Washington State Institute for Public Policy
Buprenorphine (or buprenorphine/naloxone) maintenance treatment for opioid use disorder
Substance Use Disorders: Medication-assisted Treatment
Benefit-cost estimates updated May 2017.  Literature review updated December 2016.
Buprenorphine/buprenorphine/naloxone is an opiate substitution treatment for opioid dependence. It is a daily medication generally provided in addition to counseling therapies. Buprenorphine/buprenorphine/naloxone is a partial agonist that suppresses withdrawal symptoms and blocks the effects of opioids. Two versions of buprenorphine are used in the treatment of opioid dependence. Subutex consists of buprenorphine only while Suboxone is a version of buprenorphine that combines buprenorphine and naloxone. The addition of naloxone reduces the probability of overdose and reduces misuse by producing severe withdrawal effects if taken any way except sublingually. Suboxone is generally given during the maintenance phase and many clinics will only provide take-home doses of Suboxone. Buprenorphine and buprenorphine/naloxone are alternatives to methadone treatments and, unlike methadone, can be prescribed in office-based settings by physicians that have completed a special training. We reviewed studies that evaluated the effectiveness of buprenorphine maintenance therapy. We excluded studies with treatment dosages below current guidance (< 8 mg/day).
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $1,161 Benefits minus costs $3,458
Participants $1,655 Benefit to cost ratio $1.75
Others $457 Chance the program will produce
Indirect $4,819 benefits greater than the costs 86 %
Total benefits $8,092
Net program cost ($4,633)
Benefits minus cost $3,458
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $0 $0 $0 $0 $1
Labor market earnings associated with opioid drug abuse or dependence $709 $1,561 $0 $6,901 $9,171
Health care associated with opioid drug abuse or dependence $451 $94 $457 $223 $1,225
Adjustment for deadweight cost of program $0 $0 $0 ($2,305) ($2,305)
Totals $1,161 $1,655 $457 $4,819 $8,092
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $4,431 2012 Present value of net program costs (in 2016 dollars) ($4,633)
Comparison costs $0 2012 Cost range (+ or -) 30 %
We estimated the per-participant costs of providing buprenorphine/buprenorphine/naloxone in addition to standard substance abuse treatment for 12 months. Costs reflect the average of costs reported in numerous cost-effectiveness studies (Polsky et al., 2010; Rosenheck and Kosten, 2001; Schackman et al., 2012). Costs included vary by study but generally include costs of medication, dispensing, toxicology screens, and when available, costs of medical care related to methadone treatment, equipment, administration, and clinic space. The figures shown are estimates of the costs to implement programs in Washington. Comparison group participants may have recieved counseling and other services. Polsky, D., Glick, H.A., Yang, J., Subramaniam, G.A., Poole, S.A., & Woody, G.E. (2010). Cost-effectiveness of extended buprenorphine-naloxone treatment for opioid-dependent youth: data from a randomized trial. Addiction, 105(9), 1616-1624. Rosenheck, R., & Kosten, T. (2001). Buprenorphine for opiate addiction: potential economic impact. Drug and Alcohol Dependence, 63(3), 253-262. Schackman, B.R., Leff, J.A., Moore, B.A., Moore, B.A., & Fiellin, D.A. (2012). Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care. Journal of General Internal Medicine, 27(6), 669-676. Polsky, D., Glick, H.A., Yang, J., Subramaniam, G.A., Poole, S.A., & Woody, G.E. (2010). Cost-effectiveness of extended buprenorphine-naloxone treatment for opioid-dependent youth: data from a randomized trial. Addiction, 105(9), 1616-1624. Rosenheck, R., & Kosten, T. (2001). Buprenorphine for opiate addiction: potential economic impact. Drug and Alcohol Dependence, 63(3), 253-262. Schackman, B.R., Leff, J.A., Moore, B.A., Moore, B.A., & Fiellin, D.A. (2012). Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care. Journal of General Internal Medicine, 27(6), 669-676.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Emergency department visits 1 46 -0.026 0.263 37 0.000 0.000 38 -0.026 0.920
Opioid use disorder 9 793 -0.941 0.181 37 0.000 0.000 38 -0.941 0.001
Psychiatric symptoms^ 1 51 -0.156 0.201 37 0.000 0.000 38 -0.156 0.437
Citations Used in the Meta-Analysis

Cropsey, K.L., Lane, P.S., Hale, G.J., Jackson, D.O., Clark, C.B., Ingersoll, K.S., Islam, M.A., Stitzer, M.L. (2011). Results of a pilot randomized controlled trial of buprenorphine for opioid dependent women in the criminal justice system. Drug and Alcohol Dependence, 119(3), 172-178.

Fudala, P.J., Bridge, T.P., Herbert, S., Williford, W.O., Chiang, C.N., Jones, K., . . . Tusel, D. (2003). Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. The New England Journal of Medicine, 349(10), 949-958.

Kakko, J., Svanborg, K.D., Kreek, M.J., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361(9358), 662-668.

Krook, A.L., Brørs, O., Dahlberg, J., Grouff, K., Magnus, P., Røysamb, E., & Waal, H. (2002). A placebo-controlled study of high dose buprenorphine in opiate dependents waiting for medication-assisted rehabilitation in Oslo, Norway. Addiction, 97(5), 533-542.

Liebschutz, J.M., Crooks, D., Herman, D., Anderson, B., Tsui, J., Meshesha, L.Z., Dossabhoy, S., Stein, M. (2014). Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. Jama Internal Medicine, 174(8), 1369-76.

Ling, W., Charuvastra, C., Collins, J.F., Batki, S., Brown, L.S., Kintaudi, P., . . . Segal, D. (1998). Buprenorphine maintenance treatment of opiate dependence: A multicenter, randomized clinical trial. Addiction, 93(4), 475.

Lucas, G. M., Chaudhry, A., Hsu, J., Woodson, T., Lau, B., Olsen, Y., Keruly, J. C., ... Moore, R. D. (2010). Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: A randomized trial. Annals of Internal Medicine, 152, 11, 704-711.

Rosenthal, R.N., Ling, W., Casadonte, P., Vocci, F., Bailey, G.L., Kampman, K., ... & Beebe, K.L. (2013). Buprenorphine implants for treatment of opioid dependence: Randomized comparison to placebo and sublingual buprenorphine/naloxone. Addiction, 108(12), 2141-2149.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov