Question 15: Are there cost benefits to methadone maintenance treatment?

Answer: Yes. Research has demonstrated that methadone maintenance treatment is beneficial to society, cost-effective, and pays for itself in basic economic terms.

Research Highlights

A cost-effectiveness analysis reviewed five policy questions from an economic perspective: (1) whether methadone should be a healthcare 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. The analysis found that expanded access to methadone maintenance had an incremental cost-effectiveness ratio of less than $11,000 per quality-adjusted life year (QALY). Ancillary services were shown to be an effective part of methadone maintenance therapy, especially during the beginning of a treatment episode. The cost of additional methadone was found to be low compared with the benefits of adequate doses. Short episodes of methadone maintenance were felt not likely to be cost-effective (Barnett and Hui, 2000).

A unique and timely analysis was performed that focused on the cost-effectiveness of methadone treatment based on its impact on the HIV epidemic. The analysis considered populations in which HIV prevalence among injection drug users ranged from 5 percent to 40 percent. The results demonstrated that increased methadone maintenance capacity costs $8,200 per QALY gained in high-prevalence communities and $10,900 per QALY gained in low-prevalence communities. Interestingly, the majority of benefits were gained by individuals who do not inject drugs (Zaric, Barnett, and Brandeau, 2000).

• A standard cost-effectiveness evaluation of methadone considered the incremental effect of methadone on the lifespan and treatment cost of a cohort of 25-year-old heroin users. The results demonstrated that providing opioid-dependent patients with methadone maintenance had an incremental cost-effectiveness ratio of $5,915 per life-year gained. A sensitivity analysis determined that the ratio was less than $10,000 per life-year over a range of assumptions. This cost-effectiveness ratio was lower than that of many common medical therapies and well within the $50,000 threshold typically used in developed countries for judging cost-effectiveness (Barnett, 1999).
• A systematic review from Lithuania on studies of the cost-effectiveness of methadone noted that methadone maintenance had higher economic efficiency with daily doses of 80 to 100 mg, and daily doses lower than 40 mg were considered inefficient. In addition, short treatment episodes were not likely to be cost-effective, and ancillary services were more cost-effective at the beginning of methadone maintenance than in the later stages. Economic efficiency was found to be higher as treatment program census increased as opposed to the provision of more ancillary services (Vanagas, Padaiga, and Subata, 2004).
• The most comprehensive examination of economic benefits and costs was performed on data from the Treatment Outcome Perspective Study (TOPS). After examining the average cost of a methadone maintenance treatment day, detailed measurements of criminal activities rates, and the cost to society of various crimes, the study yielded a final benefit-to-cost ratio of 4 to 1 (Harwood, Hubbard, Collins, et al., 1988).
• Rufener, Rachal, and Cruz (1977) studied the cost-effectiveness of methadone maintenance (and other treatment modalities) and determined a benefit-to-cost ratio of 4.4 to 1.
• McGlothlin and Anglin (1981), using data from low-dose programs, compared patients who left methadone maintenance treatment when a community clinic was closed in Bakersfield, California, with patients in another community’s program that remained open. For men, the ratio of crime-related economic benefits to treatment costs was 1.7 to 1 over a 2-year period. In addition, the continuous treatment group reported significantly higher rates of employment than those who had been closed out of treatment, although the factor was not formally assessed in the study.
• Methadone maintenance treatment, when implemented at sufficient resource levels, provides individual and social benefits for at least several years that are substantially higher than the cost of delivering this treatment. The daily benefits equal the daily costs in virtually every case, even among those who continue drug use at a reduced level (Gerstein and Harwood, 1990).
• There are many more costs to society associated with active heroin use (Rufener et al., 1977). These include medical costs, law enforcement costs, judicial system costs, corrections costs, nondrug crime costs, drug traffic control, drug abuse prevention costs, reducing housing stock costs, absenteeism costs, unemployment costs, and drug-related deaths. Thus, when all costs to society are considered, methadone maintenance treatment is extremely cost-effective and beneficial to society.
• A study that randomly assigned new patients to three levels of care (methadone alone, methadone plus standard counseling services, and methadone plus enhanced services [counseling, medical/psychiatric, employment, and family therapy services]) found that methadone plus standard counseling was most cost-effective. At 12 months, the annual cost per abstinent client was $16,485, $9,804, and $11,818 for the low, intermediate, and high levels of counseling, respectively (Puigdollers, Cots, Brugal, et al., 2003).
• In a study comparing ongoing methadone maintenance with 6 months of methadone maintenance followed by detoxification, total healthcare costs were greater for maintenance than detoxification treatment ($7,564 vs. $6,687; p < 0.001). However, detoxification patients incurred significantly higher costs for substance abuse and mental healthcare services. Methadone maintenance appeared to provide a small survival advantage compared with detoxification. The cost per life-year gained was $16,967. Sensitivity analysis revealed a cost-effectiveness ratio of less than $20,000 per QALY over a range of modeling assumptions (Masson, Barnett, Sees, et al., 2004).

