RESUMO
Cocaine demand is a behavioral economic measure assessing drug reward value and motivation to use drug. The purpose of the current study was to develop a brief assessment of cocaine demand (BACD). Results from the BACD were compared with self-report measures of cocaine use. Participants consisted of treatment-seeking individuals with cocaine use disorder (N = 22). Results revealed that indices of brief demand were significantly associated with various self-report measures of cocaine use. Overall, these results support the utility of a BACD for assessing cocaine demand.
Assuntos
Transtornos Relacionados ao Uso de Cocaína , Cocaína/economia , Uso de Medicamentos/estatística & dados numéricos , Comportamento de Procura de Droga , Economia Comportamental/estatística & dados numéricos , Autorrelato/estatística & dados numéricos , Comportamento Aditivo/economia , Comportamento Aditivo/psicologia , Transtornos Relacionados ao Uso de Cocaína/economia , Transtornos Relacionados ao Uso de Cocaína/prevenção & controle , Transtornos Relacionados ao Uso de Cocaína/psicologia , Controle de Medicamentos e Entorpecentes/métodos , Controle de Medicamentos e Entorpecentes/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Entorpecentes/economia , Aceitação pelo Paciente de Cuidados de Saúde , Medidas de Resultados Relatados pelo PacienteRESUMO
BACKGROUND: North America is facing an unprecedented public health crisis of opioid-related morbidity and mortality, increasingly as a result of the introduction of illicitly manufactured fentanyl into the street drug market. Although the treatment of opioid use disorder (OUD) is a key element in the response to the opioid overdose epidemic, currently available pharmacotherapies (e.g., methadone, buprenorphine) may not be acceptable to or effective in all patients. Available evidence suggests that slow-release oral morphine (SROM) has similar efficacy rates as methadone with respect to promoting abstinence, and with improvements in a number of patient-reported outcomes among persons using heroin. However, little is known about the relative effectiveness and acceptability of SROM compared to methadone in the context of fentanyl use. This study aims to address this research gap. METHODS: pRESTO is a 24-week, open-label, two arm, non-inferiority, randomized controlled trial comparing SROM versus methadone for the treatment of OUD. Participants will be 298 clinically stable, non-pregnant adults with OUD, recruited from outpatient clinics in Vancouver, Canada, where the majority of the illicit opioids are contaminated with fentanyl. The primary outcome is suppression of illicit opioid use, measured by bi-weekly urine drug screens. Secondary outcomes include: treatment retention, medication safety, overdose events, treatment satisfaction, psychological functioning, changes in drug-related problems, changes in quality of life, opioid cravings, other substance use, and cost-effectiveness. DISCUSSION: pRESTO will be among the first studies to evaluate treatment options for individuals primarily using synthetic street opioids, providing important evidence to guide treatment strategies for this population.
Assuntos
Metadona/uso terapêutico , Morfina/uso terapêutico , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto , Análise Custo-Benefício , Preparações de Ação Retardada , Overdose de Drogas/epidemiologia , Estudos de Equivalência como Asunto , Feminino , Fentanila/toxicidade , Humanos , Masculino , Metadona/economia , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/economia , Entorpecentes/administração & dosagem , Entorpecentes/economia , Satisfação do Paciente , Qualidade de Vida , Adulto JovemRESUMO
BACKGROUND: The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA). METHODS: Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost. RESULTS: A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)]. CONCLUSIONS AND RELEVANCE: The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.
