Cost-Effectiveness of Extended-Release Injectable Naltrexone Among Incarcerated Persons with Opioid Use Disorder Before Release from Prison Versus after Release

Introduction: Opioid use disorder (OUD) is highly prevalent among incarcerated populations, and the risk of fatal overdose following release from prison is substantial. Despite efficacy, few correctional facilities provide evidence-based addiction treatment. Extended-release injectable naltrexone (XR-NTX) administered prior to release from incarceration may improve health and economic outcomes.Methods: We conducted an economic evaluation alongside a randomized controlled trial of testing the effectiveness of XR-NTX before release from prison (n=74) vs. XR-NTX referral after release (n=72) of participants with OUD who were incarcerated, both groups continuing treatment at a community addiction treatment center. The incremental cost-effectiveness ratio was used to assess cost-effectiveness of the XR-NTX before release compared to referral after release for three stakeholder perspectives at 12- and 24-week periods: state policymaker, healthcare sector, and societal. Effectiveness measures included quality-adjusted life-years (QALYs) and abstinent years from opioids. Resources were categorized as OUD-related and non-OUD related medical care, state transfers payments, and other societal costs (productivity, criminal justice resources, etc.).Results: XR-NTX was associated with greater OUD-related costs and total costs from the state policymaker perspective. QALYs gained were positive but statistically insignificant between arms; however, XR-NTX was associated with an estimated 15.5 more days of opioid abstinence over 24 weeks and statistically significant at a 95% confidence level. Estimated ICERs were found to be > $500,000 per QALY for all stakeholder perspectives. For the abstinent-year effectiveness measure, XR-NTX before release was found to be cost-effective at a 95% confidence level for willingness-to-pay values >$49,000 per abstinent-year, across all perspectives. Conclusions: XR-NTX administered to persons who are incarcerated with OUD before release may provide value for stakeholders and bridge a well-known treatment gap for this vulnerable population. Lower than expected participant engagement and missing data limit our results