Date of Award

3-25-2008

Document Type

Thesis

Degree Name

Medical Doctor (MD)

First Advisor

David Fiellin

Abstract

The cost of methadone and buprenorphine treatment in office and clinic-based settings may determine their adoption in a health care system. To compare the cost of officebased buprenorphine (OBB), office-based methadone (OBM), and clinic-based methadone outpatient treatment program (OTP) among stabilized patients we analyzed costs for 6 months of treatment from the societal perspective, considering provider and patient variables. All patients had demonstrated clinical stability on an opioid agonist for at least 12 months prior to study entry. OBB (n=34) and OBM (n =21) patients completed monthly physician visits with bi-weekly or weekly medication visits, while OTP (n =23) patients were seen once to thrice weekly. Provider costs included clinician, laboratory, medication, and administrative costs. Patient costs included transportation costs, lost wages, and childcare expenses. Statistical comparisons were performed using ANOVA and chi-square analyses. At baseline, the OBB group was younger (mean=35.6 years versus 42.8 in OBM and 41.0 in OTP, p<0.001), was less likely to have a history of IV drug use (29.4% versus 57.1% in OBM and 87.0% in OTP, p<0.001), had fewer years of regular opioid use (mean=7.7 years versus 12.0 in OBM and 15.2 in OTP, p=0.001), and had a higher monthly income (mean=$2,537 versus $1,375 in OBM and $1,192 in OTP, p=0.017). Both the OBB and OBM groups had fewer known HIV+ subjects than the OTP group (2.9% and 4.3% versus 28.6%, p=0.005). There were no differences between the groups in sex, marital, educational, and work status. Six month treatment retention (85.3% in OBB, 90.5% in OBM, and 82.6% in OTP, p=0.749) and percentage of urine samples free of illicit opioids (82.7% in OBB, 95.3% in OBM, and 85.7% in OTP, p=0.159) did not differ between groups. The cost of providing one month of treatment per patient was $411 (OBB), $239 (OBM), and $179 (OTP) (p<0.001). Mean monthly medication cost were $257 (OBB), $86 (OBM) and $93 (OTP). The cost of receiving treatment was $58 (OBB), $68 (OBM), and $99 (OTP), (p=0.312). The total cost to society annually was $5,679 (OBB), $3,578 (OBM), and $3,343 (OTP), (p<0.001). Sensitivity analysis indicates that variation in clinical contact and cost estimates result in total costs between $4,488 and $13,176 (OBB), $2,528 and $4,923 (OBM), and $2,611 and $8,095 (OTP). Patient costs, however, were lower for the OBB group, $33.55 to $64.92 versus $49.18 to $105.02 (OBM), and $83.87 to $254.12 (OTP). We conclude that office-based treatment with buprenorphine is more expensive than treatment with methadone in most scenarios, the price of buprenorphine accounts for a major portion of the difference in costs, the value placed on patient time is an important part of determining total cost, and that, for patients, office-based treatment is less expensive. As patients are likely to base their decision to enter treatment on economic factors, this has important implications for the expansion of treatment.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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