Value for money in reducing opioid-related deaths
Authors: Wayne Hall, John Strang
Journal: The Lancet Public Health (2017)

During the past decade, overlapping epidemics of opioid overdose deaths have occurred in the USA. A steep increase in overdose deaths caused by pharmaceutical opioids during the past 15 years1Paulozzi LJ Weisler RH Patkar AA A national epidemic of unintentional prescription opioid overdose deaths: how physicians can help control it.J Clin Psychiatry. 2011; 72: 589-592Crossref PubMed Scopus (120) Google Scholar has been followed more recently by a new epidemic of heroin overdose deaths.2Rudd RA Aleshire N Zibbell JE Gladden RM Increases in drug and opioid overdose deaths--United States, 2000-2014.MMWR Morb Mortal Wkly Rep. 2016; 64: 1378-1382Crossref PubMed Scopus (1396) Google Scholar Opioid overdose deaths have been a major contributor to the reversal in life expectancy of middle-aged white people in the USA,3Case A Deaton A Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.Proc Natl Acad Sci USA. 2015; 112: 15078-15083Crossref PubMed Scopus (1468) Google Scholar and opioids cause the greatest loss of life from fatal drug overdoses worldwide.4Degenhardt L Whiteford HA Ferrari AJ et al.Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 382: 1564-1574Summary Full Text Full Text PDF PubMed Scopus (569) Google Scholar Opioid overdose deaths can be prevented by engaging opioid-dependent people in methadone or buprenorphine substitution treatment, and distributing the opioid antagonist naloxone to enable bystanders to reverse opioid overdoses.2Rudd RA Aleshire N Zibbell JE Gladden RM Increases in drug and opioid overdose deaths--United States, 2000-2014.MMWR Morb Mortal Wkly Rep. 2016; 64: 1378-1382Crossref PubMed Scopus (1396) Google Scholar In a study reported in The Lancet Public Health, Jennifer Uyei and colleagues5Uyei J Fiellin DA Buchelli M Rodriguez-Santana R Braithwaite RS Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling study.Lancet Public Health. 2017; (published online Feb 9.)http://dx.doi.org/10.1016/S2468-2667(17)30006-3Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar used economic modelling to identify the most efficient ways of reducing mortality from injected opioids in the USA. They probabilistically modelled the cost-effectiveness of current practice in Connecticut—namely, distributing naloxone via syringe service programmes. They also modelled the cost-effectiveness of combining naloxone distribution with linkage to addiction treatment and adding an HIV prevention measure—namely, antiretroviral drugs for pre-exposure prophylaxis (PrEP) against HIV infection. The investigators developed a decision analytic Markov model to simulate the effects of these combinations of interventions on opioid overdoses, HIV incidence, overdose-related deaths, and HIV-related deaths. They compared the modelled effects of each strategy with no additional intervention (syringe service programme only) and considered the cost-effectiveness of all feasible combinations of the strategies. They also did sensitivity analyses to assess the effects on estimated cost-effectiveness of the uncertainty about the values of key parameters in their modelling (eg, baseline prevalence of HIV infection, uptake in the at-risk population, and likely degree of compliance). The investigators' findings support those of a previous modelling study in demonstrating that it is cost-effective for syringe service programmes to distribute naloxone to opioid users so that bystanders and peers can reverse opioid overdoses.6Coffin PO Sullivan SD Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal.Ann Intern Med. 2013; 158: 1-9Crossref PubMed Scopus (220) Google Scholar The small incremental cost-effectiveness ratio (ICER) for distributing naloxone via syringe service programmes (US$323 per quality-adjusted life year) reflects the modest cost of naloxone, its effectiveness in reversing opioid overdoses, the strong interest among opioid injectors in using naloxone, and the minimal risks of doing so.7Kim HK Nelson LS Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review.Expert Opin Drug Saf. 2015; 14: 1137-1146Crossref PubMed Scopus (79) Google Scholar For these reasons, naloxone distribution to high-risk opioid injectors has already been implemented in parts of the USA8Wheeler E Jones TS Gilbert MK Davidson PJ Opioid overdose prevention programs providing naloxone to laypersons - United States, 2014.MMWR Morb Mortal Wkly Rep. 2015; 64: 631-635PubMed Google Scholar and Scotland.9Bird SM McAuley A Perry S Hunter C Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison.Addiction. 2016; 111: 883-891Crossref PubMed Scopus (157) Google Scholar Uyei and colleagues' analysis also suggested that the combination of naloxone distribution plus linking syringe service programme attendees into methadone treatment is cost saving. This finding is consistent with a substantial body of evidence that opioid substitution treatment reduces illicit heroin use and opioid overdose mortality10Mattick RP Breen C Kimber J Davoli M Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.Cochrane Database Syst Rev. 2009; 3 (CD002209)Google Scholar and is a highly cost-effective intervention.11Zaric GS Barnett PG Brandeau ML HIV transmission and the cost-effectiveness of methadone maintenance.Am J Public Health. 2000; 90: 1100-1111Crossref PubMed Scopus (172) Google Scholar The sensitivity analyses suggest that we can have reasonable confidence in the public health benefits and cost-effectiveness of combining naloxone distribution with linkage to methadone treatment. The combination was no longer cost saving if the risk of relapse to drug use was higher than in the base model, but the combination remained highly cost-effective. The cost-effectiveness of adding PrEP to naloxone distribution and linkage to methadone treatment alone or in combination was less certain. The best case estimate was that the ICER for this combined intervention was just under $100 000, a commonly used threshold for funding health-care interventions in the USA. The sensitivity analyses suggested substantial uncertainty about this estimate because the ICER remained below the $100 000 threshold in only a third of simulated cases. The $100 000 threshold may be acceptable for the USA, which has a high prevalence of HIV infection in injecting drug users (because of failure to implement syringe service programmes early in the HIV epidemic). However, the total cost of distributing PrEP to injecting opioid users would be substantial, even for the USA. This caveat raises the question of whether it would be more efficient to expand access to opioid substitution treatment (including buprenorphine), which is still difficult to access in many parts of the USA. Uyei and colleagues' analyses should provide an important stimulus to more sophisticated modelling of policies to reduce opioid overdose deaths in the USA. Such modelling will require more epidemiological research and clinical trials to reduce uncertainties about the likely uptake, compliance with, and effectiveness of different combinations of interventions. In the meantime, these findings support decisions by many public health authorities in the USA to distribute naloxone to high-risk opioid users.8Wheeler E Jones TS Gilbert MK Davidson PJ Opioid overdose prevention programs providing naloxone to laypersons - United States, 2014.MMWR Morb Mortal Wkly Rep. 2015; 64: 631-635PubMed Google Scholar They also strengthen the case for expanding access to and engaging more opioid-dependent people in addiction treatment. Public health interventions to reduce opioid-related deaths should be accompanied by prospective investigations to assess the extent to which the modelled public health benefits and cost-effectiveness findings are realised when these interventions are scaled up on a population level. JS reports grants and consultancy payments from Martindale Pharma, Mundipharma, and Braeburn Pharmaceuticals, outside the submitted work. JS has a patent with Euro-Celtique issued, and a patent with King's College London pending. WH declares no competing interests. Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling studyNaloxone distribution through syringe service programmes is cost-effective compared with syringe distribution alone, but when combined with linkage to addiction treatment is cost saving compared with no additional services. A strategy that combines naloxone distribution, PrEP, and linkage to addiction treatment results in greater health benefits in people who inject drugs and is also cost-effective. Full-Text PDF Open Access