Buprenorphine versus methadone maintenance: a cost-effectiveness analysis. Doran CM, Shanahan M, Mattick RP, Ali R, White J, Bell J. Drug Alc Dependence 2003 71;3:295-302
Dear Colleagues,
This monumental study was one of the steps required in the licensing of buprenorphine in Australia. It is a credit to the authors who went against almost all previous studies of comparative opioid addiction treatments in keeping the randomised interventions 'naturalistic' rather than arbitrary, fixed or even placebo. Doses were not capped and the initial period was double blind. Pregnant women, dual diagnosis folk and those currently in agonist treatment were exluded.
This analysis is of the costs versus benefits and has a brief but important literature review of the subject. The summaries are worth quoting: "The most comprehensive cost-benefit analysis to date … by Gerstein [CALDATA study] … found that for each modality of treatment the summed benefits significantly exceeded the cost of delivering the episode of care. For residential treatment the ratio of benefits to costs was 4.8. Comparable ratios were obtained for social model treatment and for continuing methadone. Much higher ratios of 11 to 1 and 12.6 to 1 were estimated for outpatient and discharged methadone participants."
[In this study:] "Treatment with methadone was found to be both less expensive and more effective than treatment with buprenorphine, which suggests methadone dominates buprenorphine. However, [this may not be] statistically significant. The results of this study . indicate that buprenorphine provides a viable alternative to methadone in the treatment of opioid dependence."
The authors could not directly test the cost of those opioid dependent patients who do not do well on methadone treatment. Other studies indicate that they are more likely to die and to be involved in high risk behaviours. Hence an alternative as effective as methadone must be a boon and would increase the cost-efficiency even further, even in the case of slightly higher costs of buprenorphine and its delivery.
Comments by Andrew Byrne ..
Reference: Gerstein DR, Johnson RA, Harwood HJ, Fountain D, Suter N, Mallow K. 1994 Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA). Report by NORC at University of Chicago and Lewin-VHI Inc, Fairfax Virginia.
