BACKGROUND/RATIONALE:
Opioid dependence is a life-threatening condition. Outside of treatment, annual mortality rates range between 3 and 7%. Individuals with this disease account for 40% of new HIV infections in the U.S. Veterans are particularly prone to opioid dependence, with 22,045 VHA users diagnosed with this condition in FY05. Opiate Agonist Treatment (OAT), chiefly methadone maintenance, is the most successful treatment. Methadone treatment reduces injection drug use, HIV transmission, Hepatitis C infection, and mortality. VA offers methadone at fewer than 40 of its more than 750 health care sites, however. Only about 35% of opioid-dependent VHA patients receive methadone. Buprenorphine is another agonist treatment that has been shown to be effective in 13 randomized clinical trials. Buprenorphine is more expensive than methadone, but this may be offset by lower cost for dispensing, adjunctive psychosocial treatment, and regulatory compliance.

OBJECTIVE(S):
This project will determine the number of individuals who received buprenorphine from VA in FY05. It will determine the cost of buprenorphine OAT therapy and whether this is greater than the cost of methadone OAT therapy. To answer the question of whether buprenorphine leads to an influx of new patients, it will determine the percentage of buprenorphine patients who were new to VA, and determine if this was significantly more than the percentage of all patients who were new to VA.

METHODS:
We will identify patients who oral buprenorphine in the year ending 9/30/05 in the DSS prescription and characterize duration of treatment and dose. We will use VA administrative data to identify individuals in methadone maintenance during that same year. We will tally DSS national data extracts to find the cost incurred by these groups. We will determine the percentage of individuals who received methadone and buprenorphine in FY05 that had used VHA in the prior fiscal year (FY04), and find the percentage of all VHA patients who had used VHA services in the prior fiscal year. We will use information from a survey of VA clinics to validate the completeness of buprenorphine prescription data.

FINDINGS/RESULTS:
Prescriptions of buprenorphine, methadone treatment visits, health-care utilization and cost, and diagnostic data were obtained from the U.S. Veterans Health Administration for fiscal year 2005. VHA dispensed buprenorphine to 606 patients and methadone to 8191 other patients during the study year. An analysis that controlled for age and diagnosis found that the mean cost of care for the 6 months after treatment initiation was $11 597 for buprenorphine and $14 921 for methadone (P < 0.001). Cost was not significantly different in subsequent months. The first 6 months of buprenorphine treatment included an average of 66 ambulatory care visits, significantly fewer than the 137 visits in methadone treatment (P < 0.001). In subsequent months, buprenorphine patients had 8.4 visits, significantly fewer than the 21.0 visits of methadone patients (P < 0.001). Compared to new methadone episodes, new buprenorphine episodes had 0.634 times the risk of ending [95% confidence interval 0.547-0.736]. Implementation of buprenorphine treatment was not associated with an influx of new opioid-dependent patients. Despite the higher cost of medication, buprenorphine treatment was no more expensive than methadone treatment. VHA methadone treatment costs were higher than reported by other providers.

IMPACT:
Buprenorphine has been identified as a best practice for sites that currently do not offer opioid agonist therapy and for patients who are not candidates for methadone. This study determined that although buprenorphine is more expensive than methadone, buprenorphine treatment is not more expensive than methadone treatment.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Barnett PG. Comparison of costs and utilization among buprenorphine and methadone patients. Addiction. 2009 Jun 1; 104(6):982-92. [view]
2. Gordon AJ, Geppert C, Saxon A, Cotton A, Bondurant T, Krumm M, Acquaviva MP, Trafton JA. Models for implementing buprenorphine treatment in the VHA. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2009 Jan 1; 26(5):48-57. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Cost, Drug abuse, Pharmaceuticals
MeSH Terms: none