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Economic Overview of Methadone
Maintenance Treatment in New
Brunswick
Timothy Christie, Regional Director, Horizon Health Network
Julie Dingwell, Executive Director, AIDS Saint John
Bill Reid, Chief, Saint John Police Force
Contact Information
Dr. Timothy Christie
Regional Director, Ethics Services
Horizon Health Network
Saint John Regional Hospital
Saint John, New Brunswick, Canada
Phone (506) 647-6579
E-mail: [email protected]
Outline
1. Historical Development
2. Discovered as a treatment for Addiction
3. Local Data
– One-year retention rates
– Illicit Drug Use
– Crime
4. Economics of Methadone in NB
Historical Development
History of “va 1082”
• In 1937 I.G. Farbenkonzein and Faberwerke synthesized
formula va 1082 (given the name methadone in 1947)
• va 1082 was chemically unlike morphine and heroin but
it acted on the same receptors.
• After the war all German patents were expropriated by
the allies, particularly the US.
• In 1947 the “Council on Pharmacy and Chemistry of the
American Medical Association” coined the generic name
methadone.
History of “va 1082”
• “Since the patent rights of the I.G. Favenkonzein and Faberwerke
were no longer protected each pharmaceutical company interested
in the formula could by the rights for commercial production of
methadone for just one dollar.”
–
–
–
–
–
–
–
–
Adanon®,
AN-148®,
Diskets®,
Eptadone®,
Heptanon®,
Methadone®,
Pallidone®,
Sedo Rapide®,
Adolan®,
Anadon®,
Dolamid®,
Heptadon®,
Ketalgin®,
Methadose®,
Petalgin®,
Symoron®,
Althose®,
Biodone®,
Dolophine®,
Heptalgin®,
Mephenon®,
Methox,
Phenadone®,
Tussol®,
Amidone®,
Butalgin®,
Dopridol®,
Heptanal®,
Metasedin®,
Miadone®,
Physeptone®,
Westadone®
Methadone as Treatment for Opioid
Addiction 1965-Present
Methadone maintenance therapy versus no opioid
replacement therapy for opioid dependence (Review)
Mattick RP, Breen C, Kimber J, Davoli M
The Cochrane Collaboration
Copyright © 2009 The Cochrane
Collaboration. Published by John Wiley
& Sons, Ltd.
Conclusion
“Methadone maintenance treatment can keep people
who are dependent on heroin in treatment programs
and reduce their use of heroin. Methadone is the
most widely used replacement for heroin in
medically-supported maintenance or detoxification
programs. Several non-drug detoxification and
rehabilitation methods are also used to try and help
people withdraw from heroin. However the review
found that people have withdrawn from trials when
they are assigned to a drug-free program. […] These
trials show that methadone can reduce the use of
heroin in dependent people, and keep them in
treatment programs.”
Controversy
• To date, methadone maintenance therapy has been the
most systematically studied and most successful, and
most politically polarizing, of any pharmacotherapy for
the treatment of drug addiction patients.
• Functional Patients vs Abstinent Patients
Issue
• Social Policy Issues
– Untreated opioid addiction
– Waitlists
• MMT Program vs LTHT Approach
– Admission
– Group and Individual Counselling
– Random Urine Testing
– Involuntary Discharge
One-Year Retention Rates
Objective
• The objective of this study is to determine the one-year
retention rate for the Low Threshold/High Tolerance
(LTHT) methadone clinic and whether the LTHT
approach would be a safe and effective means of
managing waitlists in this province.
Method
• The one-year retention rate was determined by collecting
data on each patient who received MMT from the clinic
between August 04, 2009 and August 04, 2010. The
total number of patients enrolled in the clinic was
compared to the number of patients still in the program
after a minimum of one-year of treatment.
95% One-Year Retention Rate
Summary
• The one-year retention rate was 95%. There were a
total of 179 patients enrolled in the clinic and 170 were
receiving treatment after one-year. Of those no longer
receiving treatment, three were incarcerated, two were
transferred to other care providers, three voluntarily
withdrew from the program and one person went into
witness protection.
Illicit Drug Use
Objective
• The objective of this study is to determine the prevalence
of illicit opioid and cocaine use in the LTHT methadone
maintenance treatment clinic.
Methods
• A randomly selected retrospective cohort of 84 research
participants.
• The results of six consecutive urine tests for the most
recent three months of treatment were compared to the
results of the first six consecutive urine tests after
entering treatment.
• Paired t-tests were conducted to determine whether the
mean number of positive tests was different between
these two time periods and then an effect size was
calculated using Cohen’s D. The alpha level was set at
p<.05.
Time Period
Time in
Treatment
August 2009
– January
2011
16.2 months
(mean)
[range 9-18
months]
Patients
N = 84
95% CI
(15.73,16.67)
Methadone
Dose
Gender
Age
72.75mg
62% Men
35.5-yearsold
38% Women
95% CI
(67.48,78.02mg
)
95% CI
(33.26, 37.74)
Prevalence of Illicit Opioid Use at
Program Entry = 100%
Prevalence of Illicit Opioid
Use after stabilization on
methadone = 44%
Illicit Opioid Tests: First Six vs Most Recent Six
56
60
50
66.6% increase in the number of people
abstaining from illicit opioids.
