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Moore T.J., Ritter A., Caulkins J.P.
Drug and Alcohol Review: 2007, 26(4), p. 369–378.
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Australian study addressing an issue greatly exercising the UK: do you get greater returns per £ from residential rehabilitation or from substitute prescribing? In terms of reduction in the frequency of heroin use, prescribing was one-and-a-half to three times more cost-effective.
Summary This study compares the costs and consequences of three interventions for reducing heroin dependence among dependent heroin users who have come to the attention of the authorities in a form which puts them at risk of a one-year prison term: pharmacotherapy maintenance (such as methadone maintenance), residential rehabilitation, and prison. Using Australian data, the interventions' cost-consequence ratio was estimated, taking into consideration: reduction in heroin use during the intervention; the length of intervention; and post-intervention effects (as measured by abstinence rates). Sensitivity analyses were conducted, including varying the magnitude and duration of treatment effects, and ascribing positive outcomes only to treatment completers. A hybrid model which combined pharmacotherapy maintenance with a prison term was also considered. If the post-programme abstinence rates were sustained for two years, then for an average heroin user the cost of averting a year of heroin use is approximately $5000 (Australian dollars) for pharmacotherapy maintenance, $11,000 for residential rehabilitation and $52,000 for prison. Varying the parameters does not alter the ranking of the programmes. If the threat of imprisonment for non-completers raised the completion rate in pharmacotherapy maintenance to over 95%, the combined model of treatment plus prison may become the most cost-effective option.
The Australian drug problem and responses to it are relatively similar to those in the UK, so the analysis may be applicable to Britain.
this study addresses an issue greatly exercising commentators in the UK: for heroin addiction, do you get greater returns per £ from residential rehabilitation or from substitute prescribing programmes such as methadone maintenance? When the measure was reduction in the frequency of heroin use, the answer was that substitute prescribing was between one-and-a-half and three times more cost-effective than residential rehabilitation. We know from the English NTORS study that heroin use frequency is a reasonable proxy for other outcomes such as crime, convictions, and
infection risk behaviour. Since patients were assumed to be on probation in lieu of imprisonment, costs accounted for in the study included a hefty sum for criminal justice supervision. Without this assumption, the relative advantage of substitute prescribing would have been over 50% greater. One gap is that only the initial treatment episode was costed in. From the
cost analysis on which the study was based, it seems that if follow-on addiction treatment and other medical costs had also been accounted for, the effect would have been to further increase the relative cost-effectiveness of substitute prescribing. The study's other conclusion – that prison is by far the least cost-effective option – is now widely accepted and the reason for the proliferation of schemes to divert drug-driven offenders in to treatment.
As the authors stress, such findings do not justify the abandonment of residential rehabilitation or indeed of imprisonment. Some patients will only profit, or profit most, from these more expensive alternatives. In the case of residential rehabilitation in the UK, that number may be higher than are currently able to access this option.
Last revised 08 December 2008
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