Cost-effectiveness of integrating buprenorphine-naloxone treatment for opioid use disorder into clinical care for persons with HIV/hepatitis C co-infection who inject opioids.

BACKGROUND: Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD. METHODS: We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios. RESULTS: Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights. CONCLUSIONS: Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.

Internalized stigma and its correlates among treatment seeking opium users in India: A cross-sectional observational study.

Opium has been used in India since ancient times for social, recreational, religious and medicinal purposes. Opium users seem to constitute a distinct sub-population among opioid users, who have minimal complications, better functioning and socio-cultural acceptance. Prominent levels of stigma have been reported against people who use opioid drugs, but the same cannot be extrapolated to opium users. There is a vast number of opium users in India, and it is prudent to understand the stigma faced by them to better address their problems. Hence, in the current study we aimed to assess the internalized stigma and its correlates among opium users who seek treatment at a tertiary care drug treatment centre in North India. 117 adult male participants having opioid dependence (opium being the most common opioid in last 3 months) were assessed using Internalized Stigma of Mental Illness (ISMI) scale - Hindi version. The stigma scores were in the mild to moderate range, which was less than that found in previous studies among heroin and alcohol users in similar setting. Moreover, higher stigma scores were associated with lower educational status and higher proportions of income spent on substances. This is the first study to document stigma among opium users. Further research needs to be conducted to understand the determinants of stigma in this population.

Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System.

Importance: Opioids are commonly used for pain control during and after invasive procedures. However, opioid-related adverse drug events (ORADEs) are common and have been associated with worse patient outcomes. Objectives: To examine the incidence of ORADEs in patients undergoing hospital-based surgical and endoscopic procedures and to evaluate the association of ORADEs with clinical and cost outcomes. Design, Setting, and Participants: In this retrospective study of clinical and administrative data, ORADEs were identified using International Classification of Diseases, Ninth Revision diagnosis codes for known adverse effects of opioids or by opioid antagonist use. Multivariable regression analysis was used to measure the association of ORADEs with outcomes after adjusting for potential confounding factors. The setting was 21 acute care hospitals in a large integrated health care delivery system. Participants were 135 379 patients (aged ≥18 years, admitted from January 1, 2013, to September 30, 2015) who underwent surgical and endoscopic procedures and were given opioids. Exposure: Opioid use, reported as morphine milligram equivalent doses. Main Outcomes and Measures: Opioid-related adverse drug events and their association with inpatient mortality, discharge to another care facility, length of stay, cost of hospitalization, and 30-day readmission. Results: Among 135 379 adult patients in this study (67.5% female), 14 386 (10.6%) experienced at least one ORADE. Patients with ORADEs were more likely to be older, of white race/ethnicity, and male and have more comorbidities. Patients with ORADEs received a higher total dose of opioids (median morphine milligram equivalent dose, 46.8 vs 30.0 mg; P < .001) and for a longer duration (median, 3.0 vs 2.0 days; P < .001). In adjusted analyses, ORADEs were associated with increased inpatient mortality (odds ratio [OR], 28.8; 95% CI, 24.0-34.5), greater likelihood of discharge to another care facility (OR, 2.9; 95% CI, 2.7-3.0), prolonged length of stay (OR, 3.1; 95% CI, 2.8-3.4), high cost of hospitalization (OR, 2.7; 95% CI, 2.4-3.0), and higher rate of 30-day readmission (OR, 1.3; 95% CI, 1.2-1.4). ORADEs were associated with a 2.9% increase in absolute mortality, an $8225 increase in cost for the index hospitalization, and a 1.6-day increase in length of stay for the index hospitalization. Conclusions and Relevance: Opioid-related adverse drug events were common among patients undergoing hospital-based invasive procedures and were associated with significantly worse clinical and cost outcomes. Hospital-acquired harm from ORADEs in the surgical patient population is an important opportunity for health systems to improve patient safety and reduce cost.

Natural Language Processing-Identified Problem Opioid Use and Its Associated Health Care Costs.

