Are Relaxed Telehealth and Take-Home Medication Regulations for Treating Opioid Use Disorder Cost-Effective?
A multidisciplinary team of Stanford researchers has found that relaxed guidelines for opioid use disorder during the COVID-19 pandemic were likely not only effective, but cost-effective as well.
It became risky for people with opioid use disorder (OUD) to get in-person treatment during the COVID-19, so the Substance Abuse and Mental Health Services Administration (SAMHSA) issued an exemption that expanded the use of telehealth visits and take-home doses of medications during the pandemic emergency.
In December 2022, the federal agency issued a Notice of Proposed Rule Making (NPRM) to make these relaxed treatment regulations permanent, allowing Americans to access take-home doses of methadone and telehealth visits to initiate buprenorphine treatment.
In a new study published in the journal Drug and Alcohol Dependence, Stanford researchers have found these relaxed guidelines for buprenorphine and methadone treatments—which diminish the physical cravings and withdrawal symptoms for opioids—are likely not only effective treatments, but cost-effective as well.
“The changes we’ve made to providing opioid treatment during the pandemic – such as telehealth and take-home medications – could be viable long-term solutions. In our simulation study, we show that these relaxed guidelines are both effective and cost-effective,” said Gary Qian, a PhD student in management science and engineering in the Stanford School of Engineering and the lead author of the study.
The authors used a model-based analysis to simulate a cohort of 100,000 individuals receiving medications for opioid use disorder both in the presence and in absence of the proposed regulatory relaxations. In their study published March 1 in the journal Drug and Alcohol Dependence, the researchers found that provision of both buprenorphine and methadone for treatment under the relaxed NPRM would be effective and cost-effective.
The researchers estimated that for buprenorphine treatment 1.21 quality-adjusted life years (QALYs) would be gained at a cost of $19,200/QALY gained under the status quo when compared to no treatment, and a cost of $18,900/QALY gained if the retention rate in treatment were to increase by 20%. For methadone treatment under the NPRM, 1.11 QALYs would be gained at a cost of $17,900/QALY gained compared to no treatment. In all scenarios, the authors wrote, methadone provision cost less than $20,000/QALY gained compared to no treatment, and less than $50,000/QALY gained compared to status quo methadone treatment.
“New flexibilities give the health-care system a golden opportunity to bring effective treatment to millions of people with OUD who would not access it otherwise,” said Keith Humphreys, PhD, professor of psychiatry and behavioral sciences who served as a drug policy advisor in the Bush and Obama administrations.
The authors note that multiple studies have shown that telemedicine has the same or better chances in retaining OUD patients compared to in-person buprenorphine treatment. Increased take-home doses of methadone, as would be allowed under the NPRM, have also been shown to increase treatment retention rates.
There Are Increased Overdose Risks
The NPRM stated that “increases in take-home doses following the SMHSA exemption did not lead to worse treatment outcomes, higher overdose rates, or diversion of medication, but resulted in increased treatment engagement and improved patient satisfaction with care.” The federal agency cited a cross-sectional survey study involving 183 participants from a methadone clinic which found that even though the average number of take-home doses of methadone increased by nearly 200%, there was no significant change in either the number of individuals experiencing overdoses or the frequency of negative methadone urine drug tests.
However, some studies in other settings found that overdose risk may have increased when take-home methadone doses were allowed. Thus, the Stanford authors of the current study examined the potential impact of increased overdoses due to take-home methadone.
They found that while buprenorphine and methadone OUD treatments under the federal rule would likely continue to be effective and cost-effective, increases in overdose risk with take-home methadone would reduce health benefits because of increased overdose fatalities.
“Efforts are needed to reduce these potential risks,” the authors wrote. “These could include, for example, careful assessment of factors such as a patient’s drug use history, medical comorbidities, and housing stability when prescribing (or more precisely, ordering and dispensing) take-home methadone doses, and systematic follow-up to track adverse events.”
The technological solutions, they wrote, might include remotely observed or monitored dosing.
“Responsible decision makers weigh the risks and benefits of the available policy alternatives. Our study extensively explores the potential implications of negative unintended consequences that may occur by extending the NPRM to support decision makers. This is a key benefit of leveraging decision science and computer simulation modeling,” said Jeremy Goldhaber-Fiebert, PhD, professor of health policy.
Margaret Brandeau, PhD, a professor of management science and engineering and of health policy (by courtesy), was the senior author of the study. She noted, “While there are potential benefits and harms associated with treatment for opioid use disorder under the NPRM, our study shows that the benefits outweigh the harms, and that such treatment is highly cost-effective.”
