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The American Journal of Managed Care November 2018
A Randomized, Pragmatic, Pharmacist-Led Intervention Reduced Opioids Following Orthopedic Surgery
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
Understanding and Improving Value Frameworks With Real-World Patient Outcomes
Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
From the Editorial Board: Glen D. Stettin, MD
Glen D. Stettin, MD
A Narrow View of Choosing Wisely
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
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Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
Effects of a Community-Based Care Management Model for Super-Utilizers
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
Predicting 30-Day Emergency Department Revisits
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
Patients' Adoption of and Feature Access Within Electronic Patient Portals
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Impact of Dementia on Costs of Modifiable Comorbid Conditions
Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
Hospital Cancer Pain Management by Electronic Health Record–Based Automatic Screening
Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD

Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification

Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
The mean 24-week cost per participant was $5416 for extended-release injectable naltrexone (57% detoxification, 37% medication, 6% provider/patient) and $4148 for buprenorphine-naloxone (64% detoxification, 12% medication, 24% provider/patient).

Objectives: To estimate the costs of providing extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) following inpatient detoxification using data derived from a multisite randomized controlled trial at 8 US community-based treatment programs.

Study Design: Cost data were collected for 3 intervention phases: program start-up, inpatient detoxification, and up to 24 weeks of medication induction and management visits (post detoxification). Cost analyses were from the healthcare sector perspective (2015 US$); patient costs are also reported.

Methods: We conducted site visits, administered a cost survey to treatment programs, and analyzed study data on medication and services utilization. Nationally representative sources were used to estimate unit costs. Uncertainty was evaluated in sensitivity analyses.

Results: Mean start-up costs were $1071 per program for XR-NTX and $828 per program for BUP-NX. Mean costs per participant were $5416 for XR-NTX (57% detoxification, 37% medication, 3% provider, 3% patient) and $4148 for BUP-NX (64% detoxification, 12% medication, 10% provider, 14% patient). Total cost per participant ranged by site from $2979 to $8963 for XR-NTX and from $2521 to $6486 for BUP-NX.

Conclusions: For treatment providers, offering XR-NTX and/or BUP-NX as part of existing detoxification treatment modalities generates modest costs in addition to the costs of detoxification, which vary substantially among the 8 sites. From the patient’s perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.

Am J Manag Care. 2018;24(11):526-531
Takeaway Points
  • Offering extended-release injectable naltrexone and/or buprenorphine-naloxone as part of existing detoxification treatment generated modest costs beyond the cost of inpatient detoxification.
  • From the patient’s perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.
Addressing opioid use disorders (OUDs), heroin and fentanyl use, and escalating rates of overdose deaths in the United States is a top priority among clinicians, policy makers, payers, and other stakeholders.1 The latest statistics on opioid overdose rates are staggering, showing a national increase of 30% from 2016 to 2017.2 Opioid agonist and antagonist medications are the recommended first line of treatment for OUDs.3,4 FDA-approved medications for OUDs currently include methadone, buprenorphine, and naltrexone.5 Both naltrexone and buprenorphine have short- and long-acting formulations. Whereas methadone can be dispensed only from approved facilities, buprenorphine and naltrexone can be prescribed by a physician or other practitioner with prescribing privileges, such as a nurse practitioner or physician assistant (PA).

Recent clinical trials have established similar effectiveness of these medications in preventing relapse up to 6 months among those who successfully initiate treatment post detoxification.6,7 Adoption of these medications by treatment providers is low, however, and reimbursement for these medications varies considerably among private and public payers.8 Other provider concerns, such as staff burden, increased practice costs, large patient caseloads, and long-term effectiveness, may also contribute to limited adoption.9

As new evidence regarding the effectiveness and cost-effectiveness of these treatments is established, providers, payers, and other stakeholders need to understand the resources and associated costs of implementation and ongoing provision of different treatment models. This information can help address and quantify some of the barriers to adoption by enumerating the types of resources required to successfully provide treatment, categories of expenditures (eg, training, staff time, special equipment), and total expected annual and per-patient costs.

This study describes the approach and results of a comprehensive multisite cost analysis of the first head-to-head randomized clinical trial in the United States of extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) for preventing opioid relapse (NCT02032433).7 Our objective was to provide rigorous estimates of the costs of introducing pharmacotherapy treatment at the programs, inpatient detoxification, and medication management (MM) visits over the 24-week intervention phase, highlighting the variation in these costs across sites.


The cost analysis was conducted alongside the NIDA Clinical Trials Network CTN-0051: Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT) trial, a multisite, 2-arm, open-label, randomized controlled trial that tested the effectiveness of XR-NTX versus BUP-NX with regard to patient survival, free of opioid relapse, at 24 weeks.10 Participants (n = 570) were recruited from 8 US community-based inpatient detoxification or short-term residential treatment programs and randomized 1:1 to XR-NTX (n = 283) or BUP-NX (n = 287). Participant-level data (eg, intervention medication dispensing/administration, opioid relapse) were collected at each study visit as part of the main X:BOT protocol, whereas economic data on the costs of providing inpatient detoxification, XR-NTX and BUP-NX medications, and MM, as well as the time and travel costs incurred by study participants, were collected from agency research and clinical staff at in-person site visits.


Analytic Overview

We employed a microcosting approach from the healthcare sector and patient perspectives.11,12 The costs of research-related activities were excluded.12 Resource utilization and expenditures were categorized by 3 distinct X:BOT study phases: setup/preimplementation (eg, training and other preparations needed to offer the medications), inpatient/residential detoxification treatment, and the intervention phase following randomization to XR-NTX or BUP-NX (medication induction and up to 24 weeks of MM).

Across all sites, cost estimates per participant are reported as means for future economic evaluation purposes and as medians/interquartile ranges for programmatic comparison.12 Cost data were collected for fiscal years 2015 or 2016 and were adjusted using the consumer price index for all consumer goods and reported in 2015 US dollars.12,13 The Weill Cornell Medical College Institutional Review Board reviewed and approved study procedures. Cost data were analyzed in Microsoft Excel 2013 (Microsoft Corp; Redmond, Washington) and Stata 15.1 (Stata Corp; College Station, Texas).

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