The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation

James Shearer; Nicola Metrebian; Tim Weaver; Kimberley Goldsmith; John Strang; Stephen Pilling; Luke Mitcheson; Ed Day; John Dunn; Anthony Glasper; Shabana Akhtar; Jalpa Bajaria; Vikki Charles; Roopal Desai; Farjana Haque; Nicholas Little; Hortencia McKechnie; Franziska Mosler; Julian Mutz; Dilkushi Poovendran; Sarah Byford

doi:10.1016/j.jval.2022.11.021

The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation

James Shearer^*, Nicola Metrebian, Tim Weaver, Kimberley Goldsmith, John Strang, Stephen Pilling, Luke Mitcheson, Ed Day, John Dunn, Anthony Glasper, Shabana Akhtar, Jalpa Bajaria, Vikki Charles, Roopal Desai, Farjana Haque, Nicholas Little, Hortencia McKechnie, Franziska Mosler, Julian Mutz, Dilkushi PoovendranSarah Byford

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Objectives: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU).

Methods: A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples.

Results: At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] −0.397 to 0.901) for CM abstinence and 0.089 (95% CI −0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI −£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%).

Conclusions: Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.

Original language	English
Pages (from-to)	658-665
Number of pages	8
Journal	Value in Health
Volume	26
Issue number	5
Early online date	9 Dec 2022
DOIs	https://doi.org/10.1016/j.jval.2022.11.021
Publication status	Published - May 2023

Bibliographical note

Funding Information:

Conflict of Interest Disclosures: Dr Metrebian reported receiving grants from the National Institute for Health and Care Research (NIHR) during the conduct of the study; grants from NIHR, Society for Study on Addiction, and Mundipharma Research Ltd; and other from Mayne Pharma International outside the submitted work. Dr Goldsmith reported receiving grants from NIHR during the conduct of the study and grants from NIHR, MRC, Juvenile Diabetes Research Foundation Ltd, UKRI, National Institutes of Health (United States), and the Stroke Association outside the submitted work. Dr Strang reported receiving grants from MundiPharma, Camurus, Molteni/Accord, and NIHR and other from Maudsley NHS Foundation Trust, King's College London, and NIHR Biomedical Research Centre for Mental Health at South London outside the submitted work. Dr Pilling reported receiving grants from National Institute for Health and Care Excellence and Royal Society of Psychiatrists outside the submitted work. Dr Mitcheson reported receiving grants as coinvestigator on a trial of depot buprenorphine funded by Indiviour, the product manufacturer; as collaborator on an NIHR-funded project looking at co-occurring mental health and substance use outside the submitted work; and as clinical advisor seconded to the Office of Health Improvement and Disparities in the Department of Health and Social Care. Dr Day reported receiving grants from the NIHR during the conduct of the study and as a consultant psychiatrist in a specialist addiction service in the NHS. Dr Byford reported receiving grants from NIHR during the conduct of the study. No other disclosures were reported. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

This article presents independent research funded by NIHR under its Programme Grants for Applied Research Programme (grant reference number RP-PG-0707-10149). This article represents independent research part funded by NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London and by the Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust.

Publisher Copyright:
© 2023

Keywords

cluster randomized trial
contingency management
cost-effectiveness analysis
opioid agonist treatment

ASJC Scopus subject areas

Health Policy
Public Health, Environmental and Occupational Health

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.jval.2022.11.021

https://kclpure.kcl.ac.uk/portal/en/publications/the-cost-effectiveness-of-financial-incentives-to-achieve-heroin-Licence: Creative Commons: Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)

Cite this

Shearer, J., Metrebian, N., Weaver, T., Goldsmith, K., Strang, J., Pilling, S., Mitcheson, L., Day, E., Dunn, J., Glasper, A., Akhtar, S., Bajaria, J., Charles, V., Desai, R., Haque, F., Little, N., McKechnie, H., Mosler, F., Mutz, J., ... Byford, S. (2023). The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation. Value in Health, 26(5), 658-665. https://doi.org/10.1016/j.jval.2022.11.021

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title = "The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation",

abstract = "Objectives: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). Methods: A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. Results: At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] −0.397 to 0.901) for CM abstinence and 0.089 (95% CI −0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI −£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). Conclusions: Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.",

keywords = "cluster randomized trial, contingency management, cost-effectiveness analysis, opioid agonist treatment",

author = "James Shearer and Nicola Metrebian and Tim Weaver and Kimberley Goldsmith and John Strang and Stephen Pilling and Luke Mitcheson and Ed Day and John Dunn and Anthony Glasper and Shabana Akhtar and Jalpa Bajaria and Vikki Charles and Roopal Desai and Farjana Haque and Nicholas Little and Hortencia McKechnie and Franziska Mosler and Julian Mutz and Dilkushi Poovendran and Sarah Byford",

