Comment on “Cost-Effectiveness of Treatment for Opioid Use Disorder in Pregnancy and Its Impact on Birth Outcomes”

Overdose-related deaths are a leading contributor to pregnancy-associated mortality in the United States, occurring alongside a recent rise in infant mortality. About 2.7% of pregnant individuals enrolled in Medicaid—or 28.4 per 1000 Medicaid-covered births—have opioid use disorder (OUD). Although OUD therapy (methadone, buprenorphine, and naltrexone) can reduce overdose deaths during pregnancy, only a quarter of individuals with OUD receive this therapy and sustain it for >1 year. Besides adverse maternal outcomes, opioid use in pregnancy has consequences to the infant, including preterm birth and low birth weight (LBW). Neonatal opioid withdrawal syndrome (NOWS) also affects some opioid-exposed infants, who may require longer, more complicated hospital stays or admission to the neonatal intensive care unit. The aim of this study was to measure the immediate and long-term health outcomes and costs of treating OUD in pregnant individuals and their infants. This was a cost-effectiveness, population-based analysis, using a stochastic time-to-event discrete event simulation model in a hypothetical cohort of 100,000 pregnant individuals with OUD who initiated treatment during pregnancy. Strategies included outpatient methadone or buprenorphine monotherapy, and buprenorphine-naloxone; naltrexone (oral and extended-release) after inpatient-managed withdrawal; outpatient methadone or buprenorphine after inpatient-managed withdrawal; and inpatient-managed withdrawal with and without behavioral support. Outcomes included return to illicit opioid use, fatal and nonfatal overdose, incremental costs, quality-adjusted life-years (QALYs), and incremental health benefit. Infant outcomes included death in ≤1 year, preterm birth, LBW, NOWS, discounted costs, QALYs, and incremental net health benefit (iNHB). In the pregnancy and postpartum simulation, buprenorphine prevented 18% more overdoses than methadone and 56% more than naltrexone. Compared with methadone, buprenorphine (monotherapy and naltrexone) was more effective and less costly (0.0008 QALYs per person and mean cost savings of $4948 per person; $198 million/40,000 pregnancies). For infant 1-year and lifetime outcomes, buprenorphine had greater cost savings than no treatment [$100,000 lifetime discounted savings ($4 billion per Medicaid-affected births); 79,000 QALYs gained]. In the combined mother and 1-year infant model, buprenorphine had an incremental effect of 0.018 QALYs per mother-infant dyad, or 1440 total QALYs for 80,000 Medicaid-affected dyads with or without NOWS. In the combined lifetime mother-infant model, buprenorphine also showed an incremental gain compared with methadone of 0.262 QALYs per dyad, for a mean lifetime cost savings of $21,512 per person or a total of $1.72 billion [interquartile uncertainty interval (IQR UI), $1.46–$1.98 billion]. Compared with naltrexone, buprenorphine showed incremental gains in the lifetime model of 0.228 to 0.229 QALYs per dyad (18,240 to 18,320 total QALYs per 80,000 dyads; IQR UI ~13,800-22,800). In conclusion, buprenorphine provided the greatest combined maternal and infant health benefit and was associated with substantial lifetime cost savings compared with methadone and naltrexone. (Summarized from Leech AA, Garbett S, Yu HA. Cost-effectiveness of treatment for opioid use disorder in pregnancy and its impact on birth outcomes. JAMA Pediatr . 2025;179:1203–1216. doi:10.1001/jamapediatrics.2025.3067)