Use of prescription opioids and problems of abuse and addiction have increased over the past decade. Claims-based studies have documented substantial economic burden of opioid abuse. This study utilized electronic health record (EHR) data to identify chronic opioid therapy (COT) patients with problem opioid use (POU) and compared costs with those for COT patients without POU. This study utilized EHR and claims data from an integrated health care system. Patients received COT (≥70 days' supply in ≥1 calendar quarter, 2006-2012). Natural language processing (NLP) identified notations of opioid addiction, abuse, misuse, or overuse, and manual validation was performed. Cases had evidence of POU (index = first POU notation), and controls, sampled 9:1, did not. Health care resource utilization was measured and costs estimated using Medicare reimbursement rates. A longitudinal analysis of costs was conducted using generalized estimating equations. Adjusted analyses controlled for baseline age, gender, region, specific comorbidities, and a comorbidity index. The analysis population included 1,125 cases and 10,128 controls. Unadjusted costs were higher for cases in all three years. After controlling for covariates, total costs remained higher in cases and were significantly higher in the first year of follow-up ($38,064 vs. $31,674, P = .0048). The largest cost difference was observed in the first month of follow-up. COT patients with POU experienced significantly higher costs compared with COT patients without POU in the first year of follow-up. The greatest difference in costs was observed around identification of POU.

Alcohol, Cannabis, and Opioid Use Disorders, and Disease Burden in an Integrated Health Care System.

OBJECTIVES: We examined prevalence of major medical conditions and extent of disease burden among patients with and without substance use disorders (SUDs) in an integrated health care system serving 3.8 million members. METHODS: Medical conditions and SUDs were extracted from electronic health records in 2010. Patients with SUDs (n = 45,461; alcohol, amphetamine, barbiturate, cocaine, hallucinogen, and opioid) and demographically matched patients without SUDs (n = 45,461) were compared on the prevalence of 19 major medical conditions. Disease burden was measured as a function of 10-year mortality risk using the Charlson Comorbidity Index. P-values were adjusted using Hochberg's correction for multiple-inference testing within each medical condition category. RESULTS: The most frequently diagnosed SUDs in 2010 were alcohol (57.6%), cannabis (14.9%), and opioid (12.9%). Patients with these SUDs had higher prevalence of major medical conditions than non-SUD patients (alcohol use disorders, 85.3% vs 55.3%; cannabis use disorders, 41.9% vs 23.0%; and opioid use disorders, 44.9% vs 26.1%; all P < 0.001). Patients with these SUDs also had higher disease burden than non-SUD patients; patients with opioid use disorders (M = 0.48; SE = 1.46) had particularly high disease burden (M = 0.23; SE = 0.09; P < 0.001). CONCLUSIONS: Common SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care. This signals the need to explore the full impact SUDs have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.

Do consumers substitute opium for hashish? An economic analysis of simultaneous cannabinoid and opiate consumption in a legal regime.

AIM: To analyze interrelationships in the consumption of opiates and cannabinoids in a legal regime and, specifically, whether consumers of opiates and cannabinoids treat them as substitutes for each other. METHOD: Econometric dynamic panel data models for opium consumption are estimated using the generalized method of moments (GMM). A unique dataset containing information about opiate (opium) consumption from the Punjab province of British India for the years 1907-1918 is analyzed (n=252) as a function of its own price, the prices of two forms of cannabis (the leaf (bhang), and the resin (charas, or hashish)), and wage income. Cross-price elasticities are examined to reveal substitution or complementarity between opium and cannabis. RESULTS: Opium is a substitute for charas (or hashish), with a cross price elasticity (߈3) of 0.14 (p<0.05), but not for bhang (cannabis leaves; cross price elasticity=0.00, p>0.10). Opium consumption (߈1=0.47 to 0.49, p<0.01) shows properties of habit persistence consistent with addiction. The consumption of opium is slightly responsive (inelastic) to changes in its own price (߈2=-0.34 to -0.35, p<0.05 to 0.01) and consumer wages (߈1=0.15, p<0.05). CONCLUSION: Opium and hashish, a form of cannabis, are substitutes. In addition, opium consumption displays properties of habit persistence and slight price and wage income responsiveness (inelasticity) consistent with an addictive substance.

Costs of care for persons with opioid dependence in commercial integrated health systems.

