Cost-Effectiveness of an Internet-Delivered Treatment for Substance Abuse: Data from a Multisite Randomized Controlled Trial

Background: Illicit drug use and excessive alcohol consumption are major public health issues, with estimated annual economic costs exceeding $220 billion and $260 billion (2014 USD), respectively. Reducing economic costs will require raising treatment utilization rates by addressing access barriers for patients, the system, and providers. Recently, internet-based interventions for substance use disorders (SUDs) have begun to surface as a means to address many of these barriers, and to offer adjunct treatment to existing care. This study examines cost-effectiveness in a multisite, randomized trial of an internet-based version of the community reinforcement approach with contingency management, known as the Therapeutic Education System (TES).

Methods: A total of 507 individuals who were seeking therapy for alcohol or drug use disorders at 10 outpatient community-based treatment programs were recruited and randomized to either treatment as usual (TAU) or TES+TAU. We performed an economic evaluation of the 12-week trial with follow-up at 24 and 36 weeks from the perspectives of the SUD treatment provider and the payer. Both a clinical and an economic measure of effectiveness were calculated. The clinical outcome is a measure of time abstinent, the abstinent year, and the economic outcome is the quality-adjusted life year (QALY). For the provider, we calculated the 12-week study-provided direct medical costs per QALY and abstinent year. These costs included the TES intervention and treatment-related counseling. For the payer’s perspective, the total direct medical costs per QALY and abstinent year were calculated for the 12- and 36-week time frames. These costs included all provider costs and the costs of medical services. Sub analyses were completed on participants with a relatively poor prognosis (i.e., those not abstinent at study entry). Given that the patient costs associated with TES are driven largely by time in treatment and the mean time in treatment for TES+TAU participants was almost a week longer than for TAU participants, we also considered the costs of the program under the assumption that patients who leave can be replaced with new patients by normalizing the overall average number of weeks in treatment across both arms, such that they reflect the intensity of costs if they occurred over an equal duration. This is a likely scenario since treatment programs often operate at capacity, in which case the treatment site experiences costs and revenue for their patient census and the financial consequences are not necessarily higher when a patient stays longer.

Results: From the provider’s perspective, TES+TAU costs $279 (SE=87) more than TAU alone after 12 weeks. Adjusting for time in treatment reduces this figure to $65 (SE=88). The QALYs gained by TES+TAU and TAU were similar; however, TES has at least a 98% chance of being considered cost-effective for providers and payers with willingness-to-pay thresholds above $50,000 per abstinent year. Findings for the subgroup not abstinent at baseline are slightly more favorable.

Conclusions: Regarding the clinical outcome abstinence, TES+TAU is likely cost-effective. Additionally, the analyses performed here serve as an economic framework for future studies integrating technology into SUD therapy.