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The cost-effectiveness of financial incentives to achieve heroin abstinence in individuals with heroin use disorder starting new treatment episodes: A cluster randomised controlled trial-based economic evaluation

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James Shearer, Nicola Metrebian, Tim Weaver, Kimberley Goldsmith, John Strang, S Pilling, Luke Mitcheson, Ed Day, John Dunn, Anthony Glasper, Shabana Akhtar, Jalpa Bajaria, Vikki Charles, Roopal Desai, Farjana Haque, Nicholas Little, Hortencia McKechnie, Franziska Mosler, Julian Mutz, Dilkushi Poovendran & 1 more Sarah Byford

Original languageEnglish
JournalValue in Health
Early online date9 Dec 2022
Accepted/In press17 Nov 2022
E-pub ahead of print9 Dec 2022

King's Authors


Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin-abstinence or attendance at weekly keyworker appointments for opioid agonist treatment (OAT), compared to treatment as usual (TAU).

Cost-effectiveness analysis was conducted alongside a cluster randomised trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to OAT plus weekly keyworker appointments with either: i) CM targeted at heroin-abstinence (CM Abstinence); ii) CM targeted at on-time attendance at weekly appointments (CM Attendance); or, iii) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks post-randomisation took a societal cost perspective with effects measured in heroin-negative urine samples.

At 24-weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95%CI -0.397 to 0.901) for CM Abstinence and 0.089 (95%CI -0.223 to 0.402) for CM Attendance. Mean differences in costs were £2562 (95%CI £32 to £5092) for CM Abstinence and £317 (95%CI -£882 to £1518) for CM Attendance. Incremental cost-effectiveness ratios were £10,167 per additional heroin-free urine for CM Abstinence and £3,562 for CM Attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM Attendance, which dominated TAU (better outcomes, lower costs) at 12-weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM Abstinence (8.6%).

Financial incentives targeted toward heroin-abstinence and treatment-attendance were not cost-effective over the 24-week follow-up. However, CM Attendance was cost-effective over the treatment period (12-weeks), when participants were receiving keyworker appointments and incentives.

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