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Clinical and Cost Outcomes of Buprenorphine Treatment in a Commercial Benefit Plan Population

Buprenorphine treatment with and without induction was found to decrease costs and utilization in opioid-dependent benefciaries.
Published Online: Feb 02,2018
Julie B. Kessel, MD; Liana D. Castel, PhD; and Douglas A. Nemecek, MD

Objectives: Opioid dependency is a significant societal burden. Buprenorphine has improved access and safety for outpatient detoxification services. The objectives of this study were to determine, based on assessment of administrative medical and pharmacy claims, if use of buprenorphine induction (with or without naloxone) in an opioid-dependent population with commercial benefit coverage improved clinical and cost outcomes compared with buprenorphine without induction and with no use of buprenorphine.
Study Design: This is a retrospective observational claims review with a 4-month pre- and posttreatment study design and analysis of medical, behavioral health, and pharmacy utilization patterns for all levels of service.
Methods: We analyzed claims data from a sample of 648 Cigna customers using analyses of variance to assess differences before and after treatment among groups (buprenorphine with induction, buprenorphine without induction, and no buprenorphine) and general linear regression to compare adjusted cost ratios.
Results: Induction and noninduction buprenorphine treatment were associated with significantly reduced inpatient utilization (81.8% reduction in hospitalizations vs 43.1% reduction in the no-treatment group; P <.05) and lower total medical, behavioral health, outpatient, and pharmacy costs (cost ratio, 0.52:1; P <.001). There was a cost and utilization shift from inpatient toward outpatient, and we observed a shift in pharmacy claims from medical to behavioral health services; we observed a cost ratio of 1.58:1 for total pharmacy (P <.05) and 2.26:1 for nonpsychotropic pharmacy (P <.0001).
Conclusions: Our findings support the use of buprenorphine with and without induction to decrease inpatient utilization and substantially lower total medical, behavioral health, and pharmacy costs.

                                                                                         Am J Pharm Benefits. 2018;10(1)e1-e6

According to the United States Substance Abuse and Mental Health Services Administration and recent research, more than 4.3 million Americans engaged in nonmedical use of prescription painkillers in 2014.1,2 Opioid dependence is a growing epidemic, impacting people of all socioeconomic backgrounds and age groups.3 Recidivism is high, and treatment programs, including pharmacotherapy options, have been limited.

The introduction of buprenorphine4,5 has offered a relatively rapid, safe, and effective means to detoxify opioid-dependent people in an office-based setting.4 Standard induction protocol generally spans 3 days and is described in detail in the Center for Substance Abuse Treatment Clinical Guidelines for Use of Buprenorphine in the Treatment of Opioid Addiction.6 Recent studies in low-income populations have demonstrated increased outpatient referrals and fewer hospitalizations/emergency department visits following buprenorphine induction,7,8 stabilization, and linkage to outpatient treatment in opioid-dependent inpatients (injection and noninjection drug users. There is great need for cost and utilization studies among commercial benefit plan populations.

Our objective was to determine, based on assessment of behavioral health and medical claims, if use of buprenorphine induction (with or without naloxone, heretofore referred to as buprenorphine, unless specifically stated otherwise) was associated with improved clinical and cost outcomes in opioid-dependent individuals with commercial coverage compared with buprenorphine without induction and compared with no use of buprenorphine.

Data Source and Comparison Groups
Eligible claims for this retrospective observational study were drawn from health maintenance organization (HMO), point-of-service (POS), and preferred provider organization Cigna products. We analyzed 69,495 behavioral health administrative claims for 8503 opioid-dependent Cigna customers 18 years and older, with dual eligibility for medical and behavioral health benefits. Individuals were included if they had a primary, secondary, or tertiary diagnosis of opioid dependence for a date of service between October 1, 2006, and December 31, 2007, that was documented on a behavioral health claim, including Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, diagnosis codes 304.0-304.03 and 304.7-304.73 (referring to all opioid dependence diagnoses).

Three groups were identified for comparison: an induction treatment group, a noninduction treatment group, and a no-treatment group. The induction group was started on buprenorphine in the induction phase and continued to maintenance (or as long as treatment lasted). The noninduction group received buprenorphine, as seen in pharmacy claims, but not for induction; instead, this group received it as part of detoxification or while hospitalized (ie, no induction or implied maintenance). The no-treatment group was actually “no treatment with buprenorphine.” This group had treatment as usual (ie, inpatient or outpatient, detoxification, rehabilitation), but did not receive buprenorphine at any point. Inclusion criteria for the induction group consisted of diagnosis of opioid dependence, the Healthcare Common Procedure Coding System procedure code H0033 (defined as “oral medication administration, direct observation”), and a physician provider. Individuals were considered undergoing induction whether or not they used all 3 authorized induction sessions. Claims were then crossed with pharmacy claims to ensure that buprenorphine was employed as part of induction. The noninduction group was identified as those who received physician services and buprenorphine within the study interval but without an H0033 claim. The no-treatment group included customers with no treatment or pharmacy claims associated with opioid dependence diagnoses within the study interval.

The First DataBank generic formulation code numbers used to identify prescriptions analyzed in this study were 18973 and 18974 (buprenorphine HCl and naloxone HCl) and 64672 and 64673 (buprenorphine HCl). Ninety-three percent of prescriptions in the baseline period treatment groups contained buprenorphine plus naloxone, 7.15% contained buprenorphine alone, and 92.5% of prescriptions in the follow-up period treatment groups contained buprenorphine plus naloxone (Suboxone), compared with 7.5% containing buprenorphine alone (Subutex). The drug groups were not analyzed separately.