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Reducing opioid use for chronic pain with a group-based intervention: Economic evaluation using randomised controlled
Sheeja Manchira Krishnan1, Vijay S Gc2, Tom Bromilow3
1Department of Health Sciences, University of York, York, UK.
Background And Aims:
Long-term strong opioid use for chronic non-malignant pain (CNMP) represents a significant public health challenge, associated with reduced health-related quality of life (HRQoL) and increased mortality. The Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) trial demonstrated that a multicomponent intervention supporting opioid withdrawal in people with CNMP successfully reduced opioid consumption compared with best usual care (BUC), without adversely affecting perceived pain levels. This study aimed to assess the value-for-money of the strategies tested in the I-WOTCH trial, from the perspective of the United Kingdom National Health Service (NHS) and Personal and Social Services.
Design, Setting And Participants:
Within-trial cost-consequence (CCA) and model-based cost-effectiveness analyses (CEA), over one year and lifetime horizons, respectively. Data were sourced from the I-WOTCH trial, which recruited 608 participants from 191 primary care centres in England between May 2017 and January 2019 and followed them up for up to 12 months. Participants received either BUC or 3 group sessions (lasting one day each) led by a trained intervention nurse and by a lay person with CNMP and lived experience with opioid tapering. These sessions, designed to develop self-management skills, were supplemented by ongoing one-to-one support from nursing and lay personnel during follow-up. We used a probabilistic state-transition model to predict expected quality-adjusted life years (QALYs) and costs (in UK £) of each strategy over the lifetime of an individual. Model input parameters were derived mostly from the I-WOTCH trial. Opioid-related excess mortality and fracture rates were extracted from the literature.
Measurements:
Individual-level healthcare resource use and generic HRQoL [measured using the EuroQOL five dimensions questionnaire (Equation 5D)] were collected at baseline, 4, 8 and 12 months, and analysed to estimate total costs and health consequences for the I-WOTCH and BUC groups.
Findings:
I-WOTCH had higher costs and similar HRQoL outcomes compared with BUC at 12 months. When accounting for long-term reductions in mortality and morbidity from decreased exposure to strong opioids, our long-term model predicted I-WOTCH to yield higher costs and higher QALYs than BUC over the patient's lifetime, resulting in a base case incremental cost-effectiveness ratio of £29 543/QALY (2019 prices). Results were sensitive to structural assumptions in the model (i.e. cohort starting age, treatment effect weaning rate). Our probabilistic sensitivity analysis found I-WOTCH to have a 50% probability of being cost-effective compared with BUC for willingness-to-pay thresholds ranging between 0 and £100 000/QALY.
Conclusions:
The Improving the Wellbeing of people with Opioid Treated CHronic pain intervention supporting opioid withdrawal in people with chronic non-malignant pain appears to be cost-effective on average, but further research is warranted to reduce current levels of decision uncertainty.
