Cost-Effectiveness of Emergency Department–Initiated Buprenorphine With Rapid Follow-Up for Opioid Use Disorder

Technical Summary: Cost-Effectiveness of Emergency Department–Initiated Buprenorphine With Rapid Follow-Up for Opioid Use Disorder

Problem Statement
Opioid use disorder (OUD) represents a critical public health crisis characterized by high morbidity, mortality, and substantial economic burdens, including healthcare utilization, lost productivity, and criminal justice costs. Despite the availability of evidence-based medications for opioid use disorder (MOUD), such as buprenorphine, methadone, and extended-release naltrexone, a significant treatment gap persists. Barriers including stigma, regulatory constraints, and limited capacity result in the majority of individuals with OUD failing to receive pharmacologic care. Emergency departments (EDs) serve as a primary point of contact for this population, yet the economic value of initiating buprenorphine in the ED compared to standard referral pathways remains incompletely defined. While clinical evidence suggests ED-initiated buprenorphine improves treatment engagement, a rigorous economic evaluation incorporating quality-adjusted life years (QALYs) and contemporary cost inputs is necessary to guide health policy and resource allocation.

Methodology
The study employed a decision-analytic Markov cohort model to evaluate the cost-effectiveness of ED-initiated buprenorphine with rapid primary care follow-up (ED-BUP) versus referral to community-based addiction treatment alone. The analysis was conducted from a healthcare sector perspective over a 5-year time horizon using monthly cycles.

• Model Structure: The model included five mutually exclusive health states: active opioid use without treatment, ED-initiated buprenorphine (stabilized), community-based treatment, abstinence, and death (an absorbing state).
• Data Sources: Clinical inputs, including transition probabilities for treatment engagement, relapse rates, and mortality, were derived from randomized controlled trials (notably D'Onofrio et al., 2015) and observational studies (e.g., Sordo et al., 2017). Cost parameters included ED visits, medication, and follow-up care, expressed in 2023 U.S. dollars. Health utility weights were assigned based on published preference-based measures.
• Analysis: The primary outcomes were total costs and QALYs. Uncertainty was assessed through one-way deterministic sensitivity analysis and probabilistic sensitivity analysis (PSA) using 1,000 Monte Carlo simulations. The study adhered to CHEERS 2022 reporting standards.

Key Contributions
This research provides an updated economic evaluation of ED-initiated buprenorphine, addressing a gap in the literature by integrating QALY-based outcomes and contemporary cost data. Key contributions include:

1. Dominant Strategy Identification: The study demonstrates that ED-BUP is a "dominant" strategy, meaning it is both more effective and less costly than referral alone.
2. Robustness Validation: Through extensive sensitivity analyses, the study confirms that the cost-effectiveness of ED-BUP holds across a wide range of parameter variations, including treatment engagement rates and cost inputs.
3. Policy-Relevant Thresholds: The analysis quantifies the probability of cost-effectiveness at standard willingness-to-pay thresholds, providing actionable data for healthcare administrators and policymakers.

Results

• Cost and Effectiveness: Compared to referral alone, the ED-BUP strategy resulted in lower total costs (a reduction of $225 per patient) and greater effectiveness (an increase of 0.012 QALYs per patient).
• Probabilistic Sensitivity Analysis: At a willingness-to-pay threshold of $100,000 per QALY, ED-BUP was found to be cost-effective in 97% of the simulations. This probability increased to 99% at a threshold of $200,000 per QALY.
• Influential Parameters: One-way sensitivity analysis identified 30-day treatment engagement rates, per-patient costs, and utility values for active opioid use as the most influential parameters. Despite variations in these inputs, ED-BUP remained cost-effective.
• Clinical Outcomes: The model reflected clinical data showing significantly higher 30-day treatment engagement in the ED-BUP group (78%) compared to the referral group (37%), alongside reductions in illicit opioid use and inpatient service utilization.

Significance and Claims
The authors claim that ED-initiated buprenorphine with rapid follow-up is a cost-effective strategy that improves health outcomes while reducing healthcare costs. The study positions these findings as support for the broader implementation of ED-based treatment as part of public health and health system strategies to address the opioid crisis.

The paper emphasizes that while the clinical evidence for ED-initiated buprenorphine is well-established, its economic validation is crucial for scaling the intervention. The authors note that despite the cost-effectiveness, utilization of ED-initiated buprenorphine remains low across U.S. emergency departments. They argue that expanding access to this intervention could significantly reduce the treatment gap, potentially saving thousands of lives given the mortality reduction associated with MOUD.

The study acknowledges limitations, including the reliance on clinical data from a single urban academic trial and the use of a static Markov model which may not fully capture the dynamic complexities of the fentanyl crisis or comorbidities. However, the authors maintain that the findings support ED-based MOUD initiation as both a clinically effective and economically efficient intervention. They conclude that these results align with recommendations to shift from stigmatized treatment models toward patient-centered, evidence-based interventions, suggesting that EDs can play a pivotal role in improving access to effective OUD treatment.