Cost-Effectiveness of Buprenorphine and Naltrexone Treatments for Heroin Dependence in Malaysia

Jennifer Prah Ruger,Mahmud Mazlan,Marek Chawarski,Nora Ng,Richard Schottenfeld,Lin Lu

doi:10.1371/journal.pone.0050673

Abstract

AimsTo aid public health policymaking, we studied the cost-effectiveness of buprenorphine, naltrexone, and placebo interventions for heroin dependence in Malaysia.DesignWe estimated the cost-effectiveness ratios of three treatments for heroin dependence. We used a microcosting methodology to determine fixed, variable, and societal costs of each intervention. Cost data were collected from investigators, staff, and project records on the number and type of resources used and unit costs; societal costs for participants’ time were estimated using Malaysia’s minimum wage. Costs were estimated from a provider and societal perspective and reported in 2004 US dollars.SettingMuar, Malaysia.Participants126 patients enrolled in a randomized, double-blind, placebo-controlled clinical trial in Malaysia (2003–2005) receiving counseling and buprenorphine, naltrexone, or placebo for treatment of heroin dependence.MeasurementsPrimary outcome measures included days in treatment, maximum consecutive days of heroin abstinence, days to first heroin use, and days to heroin relapse. Secondary outcome measures included treatment retention, injection drug use, illicit opiate use, AIDS Risk Inventory total score, and drug risk and sex risk subscores.FindingsBuprenorphine was more effective and more costly than naltrexone for all primary and most secondary outcomes. Incremental cost-effectiveness ratios were below $50 for primary outcomes, mostly below $350 for secondary outcomes. Naltrexone was dominated by placebo for all secondary outcomes at almost all endpoints. Incremental treatment costs were driven mainly by medication costs, especially the price of buprenorphine.ConclusionsBuprenorphine appears to be a cost-effective alternative to naltrexone that might enhance economic productivity and reduce drug use over a longer term.

Highlights

Opiate addiction is a global problem afflicting an estimated 13– 22 million people worldwide, more than half of whom live in Asia [1]
In 2004, the Malaysian government counted 234,000 official heroin users or dependents in its registry; other estimates reach as high as 500,000 in a population of roughly 25 million (2%) [2]. This is especially alarming given that three quarters of all human immunodeficiency virus (HIV) cases in Malaysia result from injection drug use
Buprenorphine had the highest percentages of participants using injection drugs in the past 30 days at baseline and 6 M, but if lost participants were imputed as using injection drugs, the performance of the buprenorphine arm became dramatically superior to the other two arms at both 3 M and 6 M (Table 1)

Summary

Introduction

Opiate addiction is a global problem afflicting an estimated 13– 22 million people worldwide, more than half of whom live in Asia [1]. In 2004, the Malaysian government counted 234,000 official heroin users or dependents in its registry; other estimates reach as high as 500,000 in a population of roughly 25 million (2%) [2] This is especially alarming given that three quarters of all human immunodeficiency virus (HIV) cases in Malaysia result from injection drug use. We examine treatment effects on drug-related HIV risk behaviors, other medical problems, and legal and illegal employment and income. This analysis will help policymakers evaluate the economic feasibility and comparative desirability of different heroin treatment programs – crucial issues in developing countries with limited resources and significant HIV/AIDS and drug abuse problems

Methods

Results

Discussion