Cost-effectiveness of Extended-release Injectable Naltrexone among Incarcerated Persons with Opioid Use Disorder Before Release from Prison Versus After Release

Compared to the general population, individuals with opioid use disorder (OUD) who are involved with the criminal-legal system have a much higher risk of a fatal overdose after release from incarceration. Yet, stigma, costs, and preferences for non-narcotic treatments in criminal-legal settings have stalled the implementation of life-saving treatment within the criminal-legal system.

Extended-release naltrexone (XR-NTX), methadone, and buprenorphine-naloxone are three widely studied and evidence-based medications for opioid use disorder. Given the preference for non-narcotic treatments in many carceral settings, XR-NTX is often selected rather than methadone or buprenorphine-naloxone despite its relatively high cost.

In a new study published in the Journal of Substance Abuse Treatment, researchers examined whether the combination of XR-NTX before release and linkage to community-based treatment has the potential to be a cost-effective treatment, compared to a referral to community-based treatment after release only. While there are documented barriers to meeting detoxification requirements before starting XR-NTX, randomized studies have shown XR-NTX to be just as effective as buprenorphine-naloxone among patients who successfully start treatment.

To reduce the health consequences of OUD among incarcerated populations and lower the economic burden of OUD on society, Ali Jalali, lead author, a CHERISH Research Affiliate, and assistant professor of population health science at Weill Cornell Medicine, led a comprehensive economic evaluation with colleagues at Weill Cornell Medicine, the Crime Prevention Research Center, Johns Hopkins University, and the University of Pennsylvania. They compared health economic outcomes of administrating XR-NTX before release plus linkage to community-based care, versus providing only a referral after an individual with OUD is released from incarceration. The incremental cost-effectiveness ratio was the primary measure of cost-effectiveness and was calculated at 12- and 24-week periods. Effectiveness measures included both quality-adjusted life-years (QALYs) and a clinical outcome, time free from opioids, as recommended by guidelines and the team’s own research.

Key takeaway graphic

Based on the study, Jalali and colleagues concluded:

  1. XR-NTX before release from incarceration led to higher average OUD-related and total costs from a state policymaker perspective; however, the high rate of patient attrition observed in the trial limited the study’s conclusions on other health economic outcomes.
  2. XR-NTX before release, plus referral, is likely cost-effective compared to referral-only after release, depending on stakeholders’ willingness-to-pay for a year free from opioids.

The authors found that administering XR-NTX to individuals who are incarcerated with opioid use disorder, prior to their release, may provide value for stakeholders and bridge a well-known treatment gap for this vulnerable population. The study provides a comprehensive estimate of the healthcare and non-healthcare costs for incarcerated populations following their re-entry into their community, and evidence that supports connecting individuals receiving pre-release XR-NTX for OUD to medical and social services. Additional research is needed to determine effective methods that will improve treatment retention after release.

The study, “Cost-effectiveness of Extended-release Injectable Naltrexone among Incarcerated Persons with Opioid Use Disorder Before Release from Prison Versus After Release,” was supported by funding from National Institute on Drug Abuse and published in the Journal of Substance Abuse Treatment on July 1, 2022.

Co-authors include Philip Jeng, research manager at Weill Cornell Medicine; Daniel Polsky, CHERISH Advisory Board member and Bloomberg Distinguished Professor at Johns Hopkins University; Sabrina Poole and George E. Woody from the University of Pennsylvania; Yi-Chien Ku from the Crime Prevention Research Center; and Sean M. Murphy, CHERISH Methodology Core co-director and associate professor of population health science at Weill Cornell Medicine.

This article originally appeared in the CHERISH blog. 

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