BACKGROUND: When used in general medical practices, buprenorphine is an effective treatment for opioid dependence, yet little is known about how use of buprenorphine affects the utilization and cost of health care in commercial health systems. METHODS: The objective of this retrospective cohort study was to examine how buprenorphine affects patterns of medical care, addiction medicine services, and costs from the health system perspective. Individuals with two or more opioid-dependence diagnoses per year, in two large health systems (System A: n = 1836; System B: n = 4204) over the time span 2007-2008 were included. Propensity scores were used to help adjust for group differences. RESULTS: Patients receiving buprenorphine plus addiction counseling had significantly lower total health care costs than patients with little or no addiction treatment (mean health care costs with buprenorphine treatment = $13,578; vs. mean health care costs with no addiction treatment = $31,055; p < .0001), while those receiving buprenorphine plus addiction counseling and those with addiction counseling only did not differ significantly in total health care costs (mean costs with counseling only: $17,017; p = .5897). In comparison to patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care (p < .001), other medical visits (p = .001), and emergency services (p = .020). Patients with counseling only (compared to patients with buprenorphine plus counseling) used less inpatient detoxification (p < .001), and had significantly more PC visits (p = .001), other medical visits (p = .005), and mental health visits (p = .002). CONCLUSIONS: Buprenorphine is a viable alternative to other treatment approaches for opioid dependence in commercial integrated health systems, with total costs of health care similar to abstinence-based counseling. Patients with buprenorphine plus counseling had reduced use of general medical services compared to the alternatives.

Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.

BACKGROUND: Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic. OBJECTIVE: We evaluated the cost-effectiveness of long-term office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment. DESIGN, SUBJECTS, AND INTERVENTION: A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-of-life weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated. MAIN MEASURES: Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually. KEY RESULTS: In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce quality-of-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction. CONCLUSIONS: Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.

Alcohol and opioid dependence medications: prescription trends, overall and by physician specialty.

Over the past decade, advances in addiction neurobiology have led to the approval of new medications to treat alcohol and opioid dependence. This study examined data from the IMS National Prescription Audit (NPA) Plus database of retail pharmacy transactions to evaluate trends in U.S. retail sales and prescriptions of FDA-approved medications to treat substance use disorders. Data reveal that prescriptions for alcoholism medications grew from 393,000 in 2003 ($30 million in sales) to an estimated 720,000 ($78 million in sales) in 2007. The growth was largely driven by the introduction of acamprosate in 2005, which soon became the market leader ($35 million in sales). Prescriptions for the two buprenorphine formulations increased from 48,000 prescriptions ($5 million in sales) in the year of their introduction (2003) to 1.9 million prescriptions ($327 million in sales) in 2007. While acamprosate and buprenorphine grew rapidly after market entry, overall substance abuse retail medication sales remain small relative to the size of the population that could benefit from treatment and relative to sales for other medications, such as antidepressants. The extent to which substance dependence medications will be adopted by physicians and patients, and marketed by industry, remains uncertain.

On-site medical care in methadone maintenance: associations with health care use and expenditures.

To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (>/=6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients (n = 423, with 1,161 person-years of observation). After adjustment, linked care participants had more outpatient visits (p < .001), fewer emergency department (ED) visits (24% vs. 33%, p = .02) and fewer hospitalizations (27% vs. 40%, p = .002) than the "neither" group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Long-term drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures.

Overcoming policy and financing barriers to integrated buprenorphine and HIV primary care.

Treatment for substance abuse and human immunodeficiency virus (HIV) infection historically have come from different providers, often in separate locations, and have been reimbursed through separate funding streams. We describe policy and financing challenges faced by health care providers seeking to integrate buprenorphine, a new treatment for opioid dependence, into HIV primary care. Regulatory challenges include licensing and training restrictions imposed by the Drug Addiction Treatment Act of 2000 and confidentiality regulations for alcohol and drug treatment records. Potential responses include the development of local training programs and electronic medical records. Addressing the complexity of funding sources for integrated care will require administrative support, up-front investments, and federal and state leadership. A policy and financing research agenda should address evidence gaps in the rationales for regulatory restrictions and should include cost-effectiveness studies that quantify the "value for money" of investments in integrated care to improve health outcomes for HIV-infected patients with opioid dependence.

Opiate addiction and the entanglements of imperialism and patriarchy in Manchukuo, 1932-45.

In the Japanese colonial state of Manchukuo, opiate addiction was condemned by officials and critics alike. But the state-sponsored creation of a monopoly, opium laws, and rehabilitation programs failed to reduce rates of addiction. Further, official media condemnation of opiate addiction melded with local Chinese-language literature to stigmatise addiction, casing a negative light over the state's failure to realise its own anti-opiate agenda. Chinese writers were thus transfixed in a complex colonial environment in which they applauded measures to reduce harm to the local population while levelling critiques of Japanese colonial rule. This paper demonstrates how the Chinese-language literature of Manchukuo did not simply parrot official politics. It also delegitimised Japanese rule through opiate narratives that are gendered, consistently negative, and more critical of the state than might be expected in a colonial literature.

