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

Abstract

Importance For the first time in nearly 2 decades, the US infant mortality rate has increased, coinciding with a rise in overdose-related deaths as a leading cause of pregnancy-associated mortality in some states. Prematurity and low birth weight-often linked to opioid use in pregnancy-are major contributors. Objective To assess the health and economic impact of perinatal opioid use disorder (OUD) treatment on maternal and postpartum health, infant health in the first year of life, and infant long-term health. Design, Setting, and Participants This was a cost-effectiveness, population-based analysis using a stochastic time-to-event discrete-event simulation model to simulate the clinical progression and outcomes for hypothetical pregnant individuals with OUD who initiate treatment during pregnancy. In addition, a scenario analysis was conducted assuming that individuals were stable taking OUD treatment before pregnancy and continued treatment during pregnancy. Data were analyzed from May to September 2024. Exposures Study exposures included outpatient methadone, buprenorphine monotherapy, and buprenorphine-naloxone; outpatient methadone, buprenorphine, and naltrexone after inpatient-managed withdrawal; and inpatient-managed withdrawal with and without an intensive behavioral component. Main Outcomes and Measures Outcomes included return to illicit use; fatal and nonfatal overdose; incremental discounted costs; quality-adjusted life-years (QALYs), which are a combined measure of mortality and morbidity; net health benefit; infant mortality within the first year of life; preterm birth; low birth weight; and neonatal opioid withdrawal syndrome (NOWS). Results In this economic evaluation of a hypothetical cohort of 100 000 pregnant individuals (mean [SD] starting age, 29 [5.6] years), in the pregnancy and postpartum simulation, buprenorphine dominated all strategies, yet methadone was a viable alternative. In the combined infant lifetime model, compared with methadone, buprenorphine showed an incremental effect of 0.262 QALYs per person, totaling 20 960 QALYs for 80 000 Medicaid-affected mother-infant dyads (IQR uncertainty interval [UI] 25th to 75th percentiles, 14 880-27 040 QALYs); mean cost savings of $21 512 per person, totaling $1.72 billion (IQR UI, $1.46-1.98 billion). Compared with naltrexone, buprenorphine showed an incremental effect ranging from 0.228 to 0.229 QALYs per person; 18 240 of 18 320 total QALYs for 80 000 mother-infant dyads (IQR UI, 13 840-22 720 QALYs; naltrexone-oral; IQR UI, 13 760-22 880 QALYs; naltrexone-extended release [XR]). Mean cost savings ranged from $25 316 per person ($2.03 billion; IQR UI, $1.83-$2.21 billion; naltrexone-oral) to $46 437 per person ($3.71 billion; IQR UI, $3.47-$3.96 billion; naltrexone-XR). Conclusions and Relevance Results of this analysis suggest that both methadone and buprenorphine remained viable options for managing OUD during pregnancy and post partum; however, buprenorphine offered the greatest benefits in the lifetime models that account for infant outcomes.