Economic considerations of office-based methadone as an opioid use disorder treatment option: a cost-effectiveness analysis and methodological comparison

Optimizing treatment for people with opioid use disorder (OUD) represents a critical priority to ameliorate the ongoing opioid crisis in the United States (U.S.). While methadone offered in an office environment (MO) is not currently approved by U.S. regulators, its proof of concept has been demonstrated elsewhere. The U.S.-based health economic literature on MO is limited. Among the few analyses considering MO is a 2009 cost-minimization analysis (CMA). Economists have critiqued CMA in favor of cost-effectiveness analysis (CEA). The 2009 CMA (which showed clinic-based methadone - MC- as optimal) offers an opportunity to both compare the CEA versus CMA results and provide a novel cost-effectiveness result for medication-based OUD treatments inclusive of MO. Inputs derived from a cost-only analysis of MO, MC, and office-based buprenorphine (BO) are applied in a CEA comparing MO, MC, and BO for people with OUD from the health care system perspective. Costs are adjusted to 2006 U.S. dollars. BO is less effective and more costly than - and therefore dominated by - MO. The MO vs. MC probabilistic incremental cost-effectiveness ratio is $5,270 per additional patient retained in six-month treatment. Decision uncertainty is minimal versus BO but significant versus MC. Alternative costing assumptions do not alter the basic results. These data suggest MO may be optimal under CEA, in contrast to conclusions from the published CMA. This finding is accompanied by high decision uncertainty given the limited data. More research can inform cost-effectiveness, one consideration among many to help determine if MO should be considered among U.S. treatments for OUD.