Buprenorphine Cost Effectiveness

Buprenorphine Cost
Effectiveness
Bruce R. Schackman, PhD
Division of Health Policy/Department of Public Health
Weill Cornell Medical College
May 11, 2010

Funding
• Robert Wood Johnson Foundation
Substance Abuse Policy Research Program
Grant # 63625
• U.S. Department of Health and Human
Services, HRSA HIV/AIDS Bureau’s Special
Project of National Significance
2

Buprenorphine Cost
• Cost has been considered a barrier to adoption
– Drug cost is at least 7x higher than methadone, but
methadone is very rarely used in the outpatient setting
• Brand-name buprenorphine lost patent
exclusivity in October 2009
– Brand-name buprenorphine/naloxone (Suboxone) has
no generic competitors
– Brand-name buprenorphine (Subutex) has one
generic competitor
• Cost is estimated to be 80% of Subutex cost
3

Questions Policy Makers May Ask
• How much will it cost my budget next year?
• Can I afford it?
• Is it a good value from my perspective?
– “Evidence-based” ?
– “Cost-effective” ?
4

Cost-effectiveness ≠ Cost saving

Cost-Effectiveness is About
Value for Money
• Very, very few health interventions save more
money than they cost
• Cost-effectiveness analysis is about
comparative assessment of worth
• Investments in health can be compared to
evaluate competing claims on scarce
resources
6

Questions Policy Makers Should Ask
• Is it a good long-term value from society’s
perspective?
– Use cost-effectiveness as a threshold
– If no, stop; if yes, continue
• What is the relevant comparator? (e.g.
“standard of care” = no treatment)
• Over what time period should the program be
evaluated?
• Which public and private payer budgets will be
affected? Who wins? Who loses?
7

Cost-effectiveness Ratio
Additional Resources Used ($)
Additional Health Benefits Gained (QALYs)
8

Cost-effectiveness vs cost-benefit?
• Cost-benefit analysis (CBA) allows consideration
of benefits and costs outside the health care system
– CBAs have shown methadone maintenance to be costsaving
considering savings in crime costs, welfare
payments, and health care costs and/or increases in
earnings 1
• Issues:
– Lack of data requires extrapolation from studies of
methadone treatment and heroin use; may not be relevant to
prescription opioid dependent patients
– CBA is not commonly accepted for evaluating medical
treatments; cannot compare results to other pharmaceutical
interventions
1 Simoens et. al, Drug Alcohol Dep, 2006
9

Published Cost-Effectiveness Studies (1)
• UK National Health Service (NICE) study 1
– Compared daily dispensing of buprenorphine and
methadone
– CE ratio of buprenorphine vs no treatment was
£26,400/QALY ($13,400/QALY)
– Buprenorphine was more costly and less effective
than methadone
• 3 Australian studies conducted alongside
randomized trials 2
– Time horizon 3-12 months
– Similar costs and outcomes for buprenorphine and
methadone
1 Connock et al. Health Technology Assessment, 2006
2 Doran et. al, Drug Alcohol Depend, 2003; Harris et al. Pharmacoeconomics, 2005; Gibson et al. Med J Aust, 2003 10

Published Cost-Effectiveness Studies (2)
• Cost-effectiveness based on prevention of HIV
transmission among US IDUs 1
– Compared buprenorphine to methadone and
buprenorphine to no treatment
– In most scenarios buprenorphine had a cost-effectiveness
ratio of

Current Study
• To evaluate the cost-effectiveness of long-term officebased
buprenorphine treatment compared to no treatment
for clinically stable patients
– Assume patients are unwilling or unable to engage in
methadone maintenance treatment
– Medical perspective taking into account patient benefits
measured in QALYs
• To evaluate the impact of uncertainty about model inputs
on cost-effectiveness results
– Price of buprenorphine
– Duration of treatment
– Quality of life on/off buprenorphine
12

Enter
In Treatment
Off Drugs
In Treatment
On Drugs
Model
Off Treatment
Off Drugs
Off Treatment
On Drugs
Note: Separate models run for injection drug users (IDUs) and non-IDUs
13

Data from Published Cohort Study
• Patients had been followed in an RCT of buprenorphine
management strategies and successfully completed 24 weeks on
buprenorphine/naloxone (w/ at least 9 weeks abstinence) 1
• We used follow-up study data on retention in treatment up to 24
months after completion of the RCT 2
• For those not retained in treatment, assumed 89% to be actively
using drugs when out of treatment 3
• Unit cost data from previous analysis of the same cohort 4
• Average weekly cost for IDU and non-IDUs calculated based on
patient-level resource utilization
• For sensitivity analysis on drug cost, examined generic cost 80% of
branded cost
1 Fiellin et. al, N Engl J Med, 2006
2 Fiellin et. al, Am J Addict., 2006
3 Connock et al. Health Technology Assessment, 2006
4 Jones et. al, Drug Alcohol Depend., 2009
14

Cohort Retention In Treatment By Month
Probability
of Retention
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Retention Rate by Month
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Months in Treatment
15

Preliminary cost-effectiveness results to
be presented at meeting

Limitations
• Cohort treated at a single site
• Drug use out of treatment was not observed,
we assume 89% return to drug use based on
available data
• Ignores 6-month “start-up” costs and benefits
• Ignores other costs and benefits
• Other medical costs saved or incurred
• Deaths avoided
17

Conclusions
• Office-based buprenorphine for clinically
stable patients is cost-effective compared to
no treatment using accepted thresholds for
medical treatment in the US
• Price reductions have a small effect on costeffectiveness
findings
– Not appropriate to refuse treatment coverage until
generic buprenorphine/naloxone is available on
the basis of cost-effectiveness
• Lack of certainty about quality-of-life weights
reduces robustness of findings
– Further research about quality of life on and off
buprenorphine is necessary
18

• David Fiellin, MD
• Jared Leff, MS
Acknowledgments
• Daniel Polsky, PhD
• Brent Moore, PhD
• Emlyn Jones, MD
• Ashley Eggman, MS
19