The impact of substance abuse treatment modality on birth weight and health care expenditures

Economic evaluation of a behavioral intervention versus brief advice for substance use treatment in pregnant women: results from a randomized controlled trial

BACKGROUND

Substance use in pregnancy is associated with severe maternal and fetal morbidities and substantial economic costs. However, few studies have evaluated the cost-effectiveness of substance use treatment programs in pregnant women. The purpose of this study was to evaluate the economic impact of a behavioral intervention that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) for treatment of substance use in pregnancy, in comparison with brief advice.

METHODS

We conducted an economic evaluation alongside a clinical trial by collecting data on resource utilization and performing a cost minimization analysis as MET-CBT and brief advice had similar effects on clinical outcomes (e.g., alcohol and drug use and birth outcomes). Costs were estimated from the health care system's perspective and included intervention costs, hospital facility costs, physician fees, and costs of psychotropic medications from the date of intake assessment until 3-month postpartum. We compared effects of MET-CBT on costs with those of brief advice using Wilcoxon rank sum tests.

RESULTS

Although the integrated MET-CBT therapy had higher intervention cost than brief advice (median = $1297/participant versus $303/participant, p < 0.01), costs of care during the prenatal period, delivery, and postpartum period, as well as for psychotropic medications, were comparable between the two groups (all p values ≥ 0.55). There was no statistically significant difference in overall cost of care (median total cost = $26,993/participant for MET-CBT versus $27,831/participant for brief advice, p = 0.90).

CONCLUSIONS

The MET-CBT therapy and brief advice resulted in similar clinical outcomes and overall medical costs. Further research incorporating non-medical costs, targeting women with more severe substance use disorders, and evaluating the impact of MET-CBT on participants' quality of life will provide additional insights.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00227903 . Registered 27 September 2005.

Costs of a motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice for pregnant substance users

Objectives

To determine and compare costs of a nurse-administered behavioral intervention for pregnant substance users that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) to brief advice (BA) administered by an obstetrical provider. Both interventions were provided concurrent with prenatal care.

Methods

We conducted a micro-costing study that prospectively collected detailed resource utilization and unit cost data for each of the two intervention arms (MET-CBT and BA) within the context of a randomized controlled trial. A three-step approach for identifying, measuring and valuing resource utilization was used. All cost estimates were inflation adjusted to 2011 U.S. dollars.

Results

A total of 82 participants received the MET-CBT intervention and 86 participants received BA. From the societal perspective, the total cost (including participants’ time cost) of the MET-CBT intervention was $120,483 or $1,469 per participant. In contrast, the total cost of the BA intervention was $27,199 or $316 per participant. Personnel costs (nurse therapists and obstetric providers) for delivering the intervention sessions and supervising the program composed the largest share of the MET-CBT intervention costs. Program set up costs, especially intervention material design and training costs, also contributed substantially to the overall cost.

Conclusions

Implementation of an MET-CBT program to promote drug abstinence in pregnant women is associated with modest costs. Future cost effectiveness and cost benefit analyses integrating costs with outcomes and benefits data will enable a more comprehensive understanding of the intervention in improving the care of substance abusing pregnant women.

Lessons learned from a comparison of evidence-based research in pregnant opioid-dependent women

OBJECTIVES

Lessons learned in research and treatment of opioid dependence demonstrate the need to include pregnant women in clinical trials.

METHODS

Two double-blind, double-dummy, randomized controlled trials (Pilot study, European sample(†) of MOTHER-trial) comparing buprenorphine and methadone in opioid-dependent pregnant women were conducted. In both studies, participants received voucher-based incentives for attendance and completion of study assessments. In the MOTHER trial, participants additionally received escalating voucher incentives for drug-free urine samples. Neonatal abstinence syndrome was treated with oral morphine solution based on standardized modified Finnegan scores.

RESULTS

After a mean treatment period of 13.79 weeks in the Pilot study (PS, n = 18) and 20.78 weeks in the MOTHER-trial (MT, n = 41), respectively (p < 0.001), PS patients delivered at mean doses of 14.00 mg buprenorphine/52.50 mg methadone and MT participants at 13.44 mg buprenorphine/63.68 mg methadone. Nonsignificant differences regarding dropout rates were found (22% in PS versus 10% in MT), but dropout was significantly earlier in the MT (p = 0.013). Significantly higher rates of concomitant consumption of opioids and benzodiazepines occurred in the PS compared with the MT (p < 0.001), however, with no significant differences in neonatal data between both settings.

CONCLUSIONS

Early treatment enrolment combined with contingency management contributes to reduced illicit drug use throughout pregnancy, surprisingly without influencing neonatal outcome parameters.

Should pregnant women with substance use disorders be managed differently?

Pregnant women with substance use disorders have multiple special needs, which might be best managed within a multiprofessional treatment setting involving medical, psychological and social care. Adequate treatment provision remains a challenge for healthcare professionals, who should undergo special training and education when working with this patient population. Careful assessment and screening is necessary to tailor interventions individually to the woman's needs in order to achieve beneficial clinical outcomes for mothers and newborns, whereas the choice of treatment options highly depends on the type of substance of abuse and evidence-based treatment interventions available. Economic considerations have shown that early multiprofessional treatment might yield better clinical outcomes and save healthcare costs over the lifespan.

