We’ve long known that opioid use disorder (OUD) is a significant cause of morbidity and mortality, and that far too many people lack access to the effective therapy that medication-assisted treatment (MAT) can provide.
Now an important new study published July 2021 in JAMA Psychiatry tells us much more about MAT, describing its cost-saving benefits and improved outcomes.
Authors of the new study—eleven scientists from Stanford and the VA Palo Alto Health Care System—developed a mathematical model to use in investigating MAT’s cost-effectiveness. They used the model to estimate deaths, fatal and nonfatal overdoses, discounted lifetime quality-adjusted life-years (QALYs), and costs for individuals on MAT.
What Is QALY?
QALY—quality-adjusted life year—is a measure researchers use to assess the burden of disease. It includes the quality and quantity of life. One QALY is equal to one year of perfect health.
The study found that all forms of MAT—buprenorphine, methadone, and naltrexone—along with treatment add-ons—yielded considerable cost savings: $25,000 to $105,000 per person, while also reducing the likelihood of overdose and death.
Treatment consisted of MAT with buprenorphine, methadone, or injectable extended-release naltrexone, plus add-ons: contingency management (CM), psychotherapy (beyond the level of standard counseling), and overdose education with naloxone distribution (OEND).
(The authors did not comment on the fact that some investigators have recently questioned use of the term MAT, arguing that the word “assisted” downplays the importance of medication. The authors simply noted: “We use the term MAT consistent with National Institute on Drug Abuse terminology for treatment combining medications with behavioral counseling.”)
Results: Untreated Patients
Overdoses, and Deaths From Other Causes, Over Five Years, per 100,000 Patients
QALYs Per Person, Lifetime
Deaths from other causes: 12,660
(QALYs were discounted to the present at 3% per year.)
Results, Treated Patients
Reduction in Overdoses (estimates) for MAT, over five years, with:
- Methadone: 10.7%
- Buprenorphine or naltrexone: 22.0%
- MAT combined with CM and psychotherapy: 21.0% to 31.4%
Decreases in Deaths (estimates) for MAT, over five years, with:
- Methadone: 6%
- Buprenorphine or naltrexone: 13.9%
- MAT combined with CM, OEND, and psychotherapy: 16.9%
Gains in Lifetime QALYs for MAT alone (discounted, per person)
- 1.02 to 1.07
Regarding the last item above:
MAT alone increased per-person QALYs by 1.02 to 1.07, bringing total QALYs in the treated group to 12.60 for methadone and 12.65 for buprenorphine and naltrexone.
OEND alone increased per-person QALYs by 0.22.
QALY gains were similar for the three forms of MAT. That’s because although mortality risk is higher for those entering methadone treatment, retention in treatment is higher with methadone than with buprenorphine and naltrexone.
The greatest QALY increase occurred for MAT with CM, OEND, and psychotherapy, for a gain of about 1.7 QALYs per person for all three forms of MAT.
Incremental Costs Per QALY Gained
Methadone, compared to no treatment
Methadone with OEND, compared to methadone alone
Buprenorphine with OEND and CM, compared to methadone with OEND
Buprenorphine with OEND, CM, and psychotherapy, compared to buprenorphine with OEND and CM
In the table above, regarding the substantially higher cost per QALY gained for buprenorphine with three add-ons: the analysis revealed that OEND and CM are cost-effective add-ons to MAT, but that adding psychotherapy is not always cost effective.
When criminal justice costs were included, all forms of MAT—buprenorphine, methadone, and naltrexone—were associated with substantial cost savings, when compared to no treatment. Net present lifetime cost savings were on the order of $100,000 for methadone, $60,000 for buprenorphine, and $40,000 for extended-release naltrexone. (Criminal justice costs are much lower for people who are being treated for OUD or who are abstinent because of treatment.)
Savings in lifetime costs per person were on the order of $100,000 for methadone, $60,000 for buprenorphine, and $40,000 for extended-release naltrexone.
The greatest cost savings were with methadone plus CM: $108,000 in net present lifetime savings per person.
Discussion and Conclusions
The authors emphasize a key aspect of their study: “Very few medical interventions for less stigmatized conditions are cost saving when compared with no treatment, nor are they expected to be. However, the fact that OUD treatment is cost saving further strengthens the case for providing it.”
The authors also point out that it’s likely that opioid overdoses in the US hit a record high in 2020, for reasons related to COVID-19: a rise in substance use, exacerbating stress and social isolation; and interference with opioid treatment. They note that “It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.”
The lack of widespread MAT availability greatly limits access to cost-saving reductions in morbidity and mortality from OUD. The authors advocate expanding access to MAT, overdose education, and naloxone distribution, along with contingency management, in any way possible. “Clinicians should aim to provide whatever MAT is feasible in their setting and to supplement it with CM.”
The article closes with this statement:
Policy makers and many members of Congress have proposed expanding access to MAT and OEND. Our results indicate that such a policy, especially if it included CM, would generate significant societal cost savings and, more importantly, save numerous lives.
Fairley M, Humphreys K, Joyce VR, et al. Cost-effectiveness of Treatments for Opioid Use Disorder. JAMA Psychiatry. 2021;78(7):767-777. doi:10.1001/jamapsychiatry.2021.0247