Allocative efficiency analysis of strategies to reduce overdose deaths among people with opioid use disorder and history of incarceration in Connecticut.

backgroundWhile Connecticut has successfully slowed overdose death (ODD) rates, additional progress is necessary. We examined policies that allocate resources with maximal efficiency to reduce ODDs.

methodsWe developed a mechanistic simulation of overdose policies, including medications for opioid use disorder (OUD) among people involved in the criminal justice system both during incarceration (MOUD-INC) and post-release in the community (MOUD-COM), and naloxone in the community (NLX) to determine how maximally scaling all permutations compared to current MOUD and NLX levels (i.e., status quo) would impact five-year cohort ODDs, discounted life-years (LYs), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER). A simulated cohort of 2748 people with OUD incarcerated in Connecticut moved between settings and OUD statuses. Costs were assessed in 2021 $US, employed health and public health sector perspective in base-case analyses and limited-societal perspective in sensitivity analyses, 3% discount rate, a cost-effectiveness criterion of < $100,000 per QALY gained. Analyses were performed over life-year and lifetime horizons.

resultsAt status quo, the simulated cohort experienced 345 five-year ODDs, 16.1 per-person discounted LYs, and 12.5 per-person discounted QALYs. Individually, maximally scaling MOUD-INC reduced five-year ODDs 7%, added 0.3 LYs and 0.3 QALYs at an ICER $78,000/QALY gained; MOUD-COM reduced five-year ODDs 23%, added 1.2 LYs and 1.2 QALYs at $18,000/QALY gained; NLX reduced five-year ODDs 18%, added 0.4 LYs and 0.3 QALYs at $15,000/QALY gained. Considering all permutations, compared to status quo and each other, not all met the cost-effectiveness criterion. Maximally scaling MOUD-COM and NLX together was the most beneficial option meeting cost-effectiveness criterion, reducing five-year ODDs 39%, adding 1.5 LYs and 1.5 QALYs versus baseline at $18,000/QALY gained compared to the next-best option. Maximally scaling all had similar effects but an unfavorable ICER. In sensitivity analyses using a limited societal perspective, all options were cost-saving, and maximally scaling all three interventions was most beneficial and most cost-effective, adding 1.6 LYs, 1.5 QALYs, and averting 41% of ODD while saving society $363,000.

conclusionMaximally scaling community MOUD and naloxone can reduce ODDs among people who are incarcerated by 39%. Considering societal costs, maximally scaling all three decreases ODDs while saving money.