Assuntos
Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/economia , Custos de Medicamentos , Procedimentos Endovasculares/economia , Custos Hospitalares , Entorpecentes/administração & dosagem , Entorpecentes/economia , Manejo da Dor/economia , Procedimentos Cirúrgicos Vasculares/economia , Administração Intravenosa , Idoso , Analgésicos não Narcóticos/efeitos adversos , Análise Custo-Benefício , Estudos Transversais , Bases de Dados Factuais , Custos de Medicamentos/tendências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/tendências , Feminino , Custos Hospitalares/tendências , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Entorpecentes/efeitos adversos , Manejo da Dor/efeitos adversos , Manejo da Dor/mortalidade , Manejo da Dor/tendências , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Procedimentos Cirúrgicos Vasculares/tendênciasRESUMO
Medication-assisted treatment (MAT) with methadone or buprenorphine has been shown to be more effective at reducing the use of illicit opioids, the risk of drug-related overdose, and overall healthcare costs, on average, compared to abstinence-based addiction treatments for individuals with an opioid use disorder (OUD). Individuals who are adherent to MAT are more likely to experience positive outcomes. We used physical and behavioral Medicaid claims data of individuals newly treated with methadone (nâ¯=â¯212) and buprenorphine (nâ¯=â¯972) to examine the overall predictors of adherence, differences in adherence to each medication, the relationship between adherence and ED nonfatal drug-related overdose, and differences in total cost of care between the two medications. We found that older individuals and women had significantly lower risk of non-adherence. At six months, only 3.6% of individuals who were adherent to either treatment experienced a nonfatal drug-related overdose in the ED, compared to 13.2% of individuals who were non-adherent. We found no significant difference between methadone and buprenorphine on nonfatal drug-related overdose. Non-adherence to methadone was associated with a significant increase in total cost of care. Implications for how these results could be used to improve the overall impact of MAT are discussed.
Assuntos
Buprenorfina , Serviço Hospitalar de Emergência , Custos de Cuidados de Saúde , Medicaid , Metadona , Entorpecentes , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/economia , Avaliação de Resultados em Cuidados de Saúde , Cooperação do Paciente , Adulto , Buprenorfina/economia , Buprenorfina/uso terapêutico , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Metadona/economia , Metadona/uso terapêutico , Pessoa de Meia-Idade , Entorpecentes/economia , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/economia , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Cooperação do Paciente/estatística & dados numéricos , Estados UnidosRESUMO
PURPOSE: Diverted prescription opioids are significant contributors to drug overdose mortality. Street price has been suggested as an economic metric of the diverted prescription opioid black market. This study examined variables that may influence the street price of diverted oxycodone and oxymorphone. METHODS: A cross-sectional study was conducted utilizing data from the previously validated, crowdsourcing website StreetRx. Street price reports of selected oxycodone and oxymorphone products, between August 22, 2014 and June 30, 2016, were considered for analysis. Geometric means and 95% confidence intervals were calculated comparing prices per milligram of drug in US dollars. Univariate and multivariable regressions were used to examine the influence of dosage strength, drug formulation, and bulk purchasing on street price. RESULTS: A total of 5611 oxycodone and 1420 oxymorphone reports were analyzed. Across various dosages and formulations, geometric mean prices per milligram ranged between $0.12 and $1.07 for oxycodone and $0.73 and $2.90 for oxymorphone. For a 2-fold increase in dosage strength, there is a 24.0% (95% CI: -28.1%, -19.6%, P < 0.001) and a 22.5% (95% CI: -24.2%, -20.8%, P < 0.001) decrease on average in price per milligram for oxycodone and oxymorphone, respectively. Lower potency, high dosage strength, crush-resistant opioids, and those purchased in bulk were significantly cheaper. CONCLUSION: Street prices for diverted oxycodone and oxymorphone are influenced by multiple factors including potency, dosage, formulation, and bulk purchasing. Buyers who purchase large quantities of low potency, large dosage, crush-resistant formulation prescription opioids can expect to achieve the lowest price.
