Initiating buprenorphine in the emergency department (ED), followed by ongoing primary care with buprenorphine, is cost-effective for patients with opioid dependence, researchers report.
“On average, even though more people in the ED-initiated treatment group were still receiving treatment at 30 days, there were no significant differences in total healthcare costs at 30 days,” Dr. Susan H. Busch from Yale School of Public Health, New Haven, Conn., told Reuters Health by email. “ED-initiated treatment led to better outcomes (i.e., more people in treatment), with no measurable differences in healthcare costs.”
Buprenorphine is one of multiple effective treatments available for opioid dependence, but only 11 percent of people who need emergency treatment related to drug or alcohol use go on to receive it at a specialty facility.
In a recent study, Dr. Busch and colleagues showed that opioid-dependent patients receiving ED-initiated buprenorphine-naloxone had better outcomes than people who received interventions that did not include immediate buprenorphine-naloxone.
Their new report, published online August 16 in Addiction, involved 329 opioid-dependent patients treated at an urban teaching hospital ED. The researchers evaluated the costs and effects of three approaches: (1) screening, brief intervention, ED-initiated treatment with buprenorphine-naloxone, and referral to primary care for 10-week follow-up (“buprenorphine”); (2) screening, brief intervention, and facilitated referral to community-based treatment services (“brief intervention”); and (3) screening and referral to treatment (“referral”).
After ED discharge, the buprenorphine group used more drug addiction-specific, office-based services, while the referral and brief-intervention groups used more resources based at addiction treatment centers. Despite these differences in use of services, total healthcare costs differed only slightly and nonsignificantly among the groups, although point estimates were lowest in the buprenorphine group.
Because outcomes were also superior in the buprenorphine group, referral and brief intervention were found to be much less cost-effective. Moreover, ED-initiated buprenorphine outperformed the other treatments at all willingness-to-pay levels.
“Getting individuals in to evidence-based treatments should be a priority for all health care stakeholders,” Dr. Busch said by email. “Yet, healthcare costs in the U.S. are high, and there is concern that some of the care provided may be low-value.”
“From our original study, we knew this treatment was effective,” she said. “We wanted to test whether it should be considered low- or high-value by insurers or others deciding whether to adopt initiation of this treatment in the emergency department if appropriate. We thought information about the relative costs of these interventions would be useful to organizations such as health insurers and emergency departments.”
“The ED where this study took place had access to a primary care clinic that provided buprenorphine–naloxone treatment regularly and access to near-term appointments,” Dr. Busch said. “Some EDs may not have similar primary care or other providers that can provide ongoing buprenorphine with appointments available in their vicinity. National efforts to increase access to outpatient buprenorphine treatment, including expanding treatment capacity of providers and expanding prescribing to nurse practitioners, should make it easier for EDs to provide this treatment.”
Dr. Marc Fishman from Johns Hopkins University, Baltimore, who recently reviewed the treatment of opioid use disorders, told Reuters Health by email, “This body of work (the current article about the cost-effectiveness analysis of the study and, more important, the original report of the main findings of the study) is a landmark in addiction treatment delivery systems. The dramatic result is the demonstration of impressive effectiveness of efforts to improve linkages to specialty addiction treatment for patients presenting at general medical treatment touchpoints, namely the ED.”
“Currently, only a minority of patients in need find their way to specialty addiction treatment, and when they do, it tends to be late in their course after considerable progression to very high severity and chronicity,” he said. “So interventions that take advantage of the motivational moment of a crisis-driven ED visit to move patients earlier to addiction treatment are highly effective and cost-effective. Furthermore, although not surprising, it is important to verify that ED-initiation of buprenorphine with a warm handoff to ongoing treatment is the more effective linkage strategy.”
“EDs will have to establish procedures for managing these patients, seeing buprenorphine initiation as a vital, lifesaving ‘emergency’ procedure and accepting the slowdown in throughput,” Dr. Fishman said. “Equally important will be identifying community capacity for ongoing treatment and establishing collaborative relationships with community specialty addiction providers who can serve as a ‘back door.’”