title: Effectiveness and cost-effectiveness of unsupervised buprenorphine-naloxone for the treatment of heroin dependence in a randomized waitlist controlled trial.
abstract: Access to opioid agonist treatment can be associated with extensive waiting periods with significant health and financial burdens. This study aimed to determine whether patients with heroin dependence dispensed buprenorphine-naloxone weekly have greater reductions in heroin use and related adverse health effects 12-weeks after commencing treatment, compared to waitlist controls and to examine the cost-effectiveness of this strategy.
  
  
  
  An open-label waitlist RCT was conducted in an opioid treatment clinic in Newcastle, Australia. Fifty patients with DSM-IV-TR heroin dependence (and no other substance dependence) were recruited. The intervention group (n=25) received take-home self-administered sublingual buprenorphine-naloxone weekly (mean dose, 22.7±5.7mg) and weekly clinical review. Waitlist controls (n=25) received no clinical intervention. The primary outcome was heroin use (self-report, urine toxicology verified) at weeks four, eight and 12. The primary cost-effectiveness outcome was incremental cost per additional heroin-free-day.
  
  
  
  Outcome data were available for 80% of all randomized participants. Across the 12-weeks, treatment group heroin use was on average 19.02days less/month (95% CI -22.98, -15.06, p<0.0001). A total 12-week reduction in adjusted costs including crime of $A5,722 (95% CI 3299, 8154) in favor of treatment was observed. Excluding crime, incremental cost per heroin-free-day gained from treatment was $A18.24 (95% CI 4.50, 28.49).
  
  
  
  When compared to remaining on a waitlist, take-home self-administered buprenorphine-naloxone treatment is associated with significant reductions in heroin use for people with DSM-IV-TR heroin dependence. This cost-effective approach may be an efficient strategy to enhance treatment capacity.
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Centre for Brain and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia. Electronic address: Adrian.Dunlop@hnehealth.nsw.gov.au.
authors.forename: Adrian J
authors.initials: AJ
authors.lastname: Dunlop
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Centre for Brain and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia. Electronic address: Amanda.Brown@hnehealth.nsw.gov.au.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Brown
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Clinical Research Design, IT and Statistical Support (CRεDITSS) Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia. Electronic address: Christopher.Oldmeadow@hmri.org.au.
authors.forename: Christopher
authors.initials: C
authors.lastname: Oldmeadow
authors.affiliation: Centre for Health Economics, Monash University, Clayton, Victoria, Australia. Electronic address: Anthony.Harris@monash.edu.
authors.forename: Anthony
authors.initials: A
authors.lastname: Harris
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. Electronic address: anthony.gill@svha.org.au.
authors.forename: Anthony
authors.initials: A
authors.lastname: Gill
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Alcohol and Drug Unit, Calvary Mater Newcastle, Waratah, NSW, Australia. Electronic address: Craig.Sadler@calvarymater.org.au.
authors.forename: Craig
authors.initials: C
authors.lastname: Sadler
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia. Electronic address: Karen.Ribbons@hnehealth.nsw.gov.au.
authors.forename: Karen
authors.initials: K
authors.lastname: Ribbons
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Clinical Research Design, IT and Statistical Support (CRεDITSS) Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia; Department of Medicine, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, NSW, Australia. Electronic address: john.attia@newcastle.edu.au.
authors.forename: John
authors.initials: J
authors.lastname: Attia
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. Electronic address: daniel.barker@newcastle.edu.au.
authors.forename: Daniel
authors.initials: D
authors.lastname: Barker
authors.affiliation: Centre for Health Economics, Monash University, Clayton, Victoria, Australia. Electronic address: Peter.Ghijben@monash.edu.
authors.forename: Peter
authors.initials: P
authors.lastname: Ghijben
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia. Electronic address: Jennifer.Hinman@hnehealth.nsw.gov.au.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hinman
authors.affiliation: Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia. Electronic address: Mel.Jackson@hnehealth.nsw.gov.au.
authors.forename: Melissa
authors.initials: M
authors.lastname: Jackson
authors.affiliation: Addictions Department, Institute of Psychiatry, Kings College London, London, United Kingdom; Drug Health Services, Sydney Local Health District, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. Electronic address: james.bell@kcl.ac.uk.
authors.forename: James
authors.initials: J
authors.lastname: Bell
authors.affiliation: Drug and Alcohol Services, South East Sydney Local Health District, Surry Hills, NSW, Australia; Central Clinical School,Discipline of Addiction Medicine, University of Sydney, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. Electronic address: Nicholas.Lintzeris@health.nsw.gov.au.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Lintzeris
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000191:economics / Q000627:therapeutic use*; D001315:Australia; D000069479:Buprenorphine, Naloxone Drug Combination / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D005260:Female; D006556:Heroin Dependence / Q000188:drug therapy* / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D009292:Narcotic Antagonists / Q000191:economics / Q000627:therapeutic use*; D016896:Treatment Outcome; D014850:Waiting Lists
chemical_list: D000701:Analgesics, Opioid; D000069479:Buprenorphine, Naloxone Drug Combination; D009292:Narcotic Antagonists
keywords: Buprenorphine; Controlled clinical trial; Cost-benefit analysis; Crime; Heroin dependence; Waiting lists