(90) Extended-Release Buprenorphine for Opioid Use Disorder: A Cost-Effectiveness Analysis

Background: Transmucosal Buprenorphine (T-MUCOS-BUP) is a well-established evidence-based treatment for opioid use disorder (OUD). A monthly injectable form of buprenorphine, extended-release buprenorphine (XR-BUP) was approved in 2017. Published data show that XR-BUP is effective, but its monthly cost is higher than that of T-MUCOS-BUP. Little is known about the cost-effectiveness of XR-BUP.

Methods: We used a state transition model to simulate the lifetime experience of a closed cohort of 100,000 people with OUD who are considering opioid agonist treatment with buprenorphine in Massachusetts. We competed a ‘T-MUCOS-BUP strategy’ with transitions between alternative approaches (XR-BUP, methadone, naltrexone, medically-managed withdrawal, and no treatment) with an ‘XR-BUP strategy’ with transitions to the same alternative approaches. We also included a ‘no treatment’ strategy to assess whether T-MUCOS-BUP and XR-BUP were cost-effective compared to ‘no treatment.’ We used cohort studies, clinical trials, and administrative data to inform model parameters. We estimated overdose rates, life years (LY), quality-adjusted life years (QALY), cost from the healthcare perspective, and incremental cost-effectiveness ratios (ICERs). We also conducted deterministic sensitivity analyses to determine thresholds for retention rates and costs, and interpreted ICERs using a $100,000/QALY willingness to pay threshold.

Results: Compared to ‘no treatment’, the average rate of fatal overdose for the ‘T-MUCOS-BUP strategy’ was lower by 8 per 1,000 individuals over a 10-year period, and there was a lifetime gain of 3.46 LY and 3.22 QALY per person. ‘T-MUCOS-BUP’ resulted in a 26% increase in lifetime healthcare cost when compared to ‘no treatment’, and an ICER = $19,740/QALY gained. Compared to ‘T-MUCOS-BUP’, the average rate of fatal overdose for ‘XR-BUP’ was higher by 1 per 1,000 individuals over a 10-year period, and lifetime LY and QALY were lower by 0.03 per person. As a result, the ‘XR-BUP’ strategy was dominated, meaning that it provided lower QALY at higher cost per QALY gained, and was therefore not preferred. These results were sensitive to changes in medication cost and retention. With a 70% decrease in XR-BUP medication cost or an 85% increase in retention rates compared to T-MUCOS-BUP, the ‘XR-BUP’ strategy was cost effective at a $100,000/QALY willingness to pay threshold.

Conclusion: At current medication cost and retention rates, XR-BUP does not lead to efficient allocation of limited resources when T-MUCOS-BUP is available. Future initiatives should evaluate the impact of interventions to improve retention rates or to decrease drug costs associated with XR-BUP.

Diversity, Equity, and Inclusion: Some subpopulations of individuals with opioid use disorders (OUD) may have difficulty being retained on transmucosal buprenorphine (T-MUCOS-BUP) because this medication needs to be taken daily. We plan on evaluating potential subpopulations for whom extended-release buprenorphine (XR-BUP) might be helpful given that low retention rates on T-MUCOS-BUP have been observed in some subgroups. Examples of such subgroups include individuals who are unhoused or persons recently justice-involved who disproportionally self-identify as Black or Latino. Our study might therefore increase information on potential approaches to expand access to medications for opioid use disorder in diverse communities.

References:
K., Nadipelli, V. R., Ling, W., & Heidbreder, C. (2019). Efficacy and safety of a monthly buprenorphine depot injection for opioid use disorder: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet, 393(10173), 778-790.
Ling, W., Nadipelli, V. R., Solem, C. T., Ronquest, N. A., Yeh, Y. C., Learned, S. M., Mehra, V., & Heidbreder, C. (2019). Patient-centered Outcomes in Participants of a Buprenorphine Monthly Depot (BUP-XR) Double-blind, Placebo-controlled, Multicenter, Phase 3 Study. J Addict Med, 13(6), 442-449. https://doi.org/10.1097/ADM.0000000000000517
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