Assuntos
Drogas Ilícitas/economia , Entorpecentes/economia , Oxicodona/economia , Oximorfona/economia , Desvio de Medicamentos sob Prescrição/economia , Comércio/economia , Comércio/estatística & dados numéricos , Estudos Transversais , Overdose de Drogas/etiologia , Overdose de Drogas/prevenção & controle , Humanos , Drogas Ilícitas/efeitos adversos , Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Oxicodona/efeitos adversos , Oximorfona/efeitos adversos , Desvio de Medicamentos sob Prescrição/estatística & dados numéricos , Estudos Prospectivos , Estados UnidosRESUMO
BACKGROUND AND AIMS: Previous research has found diacetylmorphine, delivered under supervision, to be cost-effective in the treatment of severe opioid use disorder, but diacetylmorphine is not available in many settings. The Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME) randomized controlled trial provided evidence that injectable hydromorphone is non-inferior to diacetylmorphine. The current study aimed to compare the cost-effectiveness of hydromorphone directly with diacetylmorphine and indirectly with methadone maintenance treatment. DESIGN: A within-trial analysis was conducted using the patient level data from the 6-month, double-blind, non-inferiority SALOME trial. A life-time analysis extrapolated costs and outcomes using a decision analytical cohort model. The model incorporated data from a previous trial to include an indirect comparison to methadone maintenance. SETTING: A supervised clinic in Vancouver, British Columbia, Canada. PARTICIPANTS: A total of 202 long-term street opioid injectors who had at least two attempts at treatment, including one with methadone (or other substitution), were randomized to hydromorphone (n = 100) or diacetylmorphine (n = 102). MEASUREMENTS: We measured the utilization of drugs, visits to health professionals, hospitalizations, criminal activity, mortality and quality of life. This enabled us to estimate incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios from a societal perspective. Sensitivity analyses considered different sources of evidence, assumptions and perspectives. FINDINGS: The within-trial analysis found hydromorphone provided similar QALYs to diacetylmorphine [0.377, 95% confidence interval (CI) = 0.361-0.393 versus 0.375, 95% CI = 0.357-0.391], but accumulated marginally greater costs [$49 830 ($28 401-73 637) versus $34 320 ($21 780-55 998)]. The life-time analysis suggested that both diacetylmorphine and hydromorphone provide more benefits than methadone [8.4 (7.4-9.5) and 8.3 (7.2-9.5) versus 7.4 (6.5-8.3) QALYs] at lower cost [$1.01 million ($0.6-1.59 million) and $1.02 million ($0.72-1.51 million) versus $1.15 million ($0.71-1.84 million)]. CONCLUSIONS: In patients with severe opioid use disorder enrolled into the SALOME trial, injectable hydromorphone provided similar outcomes to injectable diacetylmorphine. Modelling outcomes during a patient's life-time suggested that injectable hydromorphone might provide greater benefit than methadone alone and may be cost-saving, with drug costs being offset by costs saved from reduced involvement in criminal activity.
Assuntos
Hidromorfona/uso terapêutico , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Colúmbia Britânica , Análise Custo-Benefício , Crime/economia , Crime/estatística & dados numéricos , Método Duplo-Cego , Estudos de Equivalência como Asunto , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Heroína/economia , Heroína/uso terapêutico , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Hidromorfona/economia , Metadona/economia , Metadona/uso terapêutico , Mortalidade , Entorpecentes/economia , Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de DoençaRESUMO
STUDY DESIGN: Retrospective Analysis OBJECTIVE.: The aim of this study was to determine whether an association between increased acute pain, postoperative time, and direct hospital costs exists between the use of iliac crest bone grafting (ICBG) and bone morphogenic protein (BMP)-2 following a primary, single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: ICBG has been associated with enhanced fusion rates. Concerns have been raised in regards to increased operative time and postoperative pain. The advantages of ICBG compared to other spinal fusion adjuncts have been debated. METHODS: Prospective, consecutive analysis of patients undergoing primary, single-level MIS TLIF with ICBG was compared to a historical cohort of consecutive patients that received BMP-2. Operative characteristics were compared between groups using χ analysis or independent t test for categorical and continuous variables, respectively. Postoperative inpatient pain was measured using the Visual Analog Scale, and inpatient narcotics consumption was quantified as oral morphine equivalents. Outcomes were compared between groups using multivariate regression controlling for preoperative characteristics. RESULTS: A total of 98 patients were included in this analysis, 49 in each cohort. No significant differences were noted between cohorts with exception to sex (Females: ICBG, 53.06% vs. BMP-2, 32.65%, Pâ=â0.041). There was a significant increase in operative time (14.53âminutes, Pâ=â0.006) and estimated blood loss (16.64âmL, Pâ=â0.014) in the ICBG cohort. Narcotics consumption was similar between groups on postoperative days 0 and 1. ICBG was associated with decreased total direct costs ($19,315 vs. $21,645, Pâ<â0.001) as compared to BMP-2. CONCLUSION: Patients undergoing MIS TLIF with ICBG experienced increases in operative time and estimated blood loss that were not clinically significant. Furthermore, iliac crest harvesting did not result in an increase in acute pain or narcotics consumption. Further follow-up is necessary to determine the associated arthrodesis rates and long-term outcomes between each cohort. LEVEL OF EVIDENCE: 3.
