Lifetime Survival, Societal Costs and Cost-Effectiveness of Nine Options to Treat Alcohol Use Disorder

OBJECTIVES: Alcohol use disorder (AUD) is a serious public health challenge with significant undertreatment. The COMBINE (Combined Pharmacotherapies and Behavioral Interventions) trial is one of the largest evaluations of AUD treatments however, only short-term costs and relapse rates were reported. Thus, this study aimed to examine the cost-effectiveness of nine AUD treatments using data on long-term drinking patterns.

METHODS: A decision tree/Markov model was developed with an American societal perspective, yearly cycle length and lifetime time horizon. The decision tree included nine treatments that used a Markov model to estimate the long-term probability of relapse and AUD related mortality. The primary outcomes were costs, quality-adjusted life years (QALYs), years in relapse, and survival. Deterministic and probabilistic sensitivity analysis were performed to assess parameter uncertainty and an additional sensitivity analysis was conducted using different mortality measure.

RESULTS: Medical management (MM)+acamprosate+naltrexone dominated all other treatments in base case analysis. This treatment had a discounted cost of $713,247, discounted QALYs of 17.31, 7.01 relapse years and 37.76 survival years. The least effective treatment was cognitive behavioral therapy only with discounted costs of $716,181, discounted QALYs of 17.29, 7.6 relapse years and 37.81 survival years. One way sensitivity analysis identified age, utility of the abstinence and low risk states, and start age as some of the most influential parameters. Probabilistic sensitivity analysis revealed significant uncertainty with MM+acamprosate+naltrexone being the preferred treatment only 8.88% of the time with MM+placebo being the preferred treatment majority of the time (52.38%) at willingness-to-pay threshold of $100,000. The additional sensitivity analysis using hazard ratio for mortality with AUD also showed MM+acamprosate+naltrexone dominating all other treatments.

CONCLUSIONS: Medical management+ acamprosate+naltrexone was determined to be the most cost-effective treatment however, there is high uncertainty in this finding as nearly all the AUD treatments examined have similar survivals and quality adjusted survivals.