Cost-effectiveness of hydromorphone for severe opioid
use disorder: ﬁndings from the SALOME randomized
, Daphne Guh
, Eugenia Oviedo-Joekes
, Suzanne Brissette
, Scott Harrison
, Michael Krausz
, Scott MacDonald
, David C. Marsh
, Martin T. Schechter
Aslam H. Anis
Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul’s Hospital, Vancouver, British Columbia, Canada,
School of Population and Public
Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada,
Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal,
Providence Crosstown Clinic, Providence Health Care, Vancouver, British Columbia, Canada,
Department of Psychiatry, University of British
Columbia, Vancouver, Canada
and Northern Ontario School of Medicine, Sudbury, Ontario, Canada
Background and aims
Previous research has found diacetylmorphine, delivered under supervision, to be cost-effective
in the treatment of severe opioid use disorder, but diacetylmorphine is not available in many settings. The Study to Assess
Long-term Opioid Maintenance Effectiveness (SALOME) randomized controlled trial provided evidence that injectable
hydromorphone is non-inferior to diacetylmorphine. The current study aimed to compare the cost-effectiveness of
hydromorphone directly with diacetylmorphine and indirectly with methadone maintenance treatment.
within-trial analysis was conducted using the patient level data from the 6-month, double-blind, non-inferiority SALOME
trial. A life-time analysis extrapolated costs and outcomes using a decision analytical cohort model. The model incorpo-
rated data from a previous trial to include an indirect comparison to methadone maintenance.
clinic in Vancouver, British Columbia, Canada.
A total of 202 long-term street opioid injectors who had
at least two attempts at treatment, including one with methadone (or other substitution), were randomized to
hydromorphone (n = 100) or diacetylmorphine (n =102).
We measured the utilization of drugs, visits
to health professionals, hospitalizations, criminal activity, mortality and quality of life. This enabled us to estimate incre-
mental costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios from a societal perspective. Sensitivity anal-
yses considered different sources of evidence, assumptions and perspectives.
The within-trial analysis found
hydromorphone provided similar QALYs to diacetylmorphine [0.377, 95% conﬁdence interval (CI) = 0.361–0.393 versus
0.375, 95% CI = 0.357–0.391], but accumulated marginally greater costs [$49 830 ($28 401–73 637) versus $34 320
($21 780–55 998)]. The life-time analysis suggested that both diacetylmorphine and hydromorphone provide more ben-
eﬁts than methadone [8.4 (7.4–9.5) and 8.3 (7.2–9.5) versus 7.4 (6.5–8.3) QALYs] at lower cost [$1.01 million ($0.6–
1.59 million) and $1.02 million ($0.72–1.51 million) versus $1.15 million ($0.71–1.84 million)].
tients with severe opioid use disorder enrolled into the SALOME trial, injectable hydromorphone provided similar outcomes
to injectable diacetylmorphine. Modelling outcomes during a patient’s life-time suggested that injectable hydromorphone
might provide greater beneﬁt than methadone alone and may be cost-saving, with drug costs being offset by costs saved
from reduced involvement in criminal activity.
Keywords Cost-effectiveness, economics, injectable diacetylmorphine, injectable hydromorphone, methadone
maintenance therapy, opioid dependence.
Correspondence to: Aslam H. Anis, Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul’s Hospital, 588–1081 Burrard Street,
Vancouver, V6Z 1Y6, British Columbia, Canada. E-mail: email@example.com
Submitted 15 June 2017; initial review completed 26 September 2017; ﬁnal version accepted 19 January 2018
Opioid dependence has an enormous burden on individuals
and society. Maintenance treatment such as methadone
and buprenorphine can be effective for many individuals,
in terms of improving physical and psychological health,
decreasing drug use, infectious disease transmission and il-
legal activity [1–3]. However, a subpopulation of
© 2018 Society for the Study of Addiction Addiction, 113,1264–1273