Assuntos
Transplante Ósseo/tendências , Custos Hospitalares/tendências , Ílio/transplante , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Entorpecentes/uso terapêutico , Fusão Vertebral/tendências , Adulto , Idoso , Transplante Ósseo/economia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Entorpecentes/economia , Duração da Cirurgia , Medição da Dor/economia , Medição da Dor/tendências , Estudos Prospectivos , Estudos Retrospectivos , Fusão Vertebral/economia , Fusão Vertebral/métodosRESUMO
The purpose of the study is to analyze specific problems of legal regulation of the procurement of narcotic drugs in Ukraine with the involvement of international specialized organizations. To achieve this goal, statistics have been analyzed concerning the number of people who receive narcotic drugs for the SMT program, the number of their treatment applications, the quantity of drugs purchased for them from the state budget. It is proposed to divide the regulatory legal acts regulating the purchase of narcotic drugs, general and special, and analyze them. The understanding of legal constructions "state procurement" and "public procurement" in scientific literature, national legislation and international legal documents is analyzed. Two groups of subjects of legal relations in the field of procurement of narcotic drugs with the involvement of international specialized organizations have been distinguished out. In the course of the study, a number of problems have been identified that require urgent solutions: insufficient budget financing of drug provision for SMT programs; absence of control over the use of methadone and buprenorphine for SMT programs at the legislative level, as well as the differentiation of the terms "narcotic drugs", "psychotropic substances" and "drugs containing narcotic drugs, psychotropic substances and precursors"; absence of the price of the drug in the selection criteria of international organizations, the lack of economic competition in this field, existence of prepayment for SMT drugs for more than one year, which affects the efficiency of using budgetary funds. It is proposed to make a number of changes to the relevant legal acts.
Assuntos
Comércio/legislação & jurisprudência , Agências Internacionais , Legislação de Medicamentos , Entorpecentes/provisão & distribuição , Psicotrópicos/provisão & distribuição , Comércio/economia , Financiamento Governamental/legislação & jurisprudência , Regulamentação Governamental , Humanos , Agências Internacionais/economia , Entorpecentes/economia , Entorpecentes/uso terapêutico , Psicotrópicos/economia , Psicotrópicos/uso terapêutico , UcrâniaRESUMO
OBJECTIVE Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures. METHODS The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (< 25.0 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), or obese II-III (≥ 35.0 kg/m2). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics. RESULTS Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II-III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p > 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p > 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p > 0.05). CONCLUSIONS Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI.
Assuntos
Índice de Massa Corporal , Discotomia/economia , Custos Hospitalares , Entorpecentes/economia , Entorpecentes/uso terapêutico , Fusão Vertebral/economia , Artrodese/economia , Perda Sanguínea Cirúrgica , Comorbidade , Custos e Análise de Custo , Discotomia/métodos , Feminino , Seguimentos , Humanos , Incidência , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Obesidade/tratamento farmacológico , Obesidade/economia , Obesidade/epidemiologia , Obesidade/cirurgia , Duração da Cirurgia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Fusão Vertebral/métodos , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective cohort analysis of a prospectively maintained registry. OBJECTIVE: To compare the surgical outcomes, narcotic utilization, and costs between a stand-alone (SA) cage and anterior plating (AP) with an interbody device for 1-level anterior cervical discectomy and fusion (ACDF). BACKGROUND DATA: ACDF with a SA cage has gained popularity as a potential alternative to anterior cervical plating. Few studies have compared the surgical outcomes, narcotic utilization, and costs of ACDF utilizing a SA cage versus AP with an interbody device. METHODS: Patients who underwent a primary 1-level ACDF for degenerative spinal pathology between 2010 and 2013 were analyzed. Patients were stratified on the basis of the type of implant system (SA cage vs. AP) and assessed with regard to demographics, comorbidities, smoking, visual analogue scale (VAS) scores (preoperative/postoperative), procedural time, estimated blood loss (EBL), length of hospitalization, complications, reoperations, narcotic consumption, and total costs. Statistical analysis was performed with independent sample T tests for continuous variables and χ analysis for categorical data. An α level of <0.05 denoted statistical significance. RESULTS: Of the 93 patients included, 52 (55.9%) underwent an ACDF with a SA cage system. Patient demographics, comorbidity burden, body mass index, smoking status, and preoperative VAS score were similar between cohorts. The SA cohort incurred a significantly lower EBL (P<0.001) than the AP cohort. However, none required a transfusion and the procedural time, length of hospitalization, postoperative VAS score, complication rates, 1-year arthrodesis rate, and reoperation rates were similar between cohorts. Postoperative narcotics consumption and total costs were also similar between groups. CONCLUSIONS: Our findings suggest that the SA cage may be associated with a significantly lower EBL, which may not be clinically relevant. Perioperative outcomes, complications, reoperation rates, narcotics consumption in the immediate postoperative period, and total costs may be similar regardless of the instrumentation utilized in a 1-level ACDF.
