Barnett P G, Hui S S
Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA 94025, USA.
Mt Sinai J Med. 2000 Oct-Nov;67(5-6):365-74.
Although methadone maintenance is effective in reducing injection drug use, needle sharing, and the overall mortality associated with opiate abuse, many health plans offer little or no access to methadone, and many methadone providers do not comply with treatment guidelines regarding dose, duration of treatment, or provision of ancillary services. Moral and political judgments have helped shape the U.S. treatment system. Evaluations of methadone cost-effectiveness may play a role in changing public policy.
Cost-effectiveness analysis is used to compare a change, or changes, in treatment to that of current standard care. The cost of treatment and its effect on outcomes are used to find the incremental cost-effectiveness ratio, and determine whether the change(s) should be adopted. The literature on methadone maintenance is reviewed from an economic perspective, focusing on five policy questions: (1) whether methadone should be a health care benefit; (2) what level of ancillary services is optimal; (3) what methadone dose is appropriate; (4) what length of treatment is appropriate; and (5) whether contingency contracts should be employed.
Expanded access to methadone maintenance has an incremental cost-effectiveness ratio of less than $11,000 per Quality-Adjusted Life Year. This is more cost-effective than many widely used medical therapies, a finding that strongly supports the inclusion of methadone in the formulary of health care plans.Ancillary services have been shown to be an effective part of methadone maintenance therapy, especially during the beginning of a treatment episode, but there is not enough information available to tell whether the optimal amount of services is being used. There is extensive evidence that many treatment programs dispense inadequate doses of methadone. The cost of additional drugs is very small compared to the benefits of an adequate dose. Many methadone programs limit treatment to 6 months or less, but such short episodes are not likely to be cost-effective. The medical model of methadone maintenance may increase the cost-effectiveness of the treatment for long-term patients. Programs that reward patients for negative urinalysis have proven effective at reducing illicit drug use, but their cost-effectiveness will need to be demonstrated before they are widely adopted.
Cost-effectiveness researchers need to measure substance abuse outcomes in terms of Quality-Adjusted Life Years, as this will make their findings more relevant to the development of treatment policy. It will allow different substance abuse treatments to be compared to each other and to medical care interventions.
尽管美沙酮维持疗法在减少注射吸毒、共用针头以及与阿片类药物滥用相关的总体死亡率方面有效，但许多健康计划几乎不提供或根本不提供美沙酮治疗，而且许多美沙酮提供者未遵守关于剂量、治疗持续时间或提供辅助服务的治疗指南。道德和政治判断对美国的治疗体系产生了影响。美沙酮成本效益评估可能会在改变公共政策方面发挥作用。
成本效益分析用于将治疗中的一项或多项改变与当前标准治疗进行比较。治疗成本及其对结果的影响用于计算增量成本效益比，并确定是否应采用这些改变。从经济角度回顾了关于美沙酮维持疗法的文献，重点关注五个政策问题：（1）美沙酮是否应作为一项医疗福利；（2）最佳辅助服务水平是多少；（3）合适的美沙酮剂量是多少；（4）合适的治疗时长是多少；（5）是否应采用应急合同。
扩大美沙酮维持疗法的可及性，其增量成本效益比低于每质量调整生命年11,000美元。这比许多广泛使用的医学疗法更具成本效益，这一发现有力地支持将美沙酮纳入医疗保健计划的处方集。辅助服务已被证明是美沙酮维持疗法的有效组成部分，尤其是在治疗初期，但没有足够信息表明是否使用了最佳服务量。有大量证据表明，许多治疗项目美沙酮剂量不足。与足量剂量的益处相比，额外药物的成本非常小。许多美沙酮项目将治疗限制在6个月或更短时间，但如此短的疗程不太可能具有成本效益。美沙酮维持疗法的医学模式可能会提高长期患者治疗的成本效益。对尿液分析呈阴性的患者给予奖励的项目已被证明在减少非法药物使用方面有效，但在广泛采用之前，其成本效益还需要得到证实。
成本效益研究人员需要根据质量调整生命年衡量药物滥用结果，因为这将使他们的研究结果与治疗政策的制定更相关。这将使不同的药物滥用治疗方法能够相互比较，并与医疗干预措施进行比较。
