Integrating Addiction Services in Primary Care Likely Effective, Modestly Costly

A modeling study found that integrating addiction services into primary care improved clinical outcomes at a modest cost increase. These findings were published in JAMA Network Open.

The largest clinical workforce in the United States are primary care practitioners (PCPs). As such, integration of addiction services into primary care would be a practical way to increase access to addiction services.

This decision analytical model study was designed to estimate the long-term clinical outcomes and costs of integrating addiction services into primary care. Investigators used a Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model to evaluate 3 scenarios: PCPs referring patients who inject opioids to external addiction care (standard care control), PCP services with buprenorphine prescribing and referral to offsite harm reduction kits (BUP), or PCP services with onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). The primary outcomes were mortality from overdose, severe skin and soft tissue infections (SSTIs), and infective endocarditis (IE); costs; and incremental cost-effectiveness ratios (ICERs) of the 3 scenarios.

A total of 2,250,000 (mean age 44 years, 70% men) people in the US who inject opioids were simulated.

The control condition associated with a total of 772,722 deaths of which 11.17% were due to overdose, 5.76% to SSTI, and 38.94% to IE. The BUP scenario associated with 254,927 averted deaths, 517,795 deaths due to overdose (11.18%), SSTI (2.10%), and IE (36.34%). The BUP plus HR scenario associated with 260,822 averted deaths and 511,900 deaths. The proportion of deaths due to overdose (11.18%), SSTI (2.11%), and IE (36.46%) were similar to the BUP scenario.

The overall life expectancies were 70.72, 73.37, and 73.43 years for the control, BUP, and BUP plus HR scenarios, respectively.

The total costs of care per person were $67,192 for hospitalizations and $43,372 for outpatient care in the control condition compared with $65,440 and $104,649 in the BUP scenario and $63,860 and $111,373 in the BUP plus HR scenario, respectively. Overall, the total health care costs were $100,564 for standard care, $170,089 for BUP, and $175,233 for BUP plus HR.

Although more costly than the control condition, the BUP and BUP plus HR scenarios averted 159.8-160.9 overdose deaths per 10,000 people, 395.5-399.4 SSTI deaths per 10,000 people, and 576.5-599.4 IE deaths per 10,000 people.

Overall, considering costs and benefits, the BUP plus HR scenario was most cost-effective, with an ICER of $34,000.

The estimated budgetary impact of the BUP plus HR scenario was $149.00 for attending a 1-time 8-hour buprenorphine waiver training session, $707.20 in opportunity costs for attending the training session, a $5000.00 reduction in revenue from patient visits for a 1-month period to account for the PCP becoming familiar with buprenorphine prescribing, and $7092.00 for purchasing harm reduction and naloxone supplies for 30 patients.

Study authors concluded, “The findings of this decision analytical model suggest that integrating buprenorphine and harm reduction kits in primary care will improve clinical outcomes and modestly increase costs. There is a clinical and cost benefit of adding harm reduction services onsite along with buprenorphine.”