Assuntos
Placas Ósseas/economia , Discotomia/economia , Custos de Cuidados de Saúde , Entorpecentes/economia , Entorpecentes/farmacologia , Fusão Vertebral/economia , Adulto , Custos e Análise de Custo , Demografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Resultado do TratamentoRESUMO
INTRODUCTION: In Vietnam, two dominant approaches for heroin treatment are center-based compulsory rehabilitation (CCT), funded by the Vietnamese government and community-based voluntary methadone maintenance treatment (MMT), funded primarily by international donors. Recent reduction in international funding requires more efficient allocation of government funding for public health programs. A cost-effectiveness analysis comparing two approaches provides a useful source of evidence to inform the government about funding reallocation. METHODS: The study was a combined retrospective and prospective, non-randomized cohort comparison over three years of CCT and MMT in Vietnam, conducted between 2012 and 2014, involving 208 CCT participants and 384 MMT participants with heroin dependence. The primary end-point was drug-free days over three years. Total costs, including both program and participant personal costs were measured and cost-effectiveness compared. Mixed effects regression analyses were used to analyze effectiveness data and non-parametric bootstrapping method was used to compare cost-effectiveness. RESULTS: Over three years, MMT costed on average VND85.73 million (US$4108) less than CCT (95% CI: -VND76.88 million, -VND94.59 million). On average, a MMT participant had 344.20 more drug-free days compared to a CCT participant (p<0.001). The incremental cost-effectiveness ratio for MMT was -VND0.25 million (US$11.99) (95% CI: -VND0.34 million, -VND0.19 million) per drug-free day suggesting MMT is the more cost effective alternative. CONCLUSIONS: Compared to CCT, MMT is both less expensive and more effective in achieving drug-free days. If the government of Vietnam invests in MMT instead of CCT, it is potentially a cost-saving strategy for reducing illicit drug use among heroin dependent individuals.
Assuntos
Dependência de Heroína/reabilitação , Metadona/economia , Entorpecentes/economia , Tratamento de Substituição de Opiáceos/economia , Centros de Tratamento de Abuso de Substâncias/economia , Adulto , Análise Custo-Benefício , Feminino , Dependência de Heroína/economia , Humanos , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Entorpecentes/uso terapêutico , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento , VietnãAssuntos
Bupivacaína , Custos de Cuidados de Saúde/estatística & dados numéricos , Mamoplastia , Manejo da Dor , Dor Pós-Operatória/terapia , Adulto , Anestésicos Locais/economia , Anestésicos Locais/uso terapêutico , Bupivacaína/economia , Bupivacaína/uso terapêutico , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Mamoplastia/efeitos adversos , Mamoplastia/economia , Mamoplastia/métodos , Pessoa de Meia-Idade , Entorpecentes/economia , Entorpecentes/uso terapêutico , Bloqueio Nervoso/métodos , Manejo da Dor/economia , Manejo da Dor/métodosRESUMO
INTRODUCTION: Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination. METHODS: Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price. RESULTS: Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities. DISCUSSION: Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.
Assuntos
Dependência de Heroína/complicações , Dependência de Heroína/epidemiologia , Hospitalização/estatística & dados numéricos , Infecções dos Tecidos Moles/epidemiologia , Infecções dos Tecidos Moles/etiologia , Adulto , Comércio , Custos e Análise de Custo , Feminino , Heroína/economia , Dependência de Heroína/economia , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Entorpecentes/economia , Infecções dos Tecidos Moles/economia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
There is unmet need in patients suffering from chronic pain, yet innovation may be impeded by the difficulty of justifying economic value in a field beset by data limitations and methodological variability. A systematic review was conducted to identify and summarise the key areas of variability and limitations in modelling approaches in the economic evaluation of treatments for chronic pain. The results of the literature review were then used to support the development of a fully flexible open-source economic model structure, designed to test structural and data assumptions and act as a reference for future modelling practice. The key model design themes identified from the systematic review included: time horizon; titration and stabilisation; number of treatment lines; choice/ordering of treatment; and the impact of parameter uncertainty (given reliance on expert opinion). Exploratory analyses using the model to compare a hypothetical novel therapy versus morphine as first-line treatments showed cost-effectiveness results to be sensitive to structural and data assumptions. Assumptions about the treatment pathway and choice of time horizon were key model drivers. Our results suggest structural model design and data assumptions may have driven previous cost-effectiveness results and ultimately decisions based on economic value. We therefore conclude that it is vital that future economic models in chronic pain are designed to be fully transparent and hope our open-source code is useful in order to aspire to a common approach to modelling pain that includes robust sensitivity analyses to test structural and parameter uncertainty.
