Cost-Effectiveness of Treatment for Opioid Use Disorder in Pregnancy and Its Impact on Birth Outcomes

Importance: For the first time in nearly 2 decades, the US infant mortality rate has increased, coinciding with a rise in overdose-related deaths as a leading cause of pregnancy-associated mortality in some states. Prematurity and low birth weight - often linked to opioid use in pregnancy - are major contributors. Objective: To assess the health and economic impact of perinatal opioid use disorder (OUD) treatment on maternal and postpartum health, infant health in the first year of life, and infant long-term health. Design, Setting, and Participants: This was a cost-effectiveness, population-based analysis using a stochastic time-to-event discrete-event simulation model to simulate the clinical progression and outcomes for hypothetical pregnant individuals with OUD who initiate treatment during pregnancy. In addition, a scenario analysis was conducted assuming that individuals were stable taking OUD treatment before pregnancy and continued treatment during pregnancy. Data were analyzed from May to September 2024. Exposures: Study exposures included outpatient methadone, buprenorphine monotherapy, and buprenorphine-naloxone; outpatient methadone, buprenorphine, and naltrexone after inpatient-managed withdrawal; and inpatient-managed withdrawal with and without an intensive behavioral component. Main Outcomes and Measures: Outcomes included return to illicit use; fatal and nonfatal overdose; incremental discounted costs; quality-adjusted life-years (QALYs), which are a combined measure of mortality and morbidity; net health benefit; infant mortality within the first year of life; preterm birth; low birth weight; and neonatal opioid withdrawal syndrome (NOWS). Results: In this economic evaluation of a hypothetical cohort of 100000 pregnant individuals (mean [SD] starting age, 29 [5.6] years), in the pregnancy and postpartum simulation, buprenorphine dominated all strategies, yet methadone was a viable alternative. In the combined infant lifetime model, compared with methadone, buprenorphine showed an incremental effect of 0.262 QALYs per person, totaling 20960 QALYs for 80000 Medicaid-affected mother-infant dyads (IQR uncertainty interval [UI] 25th to 75th percentiles, 14880-27040 QALYs); mean cost savings of $21512 per person, totaling $1.72 billion (IQR UI, $1.46-1.98 billion). Compared with naltrexone, buprenorphine showed an incremental effect ranging from 0.228 to 0.229 QALYs per person; 18240 of 18320 total QALYs for 80000 mother-infant dyads (IQR UI, 13840-22720 QALYs; naltrexone-oral; IQR UI, 13760-22880 QALYs; naltrexone-extended release [XR]). Mean cost savings ranged from $25316 per person ($2.03 billion; IQR UI, $1.83-$2.21 billion; naltrexone-oral) to $46437 per person ($3.71 billion; IQR UI, $3.47-$3.96 billion; naltrexone-XR). Conclusions and Relevance: Results of this analysis suggest that both methadone and buprenorphine remained viable options for managing OUD during pregnancy and post partum; however, buprenorphine offered the greatest benefits in the lifetime models that account for infant outcomes.