Highlights
- •There is evidence that contingency management (CM) may be an effective strategy in heroin treatment; nevertheless, there is limited evidence of cost-effectiveness.
- •CM is not a cost-effective strategy for promoting heroin abstinence and treatment engagement in England.
- •Further research into the duration and the target of incentives is needed before CM could be considered value for money in English drug treatment services.
Abstract
Objectives
Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting
heroin abstinence or attendance at weekly keyworker appointments for opioid agonist
treatment compared with treatment as usual (TAU).
Methods
A cost-effectiveness analysis was conducted alongside a cluster randomized trial of
552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to
opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at
heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly
appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis
at 24 weeks after randomization took a societal cost perspective with effects measured
in heroin-negative urine samples.
Results
At 24 weeks, mean differences in weekly heroin-negative urine results compared with
TAU were 0.252 (95% confidence interval [CI] −0.397 to 0.901) for CM abstinence and
0.089 (95% CI −0.223 to 0.402) for CM attendance. Mean differences in costs were £2562
(95% CI £32-£5092) for CM abstinence and £317 (95% CI −£882 to £1518) for CM attendance.
Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine
for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness
of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM
attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an
88.4% probability of being cost-effective. Probability of cost-effectiveness remained
low for CM abstinence (8.6%).
Conclusions
Financial incentives targeted toward heroin abstinence and treatment attendance were
not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective
over the treatment period (12 weeks), when participants were receiving keyworker appointments
and incentives.
Keywords
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Article info
Publication history
Published online: December 09, 2022
Accepted:
November 17,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc.