Comparison of Treatment and Societal Costs of Active Heroin Addiction–A study of the cost benefits of methadone maintenance treatment showed that the costs to society of the criminal activities related to active heroin use can run as high as four times more than the costs for methadone maintenance treatment (Harwood et al., 1988).

Figure 30 illustrates the cost-benefit relationship. For example, if the approximate annual cost for providing methadone maintenance treatment is $2,400 per person, it would cost about $240,000 to provide treatment for 100 patients for 1 year. In contrast, the annual costs to society related to the criminal activities of 100 active heroin addicts not in treatment would exceed $960,000 (Harwood et al., 1988).

Through the New York State Department of Substance Abuse Services, NIDA researchers have estimated the yearly cost to maintain an opioid addict in New York: untreated and on the street ($43,000), in prison ($34,000), in a residential drug-free program ($11,000), and in methadone maintenance treatment ($2,400) (New York State Committee of Methadone Program Administrators, 1991).

Figure 31 illustrates the cost of active heroin use for one addict for a year at about $43,000 in 1991. This includes the cost of the heroin, the loss of property related to theft and burglary, and the costs of security measures to combat such crimes.

References

Barnett PG, Hui SS. The cost-effectiveness of methadone maintenance. Mount Sinai Journal of Medicine 2000;67(5-6):365-74.

Barnett PG. The cost-effectiveness of methadone maintenance as a health care intervention. Addiction1999;94(4):479-88.

Gerstein DR, Harwood HJ (eds.). Treating Drug Problems. Volume I. Washington, DC: National Academy Press, Institute of Medicine, 1990.

Harwood HJ, Hubbard RL, Collins JJ, Rachal JV. The costs of crime and the benefits of drug abuse treatment: a cost-benefit analysis using TOPS data. In: Leukefeld CG, Time FM (eds.). Compulsory Treatment of Drug Abuse: Research and Clinical Practice. NIDA Research Monograph Series 86. Rockville, MD: National Institute on Drug Abuse, 1988.

Kraft MK, Rothbard AB, Hadley TR, McLellan AT, Asch DA. Are supplementary services provided during methadone maintenance really cost-effective? The American Journal of Psychiatry 1997;154(9):1214-19.

Masson CL, Barnett PG, Sees KL, Delucchi KL, Rosen A, Wong W, Hall SM. Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification. Addiction2004;99(6):718-26.

McGlothlin WH, Anglin MD. Long-term follow-up of clients of high- and low-dose methadone programs. Archives of General Psychiatry 1981;38:1055-63.

New York State Committee of Methadone Program Administrators. COMPA’s Five Year Plan for the Methadone Treatment System in New York State. New York: New York State Committee of Methadone Program Administrators, 1991.

Puigdollers E, Cots F, Brugal MT, Torralba L, Domingo-Salvany A. Methadone maintenance programs with supplementary services: a cost-effectiveness study. [Spanish] Gaceta Sanitaria 2003;17(2):123-30.

Rufener BL, Rachal JV, Cruz AM. Management Effectiveness Measures for NIDA Drug Abuse Treatment Programs. Cost Benefit Analysis. Rockville, MD: National Institute on Drug Abuse, 1977.

Vanagas G, Padaiga Z, Subata E. Economic efficiency of methadone maintenance and factors affecting it. [Lithuanian] Medicina (Lith) 2004;40(7):607-13.

Zaric GS, Barnett PG, Brandeau ML. HIV transmission and the cost-effectiveness of methadone maintenance.American Journal of Public Health 2000;90(7):1100-11