Economic evaluation of drug abuse treatment and HIV prevention programs in pregnant women: a systematic review

Drug abuse and transmission of HIV during pregnancy are public health problems that adversely affect pregnant women, their children and surrounding communities. Programs that address this vulnerable population have the ability to be cost-effective due to resulting cost savings for mother, child and society. Economic evaluations of programs that address these issues are an important tool to better understand the costs of services and create sustainable healthcare systems. This study critically examined economic evaluations of drug abuse treatment and HIV prevention programs in pregnant women. A systematic review was conducted using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations. The search identified 6 economic studies assessing drug abuse treatment for pregnant women, and 12 economic studies assessing programs that focus on prevention of mother-to-child transmission (PMTCT) of HIV. Results show that many programs for drug abuse treatment and PMTCT among pregnant women are cost-effective or even cost-saving. This study identified several shortcomings in methodology and lack of standardization of current economic evaluations. Efforts to address methodological challenges will help make future studies more comparable and have more influence on policy makers, clinicians and the public.

Development and validation of a liquid chromatography mass spectrometry assay for the simultaneous quantification of methadone, cocaine, opiates and metabolites in human umbilical cord

A liquid chromatography mass spectrometric selected reaction monitoring mode (SRM) method for methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), cocaine, benzoylecgonine (BE), 6-acetylmorphine, morphine and codeine quantification in human umbilical cord was developed and fully validated. Analytes were extracted from homogenized tissue (1g) by solid phase extraction. Linearity was 2.5-500ng/g, except for methadone (10-2000ng/g). Method imprecision was <12.7%CV with analytical recovery 85.9-112.7%, extraction efficiency >59.2%, matrix effect 4.5-39.5%, process efficiency 48.6-92.6% and stability >84.6%. Analysis of an umbilical cord following controlled methadone administration and illicit drug use contained in ng/g, 40.3 morphine, 3.6 codeine, 442 BE, 186 methadone and 45.9 EDDP.

Health status and birth outcomes among pregnant women in substance abuse treatment

PURPOSE

We sought to examine the physical and mental health status and low birthweight and preterm birth among low-income pregnant women in substance abuse treatment.

METHODS

A prospective correlational design was used with 84 pregnant women enrolled in a university-affiliated, comprehensive, hospital-based substance abuse treatment program. The majority of the sample reported heroin as their primary substance of abuse.

RESULTS

Approximately 39% of the infants were born preterm and 27.5% were low birthweight. Poorer perception of current health, cocaine as the primary substance of abuse, and number of prior substance abuse treatment admissions were independently associated with preterm birth. Being African American and a poorer perception of current health were independently associated with low birthweight.

CONCLUSION

Asking about perceptions of their current health is a useful addition to comprehensive assessment for pregnant women with substance abuse problems in any setting. Further knowledge of women's physical and mental health status will improve identification of those who are at even greater risk in a group at high risk overall.

Simultaneous quantification of methadone, cocaine, opiates, and metabolites in human placenta by liquid chromatography-mass spectrometry

A validated method for quantifying methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine, cocaine, benzoylecgonine, 6-acetylmorphine, morphine, and codeine in human placenta by liquid chromatography-ion trap mass spectrometry is described. Specimens (1 g) were homogenized and subjected to solid-phase extraction. Chromatographic separation was performed on a Synergi Polar RP column with a gradient of 0.1% formic acid and acetonitrile. The method was linear from 10 to 2000 ng/g for methadone and 2.5 to 500 ng/g for other analytes. Limits of detection were 0.25-2.5 ng/g, imprecisions < 9.1%CV, analytical recoveries 84.4-113.3%, extraction efficiencies > 46%, matrix effects -8.0-129.9%, and process efficiencies 24.2-201.0%. Method applicability was demonstrated by analysis of five placenta specimens from opioid-dependent women receiving methadone pharmacotherapy, with methadone doses ranging from 65 to 95 mg on the day of delivery. These are the first data on placenta concentrations of methadone and metabolites after controlled drug administration. Detection of other common drugs of abuse in placenta will also improve our knowledge of the usefulness of this matrix for detecting in utero drug exposure and studying disposition of drugs in the maternal-fetal dyad.

Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates

AIMS

Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants.

METHODS

PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity.

RESULTS

Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes.

RECOMMENDATIONS

Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.

CONCLUSION

Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Opioid dependence and pregnancy

PURPOSE OF REVIEW

The management of opioid dependence during pregnancy has received considerable attention over the past three decades. Recent peer-reviewed literature in the fields of pregnancy and opioid dependence and neonatal abstinence syndrome has been evaluated and discussed.

