatment saved a total lifetime cost of $78,257 per person and raised QALYs by 0.42 per person, compared with observed standard of care.

These findings were robust according to sensitivity analyses, which revealed that 99.6% of 2,000 simulations demonstrated lower costs and more QALYs with immediate opioid agonist treatment.

“Immediate access to [opioid agonist treatment] for patients presenting for opioid use disorder treatment is more effective and less costly than the observed standard of care in publicly funded treatment facilities in California, and the model-projected savings can inform strategic investments for public health policy,” Krebs and colleagues concluded.

“Our findings further underline the need for widespread and unencumbered access to evidence-based treatment of opioid use disorder to reduce the burden to society of the current prescription opioid and heroin use epidemic,” they added.

In an accompanying editorial, Jeanette M. Tetrault, MD, and David A. Fiellin, MD, both from the Yale University School of Medicine, wrote that these data further validate the efficacy of opioid agonist treatment and prove that health care resources should focus less on medically managed withdrawal and more on outpatient opioid agonist treatment.

“Threats to health care funding may have lasting consequences, especially if lawmakers do not heed the most science-based and policy applicable data as decisions are being made,” they warned. – by Alaina Tedesco

Disclosure: Krebs and Tetrault report no relevant financial disclosures. Fiellin reports being a consultant to the American Academy of Addiction Psychiatry for service related to the HHS’s Substance Abuse and Mental Health Services Administration funded Providers’ Clinical Support System (PCSS) for Opioid Therapy and PCSS for Medication Assisted Treatment. Please see study for all other authors’ relevant financial disclosures.

    Perspective
    Lawrence Greenblatt

    Lawrence Greenblatt

    In this study, Krebs, et al, report a well-done decision analysis comparing immediate access to opioid agonist treatment using methadone to care provided under California’s regulations for treating opioid use disorder. The guidelines require trial and failure twice with medically-managed withdrawal prior to initiation of opioid agonist treatment. 

    The conclusions reached have clear implications for clinicians. Not only did the immediate access and non-time-limited approach to opioid agonist treatment result in lower health care costs, it increased duration in remission and reduced HIV infection and mortality risk. 

    In addition, non-health care outcomes were improved including criminal behavior and time spent incarcerated while simultaneously reducing the expected societal costs of the opioid epidemic. 

    Too few individuals with opioid use disorder are receiving effective therapy. When these individuals encounter the health care system, they should be offered prompt opioid agonist treatment of unlimited duration.

    • Lawrence Greenblatt, MD, FACP
    • Professor of Medicine and Community and Family Medicine Co-Chair Opioid Safety Committee Duke Health

    Disclosures: Greenblatt reports no relevant financial disclosures.

    See more from Opioid Resource Center