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 No Evidence to restrict Buprenorphine for Opioid Addiction

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PostSubject: No Evidence to restrict Buprenorphine for Opioid Addiction   Fri 13 Apr 2012, 6:44 pm

Many state Medicaid programs restrict access to buprenorphine for substance abuse treatment because officials fear the drug is costlier or less safe than other therapies, such as methadone.
But a study in the August issue of Health Affairs argues that the evidence does not support such rationing.
"Although the drug price seems high, buprenorphine is slightly less expensive than methadone and no less safe than other forms of opioid addiction treatment," according to lead study author Robin E. Clark, MD, of the Center for Health Policy and Research, University of Massachusetts Medical School, Worcester. "States that restrict access to buprenorphine are unlikely to save money and may contribute to higher mortality rates if access to methadone is not adequate," he said.
After hearing that some states were attempting to ration access to buprenorphine, Dr. Clark and his team decided to investigate whether such efforts would be likely to save money on total healthcare expenditures or to improve safety.
"At the Center for Health Policy and Research we work closely with the Massachusetts Medicaid agency, MassHealth. Spending for pharmaceuticals is an important concern for MassHealth, as it is for other Medicaid programs," Dr. Clark said.
Lower Annual Cost
The researchers analyzed MassHealth claims for more than 33,000 members during the 5-year period between 2003 and 2007, comparing total expenditures, use of relapse-related services, and mortality for individuals with opioid dependence who used buprenorphine, methadone, drug-free treatment (outpatient or residential behavioral treatment only), or no treatment at all.
They found that methadone maintenance was more effective than buprenorphine, drug-free, and no treatment in reducing relapse related events, such as hospitalizations, emergency department visits, and detoxifications.
Nineteen patients undergoing methadone maintenance treatment experienced a relapse event compared with 33 patients taking buprenorphine, 57 patients undergoing drug-free treatment, and 29 patients receiving no treatment.
However, buprenorphine was associated with $1330 lower mean annual spending than methadone when used for maintenance treatment.
Mortality rates were similar for buprenorphine and methadone and were 75% higher among patients receiving drug-free treatment and more than twice as high among those receiving no treatment compared with patients receiving buprenorphine.
Dr. Clark also pointed out that buprenorphine expanded access to treatment for opioid addiction.
"Buprenorphine can be prescribed by a physician and taken at home compared with methadone, which must be administered in an approved clinic. So it expanded access to treatment rather than serving as a substitute for other forms of treatment," he said.
States should reconsider policies that significantly restrict access to buprenorphine for treatment of opioid addiction, he added.
Short-Sighted Policy
Medscape Medical News asked Itai Danovitch, MD, director, Addiction Psychiatry Clinical Services at Cedars-Sinai Medical Center, Los Angeles, California, for his views on this study.
"Their study comes at a time when efforts at cost containment are leading to a reevaluation of what types of treatments and services should be covered by insurance programs. They found that while pill for pill, buprenorphine may have cost more — the study was completed while buprenorphine was still on patent and thus more expensive than methadone — it led to greater savings in health costs," Dr. Danovitch noted.
The findings "are a cautionary tale for discussions on healthcare expenditures across the nation," he added.
"Opioid dependence is a chronic disease with many different variations and manifestations. We need more, not fewer, available treatments. And, as the authors point out, efforts at short-term cost containment that limit the clinical resources available to treat this disease are likely to have long-term detrimental consequences to personal and societal health."
Flawed Design?
However, Alec B. O'Connor, MD, MPH, from the University of Rochester School of Medicine and Dentistry, New York, had a somewhat critical view of the study design and conclusion.
In an interview with Medscape Medical News, he noted that patients who were prescribed buprenorphine in the study were qualitatively different than those who were managed with other strategies.
"They attempted to adjust for this difference, but it is a limitation that cannot be adjusted for. Many of the factors that lead a clinician to choose one treatment strategy over another are not measured in a claims database...these patients are fundamentally different or they would have been given the same treatment, so conclusions drawn about differences in their costs and outcomes are suspect, even after adjusting for measured differences," Dr. O’Connor said.
He also raised the possibility that more restrictions to buprenorphine access might weed out those patients who are less likely to respond yet who generate more cost to the healthcare system, with less benefit.
Dr. O'Connor also suggests that it is possible that removing restrictions and allowing greater access "would result in the greatest value despite greater drug expenses and risk of abuse and diversion. Without comparing costs and outcomes of different restriction strategies, the study authors cannot conclude that reducing or eliminating restrictions on buprenorphine will result in lower costs and better outcomes."
Dr. Clark, Dr. Danovitch, and Dr. O'Connor have disclosed no relevant financial relationships.
Health Aff (Millwood). 2011;30:1425-1433. Abstract



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No Evidence to restrict Buprenorphine for Opioid Addiction
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