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Methadone, Buprenorphine, or Detoxification for Management of Perinatal Opioid Use Disorder

A Cost-Effectiveness Analysis

Premkumar, Ashish MD; Grobman, William A. MD, MBA; Terplan, Mishka MD, MPH; Miller, Emily S. MD, MPH

doi: 10.1097/AOG.0000000000003503
Contents: Substance Use Disorder: Original Research
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OBJECTIVE: To estimate whether methadone, buprenorphine, or detoxification treatment is the most cost-effective approach to the management of opioid use disorder (OUD) during pregnancy.

METHODS: We created a decision analytic model that compared the cost effectiveness (eg, the marginal cost of the strategy in U.S. dollars divided by the marginal effectiveness of the strategy, measured in quality-adjusted life-years [QALYs]) of initiation of methadone, buprenorphine, or detoxification in treatment of OUD during pregnancy. Probabilities, costs, and utilities were estimated from the existing literature. Incremental cost-effective ratios for each strategy were calculated, and a ratio of $100,000 per QALY was used to define cost effectiveness. One-way sensitivity analyses and a Monte Carlo probabilistic sensitivity analysis were performed.

RESULTS: Under base assumptions, initiation of buprenorphine was more effective at a lower cost than either methadone or detoxification and thus was the dominant strategy. Buprenorphine was no longer cost effective if the cost of methadone was 8% less than the base-case estimate ($1,646/month) or if the overall costs of detoxification were 121% less than the base-case estimate for the detoxification cost multiplier, which was used to increase the values of both inpatient and outpatient management of detoxification by a factor of 2. Monte Carlo analyses revealed that buprenorphine was the cost-effective strategy in 70.5% of the simulations. Direct comparison of buprenorphine with methadone demonstrated that buprenorphine was below the incremental cost-effective ratio in 95.1% of simulations; direct comparison between buprenorphine and detoxification demonstrated that buprenorphine was below the incremental cost-effective ratio in 45% of simulations.

CONCLUSION: Under most circumstances, we estimate that buprenorphine is the cost-effective strategy when compared with either methadone or detoxification as treatment for OUD during pregnancy. Nonetheless, the fact that buprenorphine was not the cost-effective strategy in almost one out of three of simulations suggests that the robustness of our model may be limited and that further evaluation of the cost-effective approach to the management of OUD during pregnancy is needed.

Buprenorphine administration for pregnant women with opioid use disorder is the most cost-effective management strategy when compared with methadone or detoxification.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and the Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Virginia Commonwealth School of Medicine, Richmond, Virginia.

Corresponding author: Ashish Premkumar, MD, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Evanston, IL; email: ashish.premkumar@northwestern.edu.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as an abstract at the Society for Maternal-Fetal Medicine's 39th Annual Pregnancy Meeting, February 11–16, 2019, Las Vegas, Nevada.

The authors thank Joshua A. Barocas, MD, from the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) for his assistance in a literature review.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/B566.

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.