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Nosyk and colleagues1 have analyzed data from the North American Opiate Medication Initiative (NAOMI)2 in an attempt to ascertain cost-effectiveness of diacetylmorphine versus methadone among those “refractory to treatment” (people in whom “standard” methadone maintenance has failed on average more than 3 times). For those meeting their inclusion criteria, the authors conclude, “... diacetylmorphine may be more effective and less costly than methadone maintenance.”
The maximum duration of observation by NAOMI was 12 months, with no post-trial follow-up. Only 77 diacetylmorphine recipients (67%) and 45 who received methadone (41%) were retained on their assigned medication for even this limited period, but they were the basis for calculating and comparing “incremental cost-effectiveness ratios … over 1-, 5-, 10-year and lifetime horizons.” The study results indicated that over the course of a lifetime, people receiving methadone generated a societal cost of $1.14 million compared with $1.10 million generated by those receiving diacetylmorphine.
The most striking finding is barely mentioned in either the initial NAOMI publication2 or in the article by Nosyk and colleagues.1 During the 1-year course of the study, 15% (17) of methadone participants were, at their request, transferred from the “optimized” methadone treatment provided by NAOMI to “standard” methadone treatment in the community. Seventy-six percent of those who voluntarily “switched” remained in treatment 12 months after initial enrolment. Even more remarkably, 21% (24) of those randomly assigned to diacetylmorphine left the trial to join “standard” maintenance programs (more than half did so voluntarily), and 23 of these 24 (96%) were still receiving methadone maintenance in community facilities at 12 months. No explanation is offered for this unexpected retention in treatment that, as stated, had previously proven unsuccessful in the same setting an average of more than 3 times.