RECENT FINDINGS

Pregnant opioid-dependent women must be carefully managed to minimize harm to the fetus; therefore, standardized care for maternal health is required. In a multidisciplinary care system opioid maintenance therapy is the recommended treatment approach during pregnancy. Equivalent attention must be given to the treatment of neonatal abstinence syndrome, which occurs in 55-94% of neonates after intrauterine opioid exposure with a 60% likelihood of requiring treatment; heterogeneous rating scales as well as heterogeneous treatment approaches are often responsible for extended hospital stays.

SUMMARY

Interpretation of available literature is confounded by several methodological flaws. In general, there is still a lack of evidence-based study designs for pharmacological treatment of these patients as well as neonatal abstinence syndrome.

Economic costs of drug abuse: financial, cost of illness, and services

This article examines costs as they relate to the financial costs of providing drug abuse treatment in private and public health plans, costs to society relating to drug abuse, and many smaller costing studies of various stakeholders in the health care system. A bibliography is developed from searches across PubMed, Web of Science, and other bibliographic sources. The review indicates that a wide collection of cost findings is available to policy makers. For example, the financial aspects of health plans have been dominated by considerations of actuarial costs of parity for drug abuse treatment. Cost-of-illness methods have been developed and extended to drug abuse costing to measure the national level of burden and are important to the economic evaluation of interventions at the program level. Costing is done in many small and focused studies, reflecting the interests of different stakeholders in the health care system. For costs in programs and health plans, as well as cost offsets of the impact of substance abuse treatment on medical expenditures, findings are surprisingly important to policy makers. Maintaining ongoing research that is highly policy relevant from the point of view of health services, more is needed on costing concepts and measurement applications.

Changes in quality of life for pregnant women in substance user treatment: developing a quality of life index for the addictions

Using preference weights from a community sample, items from the Addiction Severity Index (ASI) were converted into a quality of life index (QOLI) and used to compare the cost-effectiveness of five addiction treatment modalities for pregnant women.

METHODS

Interviews using the time trade-off methodology were conducted with 143 members of Massachusetts local health planning boards to determine preference weights for different health states resulting from active addiction. A multi-attribute utility formula was used to convert these seven preference weighted scores into a single QOLI. To apply the QOLI, these preference weights were combined with the number of problem days reported in each ASI domain by a sample of 439 pregnant women in MA in five treatment modalities, 1992-1996.

RESULTS

Starting at 10 years with an addiction problem, board members indicated that they would give up between 0.83 and 3.96 years to avoid the problems in one domain caused by addiction. The average QOLI was 0.68 at intake but increased by 0.19 points by 6-month follow-up to 0.87. All five treatment groups showed notable improvement in their quality of life. Mean improvements ranged from a high of 0.23 QOLIs for clients who received both residential and outpatient treatment to a low of 0.16 for clients who received only detoxification. Treatment costs ranged from 10,187 dollars for residential and outpatient combined to 2535 dollars for detoxification only, with costs per QOLI ranging from 14,912 dollars to 44,291 dollars.

CONCLUSIONS

Although this QOLI could benefit from further refinement and development, it showed promise as a single outcome measure for CEAs in the chemical dependency field. This QOLI was sensitive enough to distinguish between the treatment groups, it correlated well with other outcome measures and can be easily converted from the ASI using spreadsheet software and a simple formula.

Identifying pregnant women at risk for early attrition from substance abuse treatment

Greater treatment retention among pregnant substance abusers is associated with improved pregnancy and neonatal outcomes, so early identification of clients most at risk for early attrition is essential. Participants were 152 pregnant women enrolled in the initial 7-day residential component of a comprehensive substance abuse treatment program for pregnant women. Twenty-nine (19%) women left treatment within the first 5 days, primarily within the first 2 days. Clinical staff identified many, but not all, patients who eventually left treatment early as many indicated their desire to leave and were troubled by drug craving and withdrawal. Other predictors of attrition included not receiving methadone maintenance, being Caucasian, and reporting more prior drug treatment episodes, fewer medical problems and, to a lesser extent, more family/social and psychiatric and fewer drug problems on the Addiction Severity Index. Interventions are needed to target pregnant clients most at risk for early treatment attrition.

Reciprocal obligations: managing policy responses to prenatal substance exposure

Substance use during pregnancy poses substantial risks to the developing fetus and continues to generate considerable policy debate. Public policy responses to prenatal substance exposure (PSE) have varied depending in part on whether the substances in question are licit (e.g., tobacco and alcohol) or illicit (e.g., cocaine and heroin). The policy responses also have ranged from warning labels on the dangers to the developing fetus of using alcohol, to treating a pregnant woman's illicit substance use as child abuse. The most controversial case was Cornelia Whitner's criminal conviction in South Carolina for PSE after her newborn baby tested positive for cocaine metabolites. Although the conviction was upheld by the South Carolina Supreme Court, it is, to date, an isolated example (Whitner v. State of South Carolina, 492 S.E.2d 777 [S.C. 1997], cert denied, 523 U.S. 1145 [1998], but see Ferguson v. City of Charleston, 532 U.S. 67 [2001], and Ferguson v. City of Charleston, 308 F.3d 380 [4th Cir. 2002], ruling that PSE detection policies require the woman's informed consent).