Allocative efficiency of opioid overdose prevention strategies for people incarcerated in New Jersey.

backgroundPeople with opioid use disorder (POUD) who are incarcerated are disproportionately impacted by the overdose crisis. We sought to identify overdose policies that allocate resources with maximal efficiency to reduce mortality among POUD in the New Jersey (NJ) Department of Corrections. MAIN OUTCOMES/MEASURES: We created a probabilistic state-transition model of a simulated cohort of POUD incarcerated in NJ to simulate maximizing medication for opioid use disorder (MOUD) during incarceration and/or post-release in the community and naloxone in the community. We estimated how maximizing each intervention individually and in combinations compared to current provision would impact five-year overdose deaths (ODDs), life-years (LYs), and quality-adjusted life-years (QALYs) among the simulated cohort, who moved between different modeled settings and opioid use statuses. Inputs were derived from literature reviews and expert opinion. Costs were in 2021 USD, employing a health sector perspective in base-case analyses and a limited societal perspective in sensitivity analyses, a 3% discount rate, cost-effectiveness criterion of ≤ $100,000/QALY, and life-year and lifetime horizons.

resultsAt status quo, 141 five-year ODDs will occur in the cohort (n = 2,592), and the cohort will live an average of 17.0 discounted LYs, experiencing 13.3 discounted QALYs. Evaluating interventions individually compared to status quo, maximizing MOUD in incarceration prevents 14 five-year ODDs, adds 0.2 LYs, 0.3 QALYs per-person at a favorable incremental cost-effectiveness ratio (ICER; $34,000/QALY). Maximizing MOUD in the community prevents 40 five-year ODDs, adds 0.9 LYs, 1.1 QALYs at a favorable ICER ($25,000/QALY). Maximizing naloxone prevents 24 five-year ODDs, adds 0.3 LYs, 0.2 QALYs at a favorable ICER ($17,000/QALY). Comparing all combinations of interventions to status quo and each other, the most beneficial combination meeting cost-effectiveness criterion was jointly maximizing community MOUD and naloxone (ICER $25,000/QALY), preventing 56 five-year ODDs, adding 1.2 LYs, 1.3 QALYs. In sensitivity analyses using a limited societal perspective, all interventions were cost-saving. Maximizing all interventions was both most beneficial (42% reduction in death) and cost-saving ($300,000 per capita) over the cohort lifetime.

conclusionMaximizing MOUD and community naloxone in New Jersey can reduce five-year ODDs by 40%. Considering societal cost-savings, maximizing all three also saves money.