40
30
23
20
21
15
12
10
3
0
12
11
2
2
5 5
1
0
0
1
2
3
4
5
6
Summary Opioids
• In general, participants were more likely to test positive
for illicit opioids before stabilizing on methadone (mean =
2.88, SE = .19) than after stabilizing on methadone
(mean = 0.79, SE = .15), t(83) = -11.51, p<.001, Cohen’s
D = -1.29.
• This decrease in positive tests was statistically
significant (p<.001) and the effect size of -1.29 is
considered large.
Cocaine Tests
Prevalence of cocaine use
at program entry = 56%
Prevalence of cocaine use
after stabilization on
methadone = 43%
Positive Cocaine Tests: First Six vs Most Recent Six
60
48
50
40
37
13% increase in the number of people
abstaining from cocaine
30
20
10
8 8
6 5
4 3
6 4
1
2
3
4
13 12
9
4
0
0
5
6
Cocaine Summary
• Although methadone has no biological effect for cocaine
use, participants were more likely to test positive for
cocaine before stabilizing on methadone (mean = 2.16,
SE = .263) than after stabilizing on methadone (mean =
1.63, SE = .252), t(83) = -2.56, p=.012, Cohen’s D = 0.23.
• This decrease in positive cocaine tests was statistically
significant (p=.012) and the effect size of -0.23 is
considered small.
Suspected Crime
Objective
• The objective of this study is to determine the incidence
of crime among a cohort of MMT patients in a lowthreshold/high-tolerance methadone clinic located in
Saint John, New Brunswick, Canada.
Methods
• A random sample of 92 stable patients receiving MMT at the LTHT
clinic.
• Data on the incidence rate of criminal activity were collected from
the Computer Aided Dispatch (CAD) system and the Records
Management System (CRIME) of the Saint John Police Force
(SJPF)
• The SJPF categorized the nature of their interactions with citizens
into discrete categories, i.e., witness, victim, person reporting,
suspect, etc. Based on the nature of these data we considered only
interactions where the SJPF “suspected” the research participant of
engaging in criminal activity.
Methods
•
The date of each interaction was noted and then
grouped into six categories:
1. 12-18 months before entering methadone
treatment,
2. 6-12 months before treatment,
3. <6-months before treatment,
4. <6-months after treatment,
5. 6-12 months after treatment,
6. 12-18 months after treatment
Methods
• A Chi-square analysis was performed to identify any
statistically significant differences between the category
of 12-18 months before treatment and the other
categories.
• The incidence rate was calculated by including the
number of times a research participant was identified as
a suspect by the SJPF in a given six-month period, in the
numerator. The denominator consisted of the sum of the
different times for which each individual was observed.
Results
• Over a three year period this randomly selected cohort of
92 individuals were suspected of committing 688 crimes:
– 350 during the 18-months before entering MMT
– 338 during the 18-months after entering MMT.
12-18
Before
6-12
Before
6-Before
<6-After
6-12 After
12-18 After
Suspect
102
92
156
187
88
63
Time/Years
44
44
44
44
44
36
Incidence
Rate Per
Person Year
2.32
2.09
3.55
4.25
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
4.25
3.55
2.32
2.09
2.00
1.75
Costs
Objective
• The objective of this study is to describe the costs
associated with treating a patient with methadone via the
LTHT Model
Methods
• Data were gathered on the cost of the following:
– Methadone hydrochloride
– Laboratory costs
– Program costs (including HR)
– Pharmacy costs
Costs
Methadone Laboratory
Program
Pharmacy
Total
Individual/Year
$127.75
$512
$953.75
$4,288.75
$5,882.25
Total Clinic/Year
$22,100.75
$88,576
$165,000
$741,953.75
$1,017,630.50
72% of cost = $4288 per patient per year
regardless of what program the patient is
in.
Annual Drug Cost and Dispensing Fee per Patient Year
Year
Yearly Drug Cost
Percentage Yearly Dispensing Percentage
2006-07
$168
7%
$2285
93%
2007-08
$199
7%
$2615
93%
2008-09
$177
6%
$2635
94%
2009-10
$167
5%
$3043
95%
2010-11
$178
5%
$3571
95%
2011-12
$70
3%
$2355
97%
New Brunswick Prescription Drug Program (NBPDP)
Methadone for Opioid Dependence
Drug Cost
Total Dispensing Fees
# NBPDP Beneficiaries
2006-07
$.08M
$1.09M
477
2007-08
$.12M
$1.58M
604
2008-09
$.16M
$2.38M
903
2009-10
$.24M
$4.37M
1436
2010-11
$.30M
$6.00M
1680
2011-12*
$.12M
$4.00M
1698
Methadone Laboratory
Program
Pharmacy
Total
Individual/Year
$127.75
$512
$953.75
$4,288.75
$5,882.25
Total Clinic/Year
$22,100.75
$88,576
$165,000
$741,953.75
$1,017,630.50
72% of cost = $4288 per patient per year
regardless of what program the patient is
in.
Overall Conclusions
1.
2.
3.
4.
5.
6.
7.
8.
95% One-Year Retention Rate
66.6% achieved abstinence from illicit opioids
13% increase in those abstaining from cocaine
42% reduction in poly drug use (cocaine and illicit
opioids)
62% reduction in crime
$5,882.25 to treat a patient on the LTHT model
72% of costs are for Pharmacy dispensing fees
PNB currently spends $1,017,630.50 to treat 173 people.
Thank You!