note = "Funding Information: Conflict of Interest Disclosures: Dr Metrebian reported receiving grants from the National Institute for Health and Care Research (NIHR) during the conduct of the study; grants from NIHR, Society for Study on Addiction, and Mundipharma Research Ltd; and other from Mayne Pharma International outside the submitted work. Dr Goldsmith reported receiving grants from NIHR during the conduct of the study and grants from NIHR, MRC, Juvenile Diabetes Research Foundation Ltd, UKRI, National Institutes of Health (United States), and the Stroke Association outside the submitted work. Dr Strang reported receiving grants from MundiPharma, Camurus, Molteni/Accord, and NIHR and other from Maudsley NHS Foundation Trust, King's College London, and NIHR Biomedical Research Centre for Mental Health at South London outside the submitted work. Dr Pilling reported receiving grants from National Institute for Health and Care Excellence and Royal Society of Psychiatrists outside the submitted work. Dr Mitcheson reported receiving grants as coinvestigator on a trial of depot buprenorphine funded by Indiviour, the product manufacturer; as collaborator on an NIHR-funded project looking at co-occurring mental health and substance use outside the submitted work; and as clinical advisor seconded to the Office of Health Improvement and Disparities in the Department of Health and Social Care. Dr Day reported receiving grants from the NIHR during the conduct of the study and as a consultant psychiatrist in a specialist addiction service in the NHS. Dr Byford reported receiving grants from NIHR during the conduct of the study. No other disclosures were reported. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. This article presents independent research funded by NIHR under its Programme Grants for Applied Research Programme (grant reference number RP-PG-0707-10149). This article represents independent research part funded by NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London and by the Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust. Publisher Copyright: {\textcopyright} 2023 ",

year = "2023",

month = may,

doi = "10.1016/j.jval.2022.11.021",

language = "English",

volume = "26",

pages = "658--665",

journal = "Value in Health",

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Shearer, J, Metrebian, N, Weaver, T, Goldsmith, K, Strang, J, Pilling, S, Mitcheson, L, Day, E, Dunn, J, Glasper, A, Akhtar, S, Bajaria, J, Charles, V, Desai, R, Haque, F, Little, N, McKechnie, H, Mosler, F, Mutz, J, Poovendran, D & Byford, S 2023, 'The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation', Value in Health, vol. 26, no. 5, pp. 658-665. https://doi.org/10.1016/j.jval.2022.11.021

The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation. / Shearer, James; Metrebian, Nicola; Weaver, Tim et al.
In: Value in Health, Vol. 26, No. 5, 05.2023, p. 658-665.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes

T2 - A Cluster Randomized Trial-Based Economic Evaluation

AU - Shearer, James

AU - Metrebian, Nicola

AU - Weaver, Tim

AU - Goldsmith, Kimberley

AU - Strang, John

AU - Pilling, Stephen

AU - Mitcheson, Luke

AU - Day, Ed

AU - Dunn, John

AU - Glasper, Anthony

AU - Akhtar, Shabana

AU - Bajaria, Jalpa

AU - Charles, Vikki

AU - Desai, Roopal

AU - Haque, Farjana

AU - Little, Nicholas

AU - McKechnie, Hortencia

AU - Mosler, Franziska

AU - Mutz, Julian

AU - Poovendran, Dilkushi

AU - Byford, Sarah

N1 - Funding Information: Conflict of Interest Disclosures: Dr Metrebian reported receiving grants from the National Institute for Health and Care Research (NIHR) during the conduct of the study; grants from NIHR, Society for Study on Addiction, and Mundipharma Research Ltd; and other from Mayne Pharma International outside the submitted work. Dr Goldsmith reported receiving grants from NIHR during the conduct of the study and grants from NIHR, MRC, Juvenile Diabetes Research Foundation Ltd, UKRI, National Institutes of Health (United States), and the Stroke Association outside the submitted work. Dr Strang reported receiving grants from MundiPharma, Camurus, Molteni/Accord, and NIHR and other from Maudsley NHS Foundation Trust, King's College London, and NIHR Biomedical Research Centre for Mental Health at South London outside the submitted work. Dr Pilling reported receiving grants from National Institute for Health and Care Excellence and Royal Society of Psychiatrists outside the submitted work. Dr Mitcheson reported receiving grants as coinvestigator on a trial of depot buprenorphine funded by Indiviour, the product manufacturer; as collaborator on an NIHR-funded project looking at co-occurring mental health and substance use outside the submitted work; and as clinical advisor seconded to the Office of Health Improvement and Disparities in the Department of Health and Social Care. Dr Day reported receiving grants from the NIHR during the conduct of the study and as a consultant psychiatrist in a specialist addiction service in the NHS. Dr Byford reported receiving grants from NIHR during the conduct of the study. No other disclosures were reported. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. This article presents independent research funded by NIHR under its Programme Grants for Applied Research Programme (grant reference number RP-PG-0707-10149). This article represents independent research part funded by NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London and by the Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust. Publisher Copyright: © 2023

PY - 2023/5

Y1 - 2023/5

N2 - Objectives: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). Methods: A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. Results: At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] −0.397 to 0.901) for CM abstinence and 0.089 (95% CI −0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI −£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). Conclusions: Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.

AB - Objectives: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). Methods: A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. Results: At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] −0.397 to 0.901) for CM abstinence and 0.089 (95% CI −0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI −£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). Conclusions: Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.

KW - cluster randomized trial

KW - contingency management

KW - cost-effectiveness analysis

KW - opioid agonist treatment

UR - http://www.scopus.com/inward/record.url?scp=85146471437&partnerID=8YFLogxK

U2 - 10.1016/j.jval.2022.11.021

DO - 10.1016/j.jval.2022.11.021

M3 - Article

C2 - 36509367

AN - SCOPUS:85146471437

SN - 1098-3015

VL - 26

SP - 658

EP - 665

JO - Value in Health

JF - Value in Health

IS - 5

ER -

The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

UN SDGs

Access to Document

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Cite this