The societal cost of heroin use disorder in the United States

Ruixuan Jiang, Inyoung Lee, Todd A Lee, A Simon Pickard, Ruixuan Jiang, Inyoung Lee, Todd A Lee, A Simon Pickard

Abstract

Objective: Heroin use in the United States has reached epidemic proportions. The objective of this paper is to estimate the annual societal cost of heroin use disorder in the United States in 2015 US dollars.

Methods: An analytic model was created that included incarceration and crime; treatment for heroin use disorder; chronic infectious diseases (HIV, Hepatitis B, Hepatitis C, and Tuberculosis) and their treatments; treatment of neonatal abstinence syndrome; lost productivity; and death by heroin overdose.

Results: Using literature-based estimates to populate the model, the cost of heroin use disorder was estimated to be $51.2 billion in 2015 US dollars ($50,799 per heroin user). One-way sensitivity analyses showed that overall cost estimates were sensitive to the number of heroin users, cost of HCV treatment, and cost of incarcerating heroin users.

Conclusion: The annual cost of heroin use disorder to society in the United States emphasizes the need for sustained investment in healthcare and non-healthcare related strategies that reduce the likelihood of abuse and provide care and support for users to overcome the disorder.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Simplified structure of the cost-analytic…
Fig 1. Simplified structure of the cost-analytic model.
The cost-analytic model was used to assist in the calculation of a prevalence based estimate of the annual cost of heroin use disorder in the United States. Thus, only prevalent cases were included in the model. Not shown in model: Proportion of treatment applied for each chronic infectious health state.
Fig 2. Costs per user by type…
Fig 2. Costs per user by type of heroin user.
Exact values contained in S2 Table.
Fig 3. Tornado diagram one-way sensitivity analyses.
Fig 3. Tornado diagram one-way sensitivity analyses.
Full values contained in S3 Table.

