Cost and Cost-effectiveness of the COMBINE Study in Alcohol-Dependent Patients

Abstract

Context The COMBINE clinical trial recently evaluated the efficacy of medications, behavioral therapies, and their combinations for the outpatient treatment of alcohol dependence. The costs and cost-effectiveness of these combinations are unknown and of interest to clinicians and policy makers. Objective To evaluate the costs and cost-effectiveness of the COMBINE interventions at the end of 16 weeks of treatment. Design, Setting, and Participants A prospective cost and cost-effectiveness study of patients in COMBINE, a randomized controlled clinical trial (RCT) involving 1383 patients with diagnoses of primary alcohol dependence across 11 US clinical sites. Interventions Nine treatment arms, with 4 arms receiving medical management with 16 weeks of naltrexone (100 mg/d) or acamprosate (3 g/d), both, and/or placebo; 4 arms receiving the same options as above but delivered with combined behavioral intervention (CBI); and 1 arm receiving CBI only. Main Outcomes Measures Incremental cost per percentage point increase in percent days abstinent (PDA), incremental cost per patient of avoiding heavy drinking, and incremental cost per patient of achieving a good clinical outcome. Results Based on the mean values of cost and effectiveness, 3 interventions are cost-effective options relative to the other interventions for all three outcomes: medical management (MM) with placebo ($409 cost per patient), MM + naltrexone ($671 cost per patient), and MM + naltrexone + acamprosate ($1003 cost per patient). Conclusions This is only the second prospective RCT-designed cost-effectiveness study that has been performed for the treatment of alcohol dependence. Focusing just on effectiveness, MM + naltrexone + acamprosate is not significantly better than MM + naltrexone. However, looking at cost and effectiveness, MM + naltrexone + acamprosate may be a cost-effective choice, depending on whether the cost of the incremental increase in effectiveness is worth it to the decision maker.

Cost-Effectiveness Analysis of Motivational Interviewing With Feedback to Reduce Drinking Among a Sample of College Students

“…CEACs show the probability that an intervention is cost-effective relative to the alternative interventions for a given willingness to pay for a unit change in the effectiveness outcome (Barton et al, 2008;Fenwick et al, 2001;Zarkin et al, 2008). Nonparametric bootstrap methods were used to calculate CEACs for changes in each effectiveness outcome.…”

Cost-Effectiveness of Peer-Delivered Interventions For Cocaine and Alcohol Abuse Among Women: A Randomized Controlled Trial

“…Schumacher et al [37] estimated costs of two addiction interventions compared to usual care to be $1,007 and $1,244 for an additional week of drug abstinence among homeless persons. For non-abstinence outcomes, Zarkin et al [13] determined that medical management combined with either naltrexone or naltrexone and acamprosate was cost-effective in avoiding heavy drinking (using the same heavy drinking definition as ours), with ICERs of $2,847 and $8,095. Jofre-Bonet et al [38] examined the cost-effectiveness of disulfiram in addition to methadone maintenance for treating cocaine dependence, yielding an incremental cost of $73 per day of cocaine reduced.…”

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder

“…By 3 years, median but not mean costs (treatment cost plus social costs of AUD such as health care, arrests, and motor vehicle accidents) were diminished in the COMBINE study by a number of treatment combinations that included pharmacotherapy (Zarkin et al 2010). Treatment arms that were cost-effective, from a policy (Dunlap et al 2010) and patient-centered (Zarkin et al 2008) standpoint, were MM with placebo, MM plus naltrexone therapy, and MM plus combined naltrexone and acamprosate therapy. Other Dx: personality disorders 23% At 3 and 6 months, patients with TOP reported lower scores than those with NTX on craving and alcohol-related measures; those with TOP also scored less on disability-related measures at 6 months.…”