If the nearly 47,000 Californians who began treatment for opioid-use
disorder in 2014 had received immediate access to methadone or
another opioid-agonist treatment – instead of first being forced to
completely withdraw from opioids – the healthcare and
criminal-justice systems would have saved $3.8 billion, researchers
Moreover, 1,262 lives would have been spared, lead researcher
Emanuel Krebs, a health economist at the British Columbia Center for
Excellence in HIV/AIDS in Vancouver, British Columbia, said by Skype.
“If you offer opioid-agonist treatment from the outset, people live
longer, and they incur lower costs on society,” said senior author
Bohdan Nosyk, a health economist and professor at Simon Fraser
University in Vancouver, British Columbia.
“People may not want to stay in treatment, but it’s their best
chance of staying alive,” he said in a Skype interview.
Methadone and buprenorphine, opioid agonists, bind to the brain’s
opioid receptors; the correct dose will eliminate withdrawal
symptoms and cravings. International addiction experts consider
initial opioid-agonist treatment, or OAT, with no duration
restrictions, the evidence-based standard of care for opioid-use
disorder, the authors write online November 20 in Annals of Internal
But in California, where more people have been diagnosed with opioid
disorder than in any other U.S. state, publicly funded treatment
programs require patients to “fail” - twice - at a three-week course
of medically supervised withdrawal before they become eligible for
“My belief is that California’s persisted with this medically
managed withdrawal because they think they’re saving themselves
money,” Nosyk said. “You’re paying more than that in the criminal
justice sector, in the healthcare section in the long run.”
Using state data, Nosyk, Krebs and colleagues created a computer
model to examine the impact immediate access to OAT would have had
on Californians treated for opioid-use disorder in 2014.
It would have saved as much as $850 million over five years, not
including savings to the criminal-justice system, and more than $2
billion, including the cost of arrests and prosecutions, the study
Over 10 years, the total savings would rise to $2.87 billion, the
“We have to prevent new cases of addiction,” said Dr. Andrew Kolodny,
co-director of opioid policy research at Brandeis University's
Heller School for Social Policy and Management in Boston. “But for
the millions who are addicted, the study authors nailed it – the
effective treatment, the opioid-agonist treatment, needs to be very
easy to access.”
“It’s very hard to recover with an abstinence-based approach. Most
people can’t do it, yet that’s been the first-line treatment. That’s
why we’re failing,” he said in a phone interview.
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Opioids killed more than 33,000 people in the U.S. in 2015,
according to the U.S. Centers for Disease Control and Prevention.
Prescription painkillers are fueling the epidemic.
“If we want to see overdose deaths come down, we need to make sure
people who have opioid addiction are able to access effective
treatment more easily than they can access heroin, fentanyl or pain
pills,” said Kolodny, who was not involved with the study.
An editorial accompanying the study says it adds to decades of data
on the efficacy of opioid agonists and should lead policymakers to
spend fewer healthcare resources on medically supervised withdrawal
and more on opioid-agonist treatment.
The editorial writers, Dr. Jeanette Tetrault and Dr. David Fiellin
of Yale University School of Medicine in New Haven, Connecticut,
likened treating opioid disorder with medically assisted withdrawal
to treating diabetic ketoacidosis, a life-threatening complication
of diabetes, without addressing diabetes.
Dr. Anna Lembke, a professor at the Stanford University School of
Medicine in Stanford, California, sees opioid-use disorder as a
“A person injecting heroin is the equivalent from a medical
perspective of a person having a heart attack,” said Lembke, who
treats opioid addicts with buprenorphine and was not involved with
the new study. “Lifesaving treatment can’t wait.”
California’s guidelines should be changed to allow patients
immediate access to opioid agonists, she said by email.
“We need a model whereby patients can get immediate access to opioid-agonist
treatment, a lifesaving intervention, without obstacles,” she said.
Some patients are forced to wait months for treatment, she said, and
in the meantime most of them will relapse, and many will die.
“Among experts in the field of addiction, we already know that detox
doesn’t work, that they’re going to relapse and when they relapse,
they’re going to be at great risk for an overdose, that they’ll be
at great risk for hepatitis,” Kolodny said. “Opioid addiction is a
Ann Intern Med 2017.
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