References

    1. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. 2013;132(1–2):95–100. doi:
    1. Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use Trends Among Heroin Users—United States, 2002–2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719–25.
    1. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378–82. doi:
    1. Centers for Disease Control and Prevention. Today’s Heroin Epidemic Infographics [updated July 7, 2015; cited 2016 November 4]. Available from: - graphic.
    1. National Drug Threat Assessment—Impact on Society 2010 [cited 2016 July 1]. Available from: .
    1. National Drug Threat Assessment US Department of Justice National Drug Intelligence Center; 2011 [cited 2016 January 29]. Available from: .
    1. Tetrault JM, Fiellin DA. Current and potential pharmacological treatment options for maintenance therapy in opioid-dependent individuals. Drugs. 2012;72(2):217–28. PubMed Central PMCID: PMCPMC3701303. doi:
    1. Teesson M, Marel C, Darke S, Ross J, Slade T, Burns L, et al. Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11-year findings from the Australian Treatment Outcome Study. Addiction. 2015;110(6):986–93. doi:
    1. Boutwell AE, Nijhawan A, Zaller N, Rich JD. Arrested on heroin: a national opportunity. J Opioid Manag. 2007;3(6):328–32.
    1. Elliott JC, Hasin DS, Stohl M, Des Jarlais DC. HIV, Hepatitis C, and Abstinence from Alcohol Among Injection and Non-injection Drug Users. AIDS Behav. 2015.
    1. Factor SH, Sackoff JE, Raj-Singh S, Wu Y, Monserrate J, Munsiff S, et al. Street-outreach improves detection but not referral for drug users with latent tuberculosis, New York City. Subst Use Misuse. 2011;46(14):1711–5. doi:
    1. Weaver T, Metrebian N, Hellier J, Pilling S, Charles V, Little N, et al. Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial. Lancet. 2014;384(9938):153–63. doi:
    1. Owusu-Edusei K Jr., Chesson HW, Gift TL, Tao G, Mahajan R, Ocfemia MC, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis. 2013;40(3):197–201. doi:
    1. National Institute on Drug Abuse. Why does heroin use create special risk for contracting HIV/AIDS and hepatitis B and C? [updated November 2014; cited 2017 March 23]. Available from: .
    1. National Institute on Drug Abuse. How does heroin use affect pregnant women? [updated November 2014; cited 2017 March 23]. Available from: .
    1. Centers for Disease Control and Prevention. TB Risk Factors [updated March 18, 2016; cited 2017 March 23]. Available from: .
    1. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA. 2012;307(18):1934–40. doi:
    1. Center for Behavioral Health Statistics and Quality. Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16–4984, NSDUH Series H-51). 2016 [cited 2016 October 15]. Available from: .
    1. National Institute on Drug Abuse. DrugFacts: Nationwide Trends [updated June 2015; cited 2016 Feburary 1]. Available from: .
    1. Mumola CJK, J.C. Drug Use and Dependence, State and Federal Prisoners, 2004 2006 [cited 2016 July 29]. Available from: .
    1. US Department of Justice and National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society 2011 [cited 2016 January 29]. Available from: .
    1. Spiller MW, Broz D, Wejnert C, Nerlander L, Paz-Bailey G, Centers for Disease C, et al. HIV infection and HIV-associated behaviors among persons who inject drugs—20 cities, United States, 2012. MMWR Morb Mortal Wkly Rep. 2015;64(10):270–5.
    1. Genberg BL, Astemborski J, Vlahov D, Kirk GD, Mehta SH. Incarceration and injection drug use in Baltimore, Maryland. Addiction. 2015;110(7):1152–9. PubMed Central PMCID: PMCPMC4478154. doi:
    1. Westergaard RP, Hess T, Astemborski J, Mehta SH, Kirk GD. Longitudinal changes in engagement in care and viral suppression for HIV-infected injection drug users. AIDS. 2013;27(16):2559–66. PubMed Central PMCID: PMCPMC3795966. doi:
    1. Wakeman SE, Rich JD. HIV treatment in US prisons. HIV Ther. 2010;4(4):505–10. PubMed Central PMCID: PMCPMC2953806.
    1. Gebo KA, Fleishman JA, Conviser R, Hellinger J, Hellinger FJ, Josephs JS, et al. Contemporary costs of HIV healthcare in the HAART era. AIDS. 2010;24(17):2705–15. PubMed Central PMCID: PMCPMC3551268. doi:
    1. Center for Disease Control. HIV and Viral Hepatitis Fact Sheet 2014 [cited 2016 February 1]. Available from: .
    1. Weinbaum CM, Sabin KM, Santibanez SS. Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention. AIDS. 2005;19 Suppl 3:S41–6.
    1. Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86(5):655–61. PubMed Central PMCID: PMCPMC1380472.
    1. Fox RK, Currie SL, Evans J, Wright TL, Tobler L, Phelps B, et al. Hepatitis C virus infection among prisoners in the California state correctional system. Clin Infect Dis. 2005;41(2):177–86. doi:
    1. Grebely J, Genoway KA, Raffa JD, Dhadwal G, Rajan T, Showler G, et al. Barriers associated with the treatment of hepatitis C virus infection among illicit drug users. Drug Alcohol Depend. 2008;93(1–2):141–7. doi:
    1. Younossi ZMP, Haesuk Gordon, Stuart C.; Ferguson John R.; Ahmed Aijaz; Dieterich Douglas; Saab Sammy. Real-World Outcomes of Ledipasvir/Sofosbuvir in Treatment-Naïve Patients With Hepatitis C Am J Manag Care. 2016.
    1. Kellerman SE, Hanson DL, McNaghten AD, Fleming PL. Prevalence of chronic hepatitis B and incidence of acute hepatitis B infection in human immunodeficiency virus-infected subjects. J Infect Dis. 2003;188(4):571–7. doi:
    1. Hennessey KA, Kim AA, Griffin V, Collins NT, Weinbaum CM, Sabin K. Prevalence of infection with hepatitis B and C viruses and co-infection with HIV in three jails: a case for viral hepatitis prevention in jails in the United States. J Urban Health. 2009;86(1):93–105. PubMed Central PMCID: PMCPMC2629523. doi:
    1. Bini EJ, Perumalswami PV. Hepatitis B virus infection among American patients with chronic hepatitis C virus infection: prevalence, racial/ethnic differences, and viral interactions. Hepatology. 2010;51(3):759–66. doi:
    1. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. 2011;378(9791):571–83. PubMed Central PMCID: PMCPMC3285467. doi:
