Declaration of interest
J.S. and N.L. have contributed to UK National Treatment Agency for Substance Misuse and Department of Health guidelines on the role of injectable prescribing in the management of opiate addiction (2003; chaired by J.S.). J.S. has chaired the broader-scope pan-UK working group preparing the 2007 Orange Guidelines for the UK Departments of Health, providing guidance on management and treatment of drug dependence and misuse. J.S. has provided consultancy advice on possible novel opiate addiction treatments, products and formulations to Britannia/Genus, Auralis/Viropharma, and Martindale Pharmaceuticals, and other pharmaceutical companies. J.S. and his institution have received support and funding from the Department of Health (England) and National Treatment Agency (England); and J.S. has close associations with the charity Action on Addiction. N.L. has received honoraria, travel and conference support, and consultancy fees from Reckitt Benckiser and Schering-Plough. N.L. has an untied educational grant for research related to buprenorphine in the management of opioid dependence. J.S., N.L. and N.M. have previously undertaken a research study of British heroin policy and have given varied commentaries and contributed to professional and public debate.
Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain.
To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction.
Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources.
Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15 805 v. £13 410 injectable heroin and £10 945 injectable methadone; P = n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin.
Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.
Funded by the Community Fund (Big Lottery Research section), through Action on Addiction.
This paper has been corrected post-publication, in deviation from print and in accordance with a correction published in the November 2014 issue.
- Royal College of Psychiatrists