Disability payments, drug use and representative payees: an analysis of the relationships.

AIMS: This study attempted to determine: if US federal cash disability payments increase the use of cocaine or opiates among those requalifying for supplemental security income (SSI) disability benefits compared with those who lost benefits; if drug use peaks at the beginning of the month after the receipt of the disability cash disbursement; and if money management by representative payees of requalifying SSI recipients suppresses drug use. DESIGN: A multi-site, prospective, 2 year longitudinal design was used with follow-up interviews conducted every 6 months. Urine samples were collected at the final three follow-up interviews. SETTING: Data were collected in Chicago, IL, Los Angeles, CA, and Seattle, WA, USA. PARTICIPANTS: This study used a randomly selected sample of 740 former recipients of SSI who had received disability benefits for drug addiction and alcoholism (DA&A) in 1996, were between the ages of 21 and 59 years, had not received concurrent social security disability insurance and provided testable urine samples and complete self-report data for at least one follow-up interview. MEASUREMENTS: Independent variables included demographics, SSI status at follow-up, representative payee status, drug treatment participation and income. Time of drug testing was operationalized as the first 10 days of the month versus the last 20-21 days based on when the urine sample was collected. The dependent variables were cocaine and opiate use, determined by urinalysis results. FINDINGS: Participants were 28% more likely to test positive for cocaine use in the first 10 days of the month than later in the month. This effect was general across all subjects and was not restricted to those receiving SSI benefits. No such effect was found for opiate use. Receiving SSI benefits did not increase cocaine or opiate use generally, nor did having a representative payee suppress use. CONCLUSIONS: The findings do not support the contentions that federal cash benefits appreciably increase drug use or that representative payees discourage use, at least when use is defined dichotomously. The 'check effect' for cocaine use appears to be general and not confined to those receiving federal cash benefits. The lack of a 'check effect' for opiate use is probably the result of the difference between a relatively steady state of opiate use associated with addiction and a binge pattern of cocaine use triggered by suddenly flush resources.

Buprenorphine for opiate addiction: potential economic impact.

This study evaluated the potential economic impact of the buprenorphine/naloxone combination in the context of practice in the United States of America. In comparison to treatment provided through methadone clinics, buprenorphine/naloxone therapy in office practice may be associated with increased medication, physician, and nursing costs, but reduced costs for dispensing, toxicology screens, counseling and administration. It may also result in markedly reduced costs for patients, especially travel costs, resulting in net savings for society as a whole. A review of controlled studies suggest that buprenorphine/naloxone is not likely to be any more or less effective than methadone, but since it will be less expensive in the long run, it may be more cost-effective than methadone when provided to comparable groups of patients. Because of the convenience of office-based treatment, buprenorphine/naloxone may increase access to opiate substitution for some addicts. To the extent that treatment is provided to additional high-cost patients who are involved in extensive criminal activity or who undergo multiple detoxifications each year, net cost savings could be substantial. To the extent that treatment is extended to better adjusted addicts who are employed, married and experience fewer adverse effects from their addiction, costs could increase. The total cost impact will depend on which addict sub-populations make greatest use of the treatment opportunity presented by buprenorphine/naloxone.

Variability in opium dosage: observations from Laos, 1965-75.

Opiate addicts are generally believed to consume a fairly constant level of drug. These data indicate that, for most addicts over time, there is considerable variability in dosage. This variability occurs not only amongst addicts, but also in most individual addicts over time. Extreme constancy in dosage does prevail for some addicts over prolonged periods, but this is not the norm. Factors influencing dosage include age, gender, ethnicity, socioeconomic status, duration of addiction, drug cost and drug availability. Distributions in dosage patterns are presented in this report.

Hill tribe opium addicts: a retrospective study of 1,382 patients.

This paper presents the results of a retrospective study of 1,382 patients admitted to the Narcotics Treatment Centre for Hill Tribes in Thailand, which was operated by the WHO/UN/Thai Programme for Drug Abuse Control. The study revealed widespread opium addiction among the hill tribes. Of these, the Karen were the largest group. Mean age on admission for treatment was 35 years. The male:female ratio was 7:1. Sixty-six per cent were heads of households. About one-third came from households with more than one addict. The mean duration of daily opium use before admission was 7.9 years. Over 90% of them were addicted to opium; there were eight heroin users. The mean amount of opium used daily was 3.9 g for males and 3.2 g for females. About three-quarters of them used salicylate analgesics with opium. Illness, in particular abdominal pain, was the most frequent cause of their addiction.