2D structure of semi-synthetic opiate buprenor...

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Giving Medicaid patients with substance abuse problems access to buprenorphine (Subutex, Suboxone) is ultimately less expensive than maintaining them on methadone, the experience in one state showed.

Despite more frequent relapses into addiction, buprenorphine patients cost about $1,330 less per year than methadone patients when the drugs were used for maintenance treatment, Robin Clark, PhD, of the University of Massachusetts, and colleagues reported in the August issue of Health Affairs.


“Our paper shows that the cost concerns [that Medicaid systems have about buprenorphine] aren’t so valid if you look at everything you’re spending,” Clark said in a commentary in the issue.


Overdose deaths from prescription painkillers and heroin have been on the rise in the U.S., so opioid addiction is a major concern for state Medicaid programs, Clark and colleagues wrote.


Yet many of these programs restrict access to buprenorphine because of concerns that the drug is costlier or less safe than other treatments, they said. Its price tag can exceed $300 per month — about $100 more than monthly average Medicaid payments for methadone.


The advantage of buprenorphine, however, is that it can be prescribed in any doctor’s office, while those on methadone must travel to a methadone clinic to get their medication.


Still, there’s been little research to guide policies about access to buprenorphine, and few have assessed its impact on overall Medicaid spending, Clark and colleagues wrote.


So they looked at overall spending, relapse events, and mortality for 33,923 Massachusetts Medicaid beneficiaries who had either buprenorphine, methadone, drug-free treatment, or no treatment between 2003 and 2007.


Buprenorphine appeared to significantly expand access to treatment, as more beneficiaries received the anti-addiction medication after 2003, while numbers of patients on other treatment modalities remained nearly constant, they said.


“Most of the growth in opioid addiction treatment appears to be related to buprenorphine availability,” they wrote.


Overall, they found that buprenorphine was associated with more relapse events but lower overall spending compared with methadone.


Unadjusted results showed slightly higher spending for buprenorphine compared with methadone, though both drug therapies cost less in the long run than drug-free treatment, the researchers said. Costs were lowest for those who received no treatment, a finding the researchers suspected was attributable to underuse of healthcare.


After adjusting for confounders, however, there were no significant differences in spending for either treatment. And when the researchers also controlled for the first month of therapy — some physicians only use buprenorphine for a 14-day detoxification program — methadone patients were significantly more costly, by about an additional $111 per month (P<0.001).


They explained that longer and more expensive hospital stays among methadone patients may account for the difference.


“The perception that savings can be obtained by restricting access to buprenorphine is not supported by this analysis,” Clark and colleagues wrote.


Rates of relapse events, such as hospitalizations, emergency department visits, and detoxifications, were lower for methadone patients than for buprenorphine patients — although patients in drug-free treatment had significantly more relapses than either drug group.


In multivariate analyses, risk of relapse was 28% lower for methadone patients than for buprenorphine patients (95% CI 0.67 to 0.78, P<0.001).


This finding suggests that methadone “has some clinical advantages, including a greater likelihood that patients will stay in treatment,” they wrote.


But the relapse rate was 25% higher for drug-free patients compared with the buprenorphine group (95% CI 1.17 to 1.34, P<0.001), and almost three times higher for the no-treatment group (95% CI 2.63 to 3.35, P<0.001).


Mortality rates were similar for both drug therapies, with six-month rates of 23 to 26 per 10,000 for buprenorphine patients and 26 to 27 per 10,000 for methadone patients.


After adjustment, the risk of death was 75% greater among drug-free patients than buprenorphine patients when the first month of therapy was included, and 52% higher when looking at long-term use (P<0.05 for both).


Those not treated at all were about twice as likely as buprenorphine patients to die over six months, the researchers reported.


Clark and colleagues noted that the buprenorphine/naltrexone combination Suboxone — the currently preferred form of the drug — has recently gone off-patent, although no generic is yet available.


“If one were introduced in the future,” they concluded, “it would be likely to lower the cost of buprenorphine treatment, making the drug significantly less expensive than methadone and possibly less costly overall than drug-free treatment.”



The study was supported by the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program.


The researchers reported no conflicts of interest.



Primary source: Health Affairs

Source reference:

Clark RE, et al “The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine” Health Affairs 2011; DOI: 10.1377/hlthaff.2010.0532.

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