Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation (2007)

Background: Opiate dependence is becoming increasingly prevalent, with associated increases in the spread of infectious disease (e.g. HIV, hepatitis B and C) and overdose deaths. Methadone has traditionally been the mainstay drug used in the management of opioid-dependent individuals. Buprenorphine has been reported as an alternative to methadone. Objectives: The primary objective of this assessment report was to assess the clinical and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals from the perspective of the NHS and Personal Social Services (PSS). Although methadone is the mainstay drug used in current practice, for the purposes of this report we sought to address three specific questions: Is MMT effective and cost-effective compared with no drug therapy? Is BMT effective and cost-effective compared with no drug therapy? Is MMT or BMT more effective and cost-effective? We also sought to explore the variation in effectiveness of BMT and MMT across drug doses, patient subgroups and treatment settings; assess the cost-effectiveness of BMT and MMT from a wider societal perspective; and compare the effectiveness of BMT with buprenorphine detoxification therapy (BDT) and MMT with methadone detoxification therapy (MDT). Methods: Comprehensive bibliographic searches were undertaken, from 1996 or the year of database inception to August 2005, so as to identify clinical effectiveness and cost-effectiveness studies. Given the number of systematic reviews already published in this area, the assessment of clinical effectiveness was based on a review of these reviews plus an updated search for randomised controlled trials (RCTs). Industry submissions to the National Institute for Health and Clinical Excellence were searched for additional clinical effectiveness and cost-effectiveness evidence. A decision tree was developed with a Monte Carlo simulation model to assess the cost-effectiveness of BMT and MMT. This model was designed to estimate costs, from the perspective of the NHS and PSS and outcomes in terms of quality-adjusted life-years (QALYs) for 1 year for the three strategies. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible-dose MMT with flexible-dose BMT. Utilities were derived from a panel representing a wider societal perspective. (Author' s abstract)