Assuntos
Dor Crônica/economia , Análise Custo-Benefício , Analgésicos/efeitos adversos , Analgésicos/economia , Analgésicos/uso terapêutico , Dor Crônica/terapia , Humanos , Modelos Econométricos , Entorpecentes/efeitos adversos , Entorpecentes/economia , Entorpecentes/uso terapêutico , Anos de Vida Ajustados por Qualidade de VidaRESUMO
OBJECTIVE: Despite the undisputed effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. To mitigate these risks, the Food and Drug Administration in 1993 approved interim treatment, involving daily medication+emergency counseling only, when only a waitlist is otherwise available. We review the published research in the 20years since the approval of interim opioid treatment. METHODS: A literature search was conducted to identify all randomized trials evaluating the efficacy of interim treatment for opioid-dependent patients awaiting comprehensive treatment. RESULTS: Interim opioid treatment has been evaluated in four controlled trials to date. In three, interim treatment was compared to waitlist or placebo control conditions and produced greater outcomes on measures of illicit opioid use, retention, criminality, and likelihood of entry into comprehensive treatment. In the fourth, interim treatment was compared to standard methadone maintenance and produced comparable outcomes in illicit opioid use, retention, and criminal activity. CONCLUSIONS: Interim treatment significantly reduces patient and societal risks when conventional treatment is unavailable. Further research is needed to examine the generality of these findings, further enhance outcomes, and identify the patient characteristics which predict treatment response.
Assuntos
Buprenorfina/uso terapêutico , Metadona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/reabilitação , Listas de Espera , Adulto , Buprenorfina/economia , Feminino , Acessibilidade aos Serviços de Saúde/economia , Humanos , Masculino , Metadona/economia , Antagonistas de Entorpecentes/economia , Entorpecentes/economia , Entorpecentes/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados UnidosRESUMO
Vermont is one of the more forward-thinking states in the nation with a history of taking groundbreaking approaches to complex social issues. In his Jan 8, 2014 State of the State Address, Vermont Governor Peter Shumlin announced that Vermont was in the midst of an opioid addiction epidemic. Though Vermont had called attention to its opioid crisis, it soon became clear that many other states shared this problem. Economic modeling of expanded access to maintenance therapy with either methadone or buprenorphine is felt to have "high value" because the added health care costs of treatment are offset by reductions in other health care costs that occur when individuals with opioid dependence begin treatment. Moreover, when broader societal costs such as criminal activity and work productivity are included, maintenance treatment is estimated to produce substantial overall savings. Coordinated efforts between the Vermont Department of Health's Division of Alcohol and Drug Abuse Programs (ADAP) and the Department of Vermont Health Access (DVHA-Vermont Medicaid Authority) have resulted in the creation of the Care Alliance for Opioid Addiction (or Hub & Spoke model). Vermont intends to develop a reproducible and exportable model based on cost effective, outcomes driven public policy.
Assuntos
Política de Saúde , Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Análise Custo-Benefício , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Metadona/uso terapêutico , Entorpecentes/economia , Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/economia , VermontRESUMO
Patients with cancer are increasingly opting for home health care, resulting in a rapid increase in the number of prescriptions for narcotics aimed at pain control. As these narcotics are issued by pharmacies only upon presentation of valid prescriptions, the quantity stored in the pharmacies is of importance. Although many pharmaceutical outlets are certified for retail sale of narcotic drugs, the available stock is often extremely limited in variety and quantity. Affiliated stores of wholesale(or central wholesale)dealers do not always have the necessary certifications to provide medical narcotics. Invariably, the quantity stored by individual branches or sales offices is also limited. Hence, it may prove difficult to urgently secure the necessary and appropriate drugs according to prescription in certain areas of the community. This report discusses the problems faced by wholesalers and pharmacies during acquisition, storage, supply, and issue of prescription opioids from a stockpiling perspective.
