Volume 4, Issue 3

A Business Case for Including Medication in Treatment Plans: Toward a 21st Century System of Care for Alcohol and Drug Disorders
Dennis McCarty, PhD
Oregon Health & Science University

Acknowledgements: Awards from the National Institutes of Health supported the preparation of this essay: R33 DA035640, R01 DA036522, R01 MH1000001, P50 DA018165, R01 DA030431, R01 DA029716, U10 DA015815. Dr. McCarty is also the Principal Investigator on Research Service Agreements with Purdue Pharma and Alkermes, Inc.

Dr. Junig’s interview in this issue of The Bridge examines the limits on buprenorphine prescriptions and practitioners, limited use of buprenorphine, the role of psychosocial counseling, integration with primary care, support from health plans to sustain long-term agonist therapy with buprenorphine, and ends with a plea “to follow the science.” Treatment decisions should be driven by what works rather than more than a half century of orthodox thought about recovery. The interview, however, did not examine the business case for using buprenorphine. The good news is that there is a strong business case. Using medication for the treatment of alcohol and opioid use disorders is good for business and practice.

Recent studies provide good evidence that patients, practitioners, health plans and policy makers need to factor into decisions. Patients using medication for the treatment of alcohol and opioid dependence use less emergency and inpatient care and, as a result, are less costly to health plans and communities. Adding medication to treatment plans reduces the total cost of healthcare.

An analysis of the cost and utilization of health care among opioid dependent individuals enrolled in a large integrated health plan reported a mean annual cost per opioid dependent member of $11,200 (2004 dollars); the most expensive opioid dependent members were those with minimal (one visit) or no contact with addiction medicine (M = $18,604) while those who received addiction counseling services (M = $14,157) and methadone plus counseling (M = $7,163) used less inpatient and emergency care (McCarty, Perrin, Green, Polen, Leo & Lynch, 2010). The total costs of care for patients receiving methadone maintenance were 50% less than the costs for patients receiving counseling without medication and 62% lower when compared to opioid dependent patients who did not receive addiction medicine services.

An assessment of the total cost of care for opioid dependent patients prescribed buprenorphine updated the analyses with more current costs. Again, the most costly patients were members with minimal or no contact with addiction medicine services (M = $31,035; 2008 dollars); total annual healthcare costs were lower among opioid dependent members enrolled in addiction counseling (M = $17,017) and members receiving buprenorphine plus counseling (M = $13,578) (Lynch, McCarty, Mertens, Perrin, Green, Parthasarathy, Dickerson, Anderson & Pating, 2014). Despite the added costs of buprenorphine, opioid dependent health plan members receiving buprenorphine had the lowest total cost of care.

The benefits of including medication in treatment plans, moreover, also appeared when we examined costs of care for individuals with alcohol dependence. A meta-analysis reviewed five studies comparing costs of care for alcohol dependent patients treated with a medication approved by the Food and Drug Administration for treatment of alcohol dependence. Treatment with any medication (compared to treatment without medication) was associated with fewer days of detoxification, fewer inpatient days, and lower total costs of care (Hartung, McCarty, Fu, Wiest, Chalk & Gastfriend, 2014).

Comparative analyses among the approved medications suggest that patients receiving extended-release naltrexone tended to remain on medication for longer periods of time (relative to oral naltrexone, acamprosate, and disulfiram) and had fewer days of detoxification, fewer days of alcohol-related inpatient care, and lower total costs of care (Hartung et al., 2014). Although these studies did not randomize patients to study conditions, they used real patients treated with real clinical practices; the effects appear to be robust. The evidence is strong; the use of medication (any of the FDA-approved medication) is associated with lower total costs of care for patients with alcohol use disorders.

Importantly, these cost savings reflect healthcare costs not criminal justice costs or other social costs. Health plans that offer buprenorphine and methadone for opioid dependence reduced the use of relatively expensive emergency and inpatient services and reduced total healthcare costs. Alcohol dependent patients treated with an approved medication were also associated with reductions in the use of emergency and inpatient services and lower total costs of care. Policy makers and health plans will promote the use of medication because it is good for business – lower total health care costs.

Patients, providers and payers all benefit if 21st Century addiction treatment systems promote the use of medication for treatment of alcohol and opioid use disorders. Currently, most health plans and treatment providers can improve substantially. Medicaid utilization data from Oregon (for 2012) suggested 1 in 5 smokers (22%) received a prescription to support smoking cessation, and 1 in 20 opioid dependent patients (5%) had a prescription to treat opioid dependence (additional Medicaid recipients received methadone but these data do not appear in the pharmacy database); rates were disturbingly low for alcohol dependent patients, only 1 in 50 (2%) received an approved medication to treat alcohol dependence (McCarty, Rieckmann, McConnell, Renfro & Garvey, 2014).

The National Quality Forum’s consensus standards for addiction treatment recommend the use of pharmacotherapy for tobacco, alcohol, and opioid use disorders (National Quality Forum, 2007). The use of medication in addiction treatment should be a standard of care in the 21st Century. Health plans, providers, patients and patient families should demand that every patient be evaluated for the use of medication, educated on the value of medication, and encouraged to use and remain on medication to support their recovery. Why are we waiting?

Major health plans are not waiting; they see in their data the cost benefits of using medication in the treatment of alcohol and opioid use disorders. To promote and support the use of medication, some health plans offer preferred vendor status to addiction treatment centers that initiate the use of medication while patients are in residential and intensive outpatient settings. Other health plans offer bonuses for the use of medication or reconfigure payment rates to address added costs associated with the use of medication. Programs and payers seek better patient education, creative access to prescribers and simplified authorization for use of and access to specific medications. Rapid innovations in patient care will enhance access to medication and catalyze adoption of medication because treatment programs that offer medication now have a competitive advantage. Medication is good for business and for clinical practice.

Blanken, P., van den Brink, W., Hendriks, V.M., Huijsman, I.A., Klous, M.G., Rook, E.J., Wakelin, J.S., Barendrecht, C., Beijnen, J.H. & van Ree, J.M. (2010). Heroin-assisted treatment in the Netherlands: History, findings, and international context. European Neuropsychopharmacology, 20, Supplement 2, S106 – S158.

Hartung, D.M., McCarty, D., Fu, R., Wiest, K., Chalk, M. & Gastfriend, D.R. (2014). Extended-release naltrexone for alcohol and opioid dependence: A meta-analysis of healthcare utilization studies. Journal of Substance Abuse Treatment, 47, 113 – 121.

Lynch, F.L., McCarty, D., Mertens, J., Perrin, N.A., Green, C.A., Parthasarathy, S., Dickerson, J.F., Anderson, B.M. & Pating, D. (2014). Costs of care for persons with opioid dependence in commercial integrated health systems. Addiction Science & Clinical Practice, 9, 16.

McCarty, D., Perrin, N.A., Green, C.A., Polen, M.R., Leo, M.C. & Lynch, F. (2010). Methadone maintenance and the costs and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug and Alcohol Dependence, 111, 235 – 240.

McCarty, D., Rieckmann, T., McConnell, J., Renfro, S. & Garvey, K. (2014). Integrating addiction treatment with primary care: Early observations from Oregon. American Psychological Association Annual Meeting, Washington, DC: August 7, 2014.

National Quality Forum (2007). National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices – A Consensus Report. National Quality Forum: Washington, DC.


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