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Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction

  • Sarah Byford (a1), Barbara Barrett (a1), Nicola Metrebian (a2), Teodora Groshkova (a3), Maria Cary (a1), Vikki Charles (a2), Nicholas Lintzeris (a4) and John Strang (a2)...



Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain.


To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction.


Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources.


Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15805 v. £13410 injectable heroin and £10945 injectable methadone; P =n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin.


Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.


Corresponding author

Sarah Byford, Centre for the Economics of Mental and Physical Health, Box P024, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email:


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See editorial, pp. 325–326, this issue.

Declaration of interest

J.S. and N.L. have contributed to UK National Treatment Agency for Substance Misuse and Department of Health guidelines on the role of injectable prescribing in the management of opiate addiction (2003; chaired by J.S.). J.S. has chaired the broader-scope pan-UK working group preparing the 2007 Orange Guidelines for the UK Departments of Health, providing guidance on management and treatment of drug dependence and misuse. J.S. has provided consultancy advice on possible novel opiate addiction treatments, products and formulations to Britannia/Genus, Auralis/Viropharma, and Martindale Pharmaceuticals, and other pharmaceutical companies. J.S. and his institution have received support and funding from the Department of Health (England) and National Treatment Agency (England); and J.S. has close associations with the charity Action on Addiction. N.L. has received honoraria, travel and conference support, and consultancy fees from Reckitt Benckiser and Schering-Plough. N.L. has an untied educational grant for research related to buprenorphine in the management of opioid dependence. J.S., N.L. and N.M. have previously undertaken a research study of British heroin policy and have given varied commentaries and contributed to professional and public debate.



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Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction

  • Sarah Byford (a1), Barbara Barrett (a1), Nicola Metrebian (a2), Teodora Groshkova (a3), Maria Cary (a1), Vikki Charles (a2), Nicholas Lintzeris (a4) and John Strang (a2)...
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Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction

Robert Newman, President Emeritus
04 November 2013

Re: "Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction"1: the authors present an analysisof the results of the "Randomized Injectable Opiate Treatment Trial (RIOTT)2. Subjects of RIOTT were very few in number - less than 45 individuals in each of the three arms of the study (injectable heroin, injectable methadone and "optimized" oral methadone). It required 3 full years in 3 sites to screen 301 volunteers, of whom 127 (40%) began the trial and only 89 completed the 26-week treatment protocol.

All of the participants had been receiving "conventional" methadone treatment for more than 6 months and continued "to inject 'street' heroin regularly." On average, they had had over 4 prior treatment episodes. Accordingly, it is reasonable to assume that the overriding motivation of those who volunteered was the hope of receiving injectable opiates, and itis likely that participant bias may have had a substantial impact on outcomes. Indeed, it is revealing that among those assigned to receive "optimized" oral methadone 7 (17%) never began the trial and of the remaining 35 only 24 were still enrolled 26 weeks later.

Some of the reported findings seem to underscore the severe limitations that must be kept in mind in drawing even the most tentative conclusions. For example, while oral methadone subjects claimed to have committed roughly three times as many crimes as the intravenous methadone group (mean 21 v. 7 crimes), the latter subjects spent 15 times (!) more nights in prison (mean 6.1 v. 0.4 nights). Surely provision of oral methadone did not somehow make patients more successful in their criminal pursuits.

Perhaps inevitably, the limited ability to extrapolate has been ignored in wider distribution of the findings. Thus, one report (which refers readers seeking more information to the Press Officer of Kings College London, with which the principal author and 5 of the 7 co-authors are affiliated) had the unqualified headline: "Injectable opioid treatmentfor chronic heroin addiction more cost-effective than oral methadone," andclaimed that "... total cost savings of providing injectable opiate treatment for this chronic group in England could be between ?29 and ?59 million per year".3

The criticisms noted above must not detract from the bottom-line, common sense, conclusion with regard to injectable opioid treatment: in the interests of addicts as well as the general community it is essential that those who respond poorly to treatment (anytreatment) be provided information on and referral to the broadest possible array of alternative services.



1. Byford S, Barrett B, Metrebian N, Groshkova T, Cary M, Charles V,Lintzeris N, Strang J. Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction. B J Psychiatry. 2013 Sep 12. [Epub ahead of print].

2. Strang J, Metrebian N, Lintzeris N, Potts L, Carnwath T, Mayet S,Williams S, Zador D, Evers R, Groshkova T, Charles V, Martin A, Forzisi L.Supervised injectable heroin or injectable methadone versus optimized oralmethadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomized trial. Lancet. 2010. 375: 1885-1895.

3. No author. Injectable opioid treatment for chronic heroin addiction more cost-effective than oral methadone. HealthCanal. 2013. Accessed Oct. 11, 2013, at:

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Conflict of interest: None declared

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