    1. Sarkar M, Shvachko VA, Ready JB, Pauly MP, Terrault NA, Peters MG, et al. Characteristics and management of patients with chronic hepatitis B in an integrated care setting. Dig Dis Sci. 2014;59(9):2100–8. PubMed Central PMCID: PMCPMC4149592. doi:
    1. Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat. 2004;11(2):97–107.
    1. Golub JE, Astemborski J, Ahmed M, Cronin W, Mehta SH, Kirk GD, et al. Long-term effectiveness of diagnosing and treating latent tuberculosis infection in a cohort of HIV-infected and at-risk injection drug users. J Acquir Immune Defic Syndr. 2008;49(5):532–7. PubMed Central PMCID: PMCPMC2637943. doi:
    1. Hauck FR, Neese BH, Panchal AS, El-Amin W. Identification and management of latent tuberculosis infection. Am Fam Physician. 2009;79(10):879–86.
    1. Deiss RG, Rodwell TC, Garfein RS. Tuberculosis and illicit drug use: review and update. Clin Infect Dis. 2009;48(1):72–82. PubMed Central PMCID: PMCPMC3110742. doi:
    1. Holland DP, Sanders GD, Hamilton CD, Stout JE. Costs and cost-effectiveness of four treatment regimens for latent tuberculosis infection. Am J Respir Crit Care Med. 2009;179(11):1055–60. PubMed Central PMCID: PMCPMC2689913. doi:
    1. Evans E, Li L, Min J, Huang D, Urada D, Liu L, et al. Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006–10. Addiction. 2015;110(6):996–1005. PubMed Central PMCID: PMCPMC4452110. doi:
    1. Inocencio TJ, Carroll NV, Read EJ, Holdford DA. The economic burden of opioid-related poisoning in the United States. Pain Med. 2013;14(10):1534–47. doi:
    1. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings 2009 [cited 2016 November 10]. Available from: .
    1. Samuels J, CE. Annual Determination of Average Cost of Incarceration 2015 [cited 2016 July 27]. Available from: .
    1. Social Security Administration. Measures Of Central Tendency For Wage Data—Average and Median Amounts of Net Compensation [cited 2016 July 18]. Available from: 7s://.
    1. Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables [cited 2016 November 2]. Available from: .
    1. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35(8):650–5 PubMed Central PMCID: PMCPMC4520760. doi:
    1. Kilmer B ES, Caulkins JP, et al. What America's Users Spend on Illicit Drugs: 2000 through 2010 2014 [cited 2016 July 29]. Available from: .
    1. Solomon M, Bonafede M, Pan K, Wilson K, Beam C, Chakravarti P, et al. Direct medical care costs among pegylated interferon plus ribavirin-treated and untreated chronic hepatitis C patients. Dig Dis Sci. 2011;56(10):3024–31 doi:
    1. Henrichson C, Delaney R. The Price of Prisons—What Incarceration Costs Taxpayers Center on Setencing and Corrections,; 2012 [updated July 20, 2012; cited 2017 April 3]. Available from: .
    1. Henrichson CD, R. The Price of Prisons: What Incarceration Costs Taxpayers. New York: Vera Institute of Justice; 2012. [updated July 20, 2012; cited 2016 October 16]. Available from: .
    1. Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections through 2020. Chest. 2015;147(1):31–45. doi:
    1. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46. PubMed Central PMCID: PMCPMC3609540. doi:
    1. Mark TL, Woody GE, Juday T, Kleber HD. The economic costs of heroin addiction in the United States. Drug Alcohol Depend. 2001;61(2):195–206.
    1. Centers for Disease Control and Prevention—Division of Heart Disease and Stroke Prevention. Part II: Economic Impact Analysis. Cost of Illness: The Second of a Five-Part Series. Available from: .
    1. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821–6. doi:
    1. Thiagarajan P, Ryder SD. The hepatitis C revolution part 1: antiviral treatment options. Curr Opin Infect Dis. 2015;28(6):563–71. doi:
    1. Cicero TJ, Ellis MS. Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned From OxyContin. JAMA Psychiatry. 2015;72(5):424–30. doi:
    1. Dowell D, Zhang K, Noonan RK, Hockenberry JM. Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates. Health Aff (Millwood). 2016;35(10):1876–83.
    1. AASLD IDSA HCV Guidance Panel. Hepatitis C guidance: AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus. Hepatology. 2015;62(3):932–54. doi:
    1. Martin NK, Vickerman P, Grebely J, Hellard M, Hutchinson SJ, Lima VD, et al. Hepatitis C virus treatment for prevention among people who inject drugs: Modeling treatment scale-up in the age of direct-acting antivirals. Hepatology. 2013;58(5):1598–609. PubMed Central PMCID: PMCPMC3933734. doi:
    1. Ogbuagu O, Bruce RD. Reaching the unreached: treatment as prevention as a workable strategy to mitigate HIV and its consequences in high-risk groups. Curr HIV/AIDS Rep. 2014;11(4):505–12. doi:
    1. Ahamad K, Hayashi K, Nguyen P, Dobrer S, Kerr T, Schutz CG, et al. Effect of low-threshold methadone maintenance therapy for people who inject drugs on HIV incidence in Vancouver, BC, Canada: an observational cohort study. Lancet HIV. 2015;2(10):e445–50. PubMed Central PMCID: PMCPMC4675466. doi:
    1. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS. 2005;19 Suppl 2:S67–72.
    1. Apa ZL, Bai R, Mukherejee DV, Herzig CT, Koenigsmann C, Lowy FD, et al. Challenges and strategies for research in prisons. Public Health Nurs. 2012;29(5):467–72. PubMed Central PMCID: PMCPMC3694772. doi:
    1. Ahrnsbrak R KL, and Harter R. 2015 National Survey on Drug Use and Health: Summary of the Effects of the 2015 NSDUH Questonnaire Redesign: Implications for Data Users [cited 2016 November 11]. Available from: .
    1. Saag MS. Editorial commentary: getting smart in how we pay for HCV drugs: KAOS vs CONTROL. Clin Infect Dis. 2015;61(2):169–70. doi:
    1. Cohen J. Pharmaceuticals. Advocates protest the cost of a hepatitis C cure. Science. 2013;342(6164):1302–3. doi:
    1. Davidson J. Obama anti-heroin strategy shifts focus to treatment from arrests: Washington Post; 2016 [updated March 29, 2016; cited 2016 July 29]. Available from: .
    1. Fact Sheet: Obama Administration Announces Additional Actions to Address the Prescription Opioid Abuse and Heroin Epidemic 2016 [cited 2016 July 29]. Available from: .

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