Impact of improved access to medications for opioid use disorder in residential treatment

BACKGROUND AND AIM: Health officials in the United States (USA) are seeking strategies to mitigate overdose mortality. Medications for opioid use disorder (MOUD) are effective but underused in residential treatment centers. We used a simulation model to investigate population-level health and health economic impacts of requiring residential treatment centers to offer MOUD to patients with opioid use disorder (OUD). DESIGN, SETTING AND PARTICIPANTS: We used a cohort state-transition model in Massachusetts, USA, simulating 4 strategies: (1) status quo - a small fraction of residential centers offers MOUD; (2) 'Improved MOUD' - all residential centers routinely offer MOUD to admitted patients; (3) 'Improved MOUD with linkage' - adding linkage to outpatient MOUD for those discharged on MOUD; and (4) 'Improved MOUD with extended linkage' - adding linkage for all patients being discharged. We used two complementary simulation approaches: a closed cohort estimating per-person outcomes for residential treatment patients and an open cohort estimating state-level impacts across the Massachusetts OUD population. MEASUREMENTS: Outcomes included person-time on MOUD, overdose fatalities, costs (2024 US dollars), cost-effectiveness and budgetary impact. RESULTS: In the closed cohort, compared with the status quo, the 'Improved MOUD' strategy increased person-time in MOUD by 36% and prevented 5 [95% uncertainty interval (UI) = 1-6] overdose deaths per 10 000 individuals at one year. Over a lifetime horizon, this strategy extended life expectancy by 0.0041 life-years (LY) and discounted quality-adjusted life expectancy by 0.0034 quality-adjusted life-years (QALY) at an incremental lifetime cost per person of $309. 'Improved MOUD with extended linkage' was the preferred strategy, providing more LY (0.0096) and QALY (0.0080) at lower incremental cost ($198). The incremental cost-effectiveness ratio compared with the status quo was $40 195/QALY gained. At the state level, this strategy prevented 2.64 (95% UI = 0.49-4.76) overdose deaths per 10 000 individuals over 10 years (a 0.40% reduction). The 5-year budgetary impact to the Massachusetts health care system of providing MOUD in residential treatment was $9.65 million. Findings were robust in sensitivity analyses; however, there is some risk of unintended consequences should facilities choose to close rather than offer MOUD. In a scenario in which 21% of sites closed (reflecting centers that discourage MOUD) outcomes were worse than under the status quo. SUMMARY: Residential treatment programs for opioid use disorder appear to be an effective and cost-effective venue for expanding the use of medications for opioid use disorder, with the greatest value achieved when care navigation links patients to community-based treatment upon discharge.