Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
JAMA Netw Open. 2023 Apr 3;6(4):e237036. doi: 10.1001/jamanetworkopen.2023.7036.
Most prisons and jails in the US discontinue medications for opioid use disorder (MOUD) upon incarceration and do not initiate MOUD prior to release.
To model the association of MOUD access during incarceration and at release with population-level overdose mortality and OUD-related treatment costs in Massachusetts.
DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used simulation modeling and cost-effectiveness with costs and quality-adjusted life-years (QALYs) discounted at 3% to compare MOUD treatment strategies in a corrections cohort and an open cohort representing individuals with OUD in Massachusetts. Data were analyzed between July 1, 2021, and September 30, 2022.
Three strategies were compared: (1) no MOUD provided during incarceration or at release, (2) extended-release (XR) naltrexone offered only at release from incarceration, and (3) all 3 MOUDs (naltrexone, buprenorphine, and methadone) offered at intake.
Treatment starts and retention, fatal overdoses, life-years and QALYs, costs, and incremental cost-effectiveness ratios (ICERs).
Among 30 000 simulated incarcerated individuals with OUD, offering no MOUD was associated with 40 927 (95% uncertainty interval [UI], 39 001-42 082) MOUD treatment starts over a 5-year period and 1259 (95% UI, 1130-1323) overdose deaths after 5 years. Over 5 years, offering XR-naltrexone at release led to 10 466 (95% UI, 8515-12 201) additional treatment starts, 40 (95% UI, 16-50) fewer overdose deaths, and 0.08 (95% UI, 0.05-0.11) QALYs gained per person, at an incremental cost of $2723 (95% UI, $141-$5244) per person. In comparison, offering all 3 MOUDs at intake led to 11 923 (95% UI, 10 861-12 911) additional treatment starts, compared with offering no MOUD, 83 (95% UI, 72-91) fewer overdose deaths, and 0.12 (95% UI, 0.10-0.17) QALYs per person gained, at an incremental cost of $852 (95% UI, $14-$1703) per person. Thus, XR-naltrexone only was a dominated strategy (both less effective and more costly) and the ICER of all 3 MOUDs compared with no MOUD was $7252 (95% UI, $140-$10 018) per QALY. Among everyone with OUD in Massachusetts, XR-naltrexone only averted 95 overdose deaths over 5 years (95% UI, 85-169)-a 0.9% decrease in state-level overdose mortality-while the all-MOUD strategy averted 192 overdose deaths (95% UI, 156-200)-a 1.8% decrease.
The findings of this simulation-modeling economic study suggest that offering any MOUD to incarcerated individuals with OUD would prevent overdose deaths and that offering all 3 MOUDs would prevent more deaths and save money compared with an XR-naltrexone-only strategy.
重要性：美国大多数监狱和拘留所会在囚犯入狱时停止治疗阿片类药物使用障碍（MOUD），并且不会在释放前开始 MOUD。
目的：模拟囚犯入狱期间和释放时获得 MOUD 与马萨诸塞州人口水平的过量死亡率和 OUD 相关治疗费用的关联。
设计、设置和参与者：这项经济评估使用模拟建模和成本效益分析，成本和质量调整生命年（QALY）贴现率为 3%，以比较马萨诸塞州矫正队列和开放队列中 OUD 个体的 MOUD 治疗策略。数据分析于 2021 年 7 月 1 日至 2022 年 9 月 30 日进行。
暴露：比较了三种策略：（1）入狱期间或释放时不提供 MOUD，（2）仅在出狱时提供延长释放（XR）纳曲酮，（3）在入监时提供所有三种 MOUD（纳曲酮、丁丙诺啡和美沙酮）。
主要结果和措施：治疗开始和保留、致命过量、生命年和 QALY、成本和增量成本效益比（ICER）。
结果：在 30000 名患有 OUD 的模拟囚犯中，在 5 年内提供不提供 MOUD 与 40927 例（95%不确定性区间 [UI]，39001-42082）MOUD 治疗开始和 5 年后 1259 例（95%UI，1130-1323）过量死亡相关。在 5 年内，仅在释放时提供 XR-纳曲酮会导致额外的 10466 例（95%UI，8515-12201）治疗开始，40 例（95%UI，16-50）过量死亡减少，每人 QALY 增加 0.08（95%UI，0.05-0.11），每人增量成本为 2723 美元（95%UI，141-5244）。相比之下，与不提供 MOUD 相比，在入监时提供所有三种 MOUD 会导致额外的 11923 例（95%UI，10861-12911）治疗开始，减少 83 例（95%UI，72-91）过量死亡，每人 QALY 增加 0.12（95%UI，0.10-0.17），每人增量成本为 852 美元（95%UI，14-1703）。因此，XR-纳曲酮仅是一种被主导的策略（效果较差且成本较高），与不提供 MOUD 相比，所有三种 MOUD 的 ICER 为 7252 美元（95%UI，140-10018）/QALY。在马萨诸塞州所有患有 OUD 的人中，仅 XR-纳曲酮在 5 年内避免了 95 例过量死亡（95%UI，85-169）-占州级过量死亡率的 0.9%-而全 MOUD 策略避免了 192 例过量死亡（95%UI，156-200）-占 1.8%。
结论和相关性：这项模拟模型经济研究的结果表明，为患有 OUD 的囚犯提供任何 MOUD 都可以预防过量死亡，与 XR-纳曲酮单一策略相比，提供所有三种 MOUD 可以预防更多的死亡并节省资金。