Assuntos
Entorpecentes/provisão & distribuição , Serviços de Assistência Domiciliar , Entorpecentes/economia , Farmácia , Inquéritos e Questionários , Fatores de TempoRESUMO
Oral mucositis (OM) is one of the side effects of hematopoietic stem cell transplantation (HSCT), resulting in major morbidity. The aim of this study was to determine the cost-effectiveness of the introduction of a specialized oral care program including laser therapy in the care of patients receiving HSCT with regard to morbidity associated with OM. Clinical information was gathered on 167 patients undergoing HSCT and divided according to the presence (n = 91) or absence (n = 76) of laser therapy and oral care. Cost analysis included daily hospital fees, parenteral nutrition (PN) and prescription of opioids. It was observed that the group without laser therapy (group II) showed a higher frequency of severe degrees of OM (relative risk = 16.8, 95% confidence interval -5.8 to 48.9, p < 0.001), with a significant association between this severity and the use of PN (p = 0.001), prescription of opioids (p < 0.001), pain in the oral cavity (p = 0.003) and fever > 37.8°C (p = 0.005). Hospitalization costs in this group were up to 30% higher. The introduction of oral care by a multidisciplinary staff including laser therapy helps reduce morbidity resulting from OM and, consequently, helps minimize hospitalization costs associated with HSCT, even considering therapy costs.
Assuntos
Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Terapia com Luz de Baixa Intensidade , Infecções Oportunistas/prevenção & controle , Higiene Bucal/métodos , Estomatite/terapia , Condicionamento Pré-Transplante/efeitos adversos , Adulto , Idoso , Aloenxertos/economia , Antibacterianos/administração & dosagem , Antibacterianos/economia , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/economia , Antifúngicos/administração & dosagem , Antifúngicos/economia , Antifúngicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Brasil , Estudos de Casos e Controles , Análise Custo-Benefício , Odontólogos/economia , Custos de Medicamentos , Feminino , Transplante de Células-Tronco Hematopoéticas/economia , Custos Hospitalares , Hospitalização/economia , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/economia , Imunossupressores/uso terapêutico , Terapia com Luz de Baixa Intensidade/economia , Terapia com Luz de Baixa Intensidade/métodos , Masculino , Pessoa de Meia-Idade , Agonistas Mieloablativos/economia , Agonistas Mieloablativos/uso terapêutico , Entorpecentes/economia , Entorpecentes/uso terapêutico , Infecções Oportunistas/economia , Infecções Oportunistas/etiologia , Higiene Bucal/economia , Nutrição Parenteral/economia , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Autocuidado/economia , Estomatite/economia , Estomatite/etiologia , Estomatite/prevenção & controle , Condicionamento Pré-Transplante/economia , Transplante Autólogo/economiaRESUMO
PURPOSE: We tested the hypothesis that prescription coverage affects the prescribing of long-acting opiates to indigent inner city minority patients with cancer pain. MATERIALS AND METHODS: We conducted a chart review of 360 patients treated in the Oncology Practice at University of Medicine and Dentistry of New Jersey University Hospital, who were prescribed opiate pain medications. Half the patients were charity care or self-pay (CC/SP), without the benefit of prescription coverage, and half had Medicaid, with unlimited prescription coverage. We evaluated patients discharged from a hospitalization, who had three subsequent outpatient follow-up visits. We compared demographics, pain intensity, the type and dose of opiates, adherence to prescribed pain regimen, unscheduled emergency department visits, and unscheduled hospitalizations. RESULTS: There was a significantly greater use of long-acting opiates in the Medicaid group than in the CC/SP group. The Medicaid group had significantly more African American patients and a greater rate of smoking and substance use, and the CC/SP group disproportionately more Hispanic and Asian patients and less smoking and substance use. Hispanic and Asian patients were less likely to have long-acting opiates prescribed to them. Pain levels and adherence were equivalent in both groups and were not affected by any of these variables except stage of disease, which was equally distributed in the two groups. CONCLUSION: Appropriate use of long-acting opiates for equivalent levels of cancer pain was influenced only by the availability of prescription coverage. The group without prescription coverage and receiving fewer long-acting opiates had disproportionately more Hispanic and Asian patients.