Cost-Effectiveness of Extended-Release Injectable Naltrexone Among Incarcerated Persons with Opioid Use Disorder Before Release from Prison Versus after Release

Abstract

Introduction: Opioid use disorder (OUD) is highly prevalent among incarcerated populations, and the risk of fatal overdose following release from prison is substantial. Despite efficacy, few correctional facilities provide evidence-based addiction treatment. Extended-release injectable naltrexone (XR-NTX) administered prior to release from incarceration may improve health and economic outcomes.

Methods: We conducted an economic evaluation alongside a randomized controlled trial of testing the effectiveness of XR-NTX before release from prison (n=74) vs. XR-NTX referral after release (n=72) of participants with OUD who were incarcerated, both groups continuing treatment at a community addiction treatment center. The incremental cost-effectiveness ratio was used to assess cost-effectiveness of the XR-NTX before release compared to referral after release for three stakeholder perspectives at 12- and 24-week periods: state policymaker, healthcare sector, and societal. Effectiveness measures included quality-adjusted life-years (QALYs) and abstinent years from opioids. Resources were categorized as OUD-related and non-OUD related medical care, state transfers payments, and other societal costs (productivity, criminal justice resources, etc.).

Results: XR-NTX was associated with greater OUD-related costs and total costs from the state policymaker perspective. QALYs gained were positive but statistically insignificant between arms; however, XR-NTX was associated with an estimated 15.5 more days of opioid abstinence over 24 weeks and statistically significant at a 95% confidence level. Estimated ICERs were found to be > $500,000 per QALY for all stakeholder perspectives.  For the abstinent-year effectiveness measure, XR-NTX before release was found to be cost-effective at a 95% confidence level for willingness-to-pay values >$49,000 per abstinent-year, across all perspectives. 

Conclusions: XR-NTX administered to persons who are incarcerated with OUD before release may provide value for stakeholders and bridge a well-known treatment gap for this vulnerable population. Lower than expected participant engagement and missing data limit our results.

Note:
Trial Registration Details: NCT02617628

Funding Information: This work was supported by the National Institute on Drug Abuse [grant numbers R01DA046721, P30DA040500].

Declaration of Interests: None.

Ethics Approval Statement: This study was approved by the Human Subjects Committee for the City of Philadelphia and by the Human Subjects Committee for the University of Pennsylvania. All patients consented. The study was approved by the City of Philadelphia IRB and the University of Pennsylvania IRB. All study participants read and signed an informed consent. The consent was approved by human subjects committees at the University of Pennsylvania and the City of Philadelphia.

Keywords: Cost-effectiveness, Opioid Use Disorder, Criminal Justice, Health Econometrics, Naltrexone, Medications for Opioid Use Disorder.