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. 2023 Apr 3;6(4):e237036.
doi: 10.1001/jamanetworkopen.2023.7036.

Estimated Costs and Outcomes Associated With Use and Nonuse of Medications for Opioid Use Disorder During Incarceration and at Release in Massachusetts

Avik Chatterjee  1 , Michelle Weitz  2 , Alexandra Savinkina  3 , Alexandria Macmadu  4 , R W M A Madushani  2 , Ruth A Potee  5 , Danielle Ryan  6 , Sean M Murphy  6 , Alexander Y Walley  1 , Benjamin P Linas  2
Affiliations

Estimated Costs and Outcomes Associated With Use and Nonuse of Medications for Opioid Use Disorder During Incarceration and at Release in Massachusetts

Avik Chatterjee et al. JAMA Netw Open. .

Abstract

Importance: Most prisons and jails in the US discontinue medications for opioid use disorder (MOUD) upon incarceration and do not initiate MOUD prior to release.

Objective: 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.

Exposures: 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.

Main outcomes and measures: Treatment starts and retention, fatal overdoses, life-years and QALYs, costs, and incremental cost-effectiveness ratios (ICERs).

Results: 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.

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Chatterjee reported receiving grant funding from the National Institute on Drug Abuse (NIDA) during the conduct of the study. Dr Madushani reported receiving grant funding from the NIDA during the conduct of the study. Dr Murphy reported receiving grant funding from the NIDA during the conduct of the study. Dr Walley reported receiving grant funding from the National Institutes of Health during the conduct of the study; serving as medical director for the Massachusetts Department of Public Health, Bureau of Substance Addiction Services and as president-elect for the American College of Academic Addiction Medicine; and receiving honoraria via JSI Inc from the Health Resources and Services Administration for their Strengthening Systems of Care program for HIV and Opioid Use Disorder. Dr Linas reported receiving grant funding from the National Institute on Drug Abuse (NIDA) during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Total Treatment Starts and Treatment Retention Among Incerated Individuals With Opioid Use Disorder
Results of a simulation analysis of various strategies for treating opioid use disorder in carceral settings. A, The vertical axis is denominated in terms of total treatment starts over the lifetime of the cohort. Each cluster of bars represents the year of the simulation. Each color bar represents a different strategy. B, Visualization of the number of people retained with any medication for opioid use disorder (MOUD) for both the extended-release (XR) naltrexone–only strategy, and for the all-MOUD strategy.
Figure 2.
Figure 2.. Total Undiscounted Cost Difference of Offering Medications for Opioid Disorder (MOUD) Compared With No Intervention Over 5 Years, 2021 to 2025
Open cohort represents the population of Massachusetts. XR indicates extended release.
See this image and copyright information in PMC

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