5.1 Discussions
This study employed an implementation and
non-implementation design of methadone maintenance treatment to estimate the cost and effectiveness of methadone maintenance treatment from patient’s perspective. We found out that methadone maintenance treatment is a cost-effective treatment in terms of the improvement of quality of life, the decrease of unemployment, the decline of criminal activities and incarceration costs. We will begin our discussions by reviewing the results and then turn to the interpretations and suggestions.
The finding from the study shows that methadone maintenance treatment contributed to improvement in four domains of quality of life (social relationship domain the most and physical domain the least) (Barnett, 1999; Ha, 2010; Masson, et al., 2004; Vanagas, et al., 2010) The heroin users had rather lower scores in psychological health domain at baseline of methadone maintenance treatment which means they might have negative feelings or lower self-esteem; however, after the methadone maintenance treatment, the psychological domain scores increased. They probably felt more confident and had positive feelings. In contrast, the heroin users had rather higher scores in
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physical health domain at baseline of methadone maintenance treatment which means they might have energy and might not have pain. Because they had good enough physical health, after one-year methadone maintenance treatment, the physical domain scores only increased slightly. In terms of cost per QoL, heroin users have to pay the most money on physical domain in order to achieve one QoL gained and pay the least money on psychological domain in order to achieve one QoL gained (Vanagas, et al., 2010). It is recommended that if the government plans to pump money into addiction field, it should invest money in the psychological issues first such as providing counseling during the treatment.
The improvement of quality of life in this study implied that methadone maintenance treatment has positive effects on heroin users’
quality of life. Although we used a validated and generic QoL
measurement instrument which is suitable for addiction field, there are still other outcomes that could not be precisely measured in
quantitative analysis.
In terms of the employment, the percentage of unemployment decreased after one-year follow-up, from 45.4% to 41.8%, which was same as the variation of unemployment levels (Godfrey, et al., 2004).
However, the percentage of unemployment in this study was
substantially lower than the percentage of unemployment in Godfrey’s study (from 88% at baseline to 83% after one year), which our study
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might overestimate because the participants who finished both baseline and one-year follow-up interviews (n=196) had higher compliance of taking methadone and higher probability of going off to work.
The wages per hour among participants who had jobs prior to and after one-year methadone maintenance treatment and also the sum of wages variation decreased. The more likely explanation is the 2008 financial crisis which resulted in the collapse of large financial
institutions, national government and stock markets around the world and this directly affected the job markets in Taiwan, especially most heroin users are blue-collar workers. As soon as the recession occurred, the Blue Collars had more chances to run into the employment
problems. In addition, we found out from the analysis that there were heroin users worked at part-time jobs tended to lose their jobs during recession. Therefore, providing methadone for heroin users helps them keep away from drugs. More important, providing behavioral skills training for seeking jobs would be beneficial for heroin users.
In the part of property crimes, the results show a clear relationship that as the year goes by the averted minimum and
maximum incarceration costs increase. However, the averted minimum and maximum incarceration costs in the part of drug-related crimes appeared not to be the same, both the minimum and maximum
criminal costs abruptly increased in 2004 then decreased in 2005, and soon markedly increased in the next two years. A partial explanation
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for this may lie in the fact that the Taiwan government initiated the methadone maintenance treatment program in 2005, resulting in the alternative substitutes of using heroin.
Finally, we found that methadone patients had to pay at least 35,390 NT dollars annually in order to receive methadone treatment. It is an economic burden for heroin users to pay considerable amount of money on the medical treatment, let alone that they are a subculture or minority group in society. Therefore, in terms of the sustainability and financial accessibility of the treatment, policy makers and health professions should consider the treatment costs from patients’
perspectives, lower the threshold and provide subsidies tailored to the methadone maintenance treatment.
5.2 Limitations
This study has a number of limitations. The first limitation concerns the research design that we chose which we compared the costs and effectiveness prior to and posterior to the methadone
maintenance treatment. Although the costs and the effectiveness could be compared based on theories, there were still a variety of
uncertainties which could not be avoided from a practical point of view.
Second, the study was limited to four hospitals in northern
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Taiwan. It is likely that the data might vary from area to area. Thus, the results of four hospitals in northern Taiwan could not be generalized to other part of Taiwan or Taiwan. Also, this study chose four hospitals in northern Taiwan which volunteered to participate in the methadone maintenance treatment program. Are these four hospitals
representative of all the hospitals in northern Taiwan? Not only the hospitals but also the heroin users in four hospitals were not randomly chosen from the population. Therefore, selection bias might occur.
However, the characteristics of methadone patients were similar to the characteristics of population in Taiwan.
Third, one year follow-up may not be long enough to assess the outcome. Studies should be undertaken to observe the long-term effectiveness of methadone maintenance treatment.
Finally, there were estimates that were not yet available in the literature; therefore, we validated various assumptions.
5.2.1 Cost
We only considered the costs from the perspective of patient to represent total costs. However, there were still a variety of costs that could be contained in the study, such as personnel costs, facility costs and utility costs in the hospitals. Due to broad categories of costs, we only collected the costs which heroin users might be incurred.
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Treatment costs are partly subsidized by the government according to the subsidy regulation of Centers for Disease Control;
however, the government subsidies were not considered in this study because each heroin users might receive different subsidies in terms of their various conditions and complicate the analysis. Therefore, we assumed that the heroin users in this study had to pay all the treatment costs without government subsidies in order to examine how much money heroin users had to pay if there were no government subsidies.
Also, treatment costs were calculated according to the subsidy regulation of Centers for Disease Control. Treatment costs listed in Table 4 does not mean every heroin user receive all the treatments or examinations, in fact, whether or not conducting such treatments or examinations depends on doctors’ prescription and hospital’s usual ritual.
We assumed that all the heroin users rode scooters to the nearby hospitals from their home and then went back to their home after taking methadone in order to calculate the travel distances and the traffic costs.
However, it is very likely that the heroin users might go to work or go to other places after taking methadone rather than go back home.
Therefore, we probably underestimated or overestimated.
In this study, we ignored the opportunity costs in this study, such as the productivity loss from participating in methadone maintenance treatment and the cost of police time spent on dealing with crimes. We
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assumed that taking methadone everyday might have effects on their works but the effects were rather negligible and also the costs of police who spent time on dealing with crime were rather inestimable.
However, the ignorance of the opportunity costs has resulted in underestimation of methadone maintenance treatment costs.
5.2.2 Benefit
There were 189 (31.55%) heroin users who completed the WHOQOL-BREF questionnaires both at baseline interview and the 12-month follow-up interview. It is likely that the participants who completed the interviews were those punctual and with higher
compliance. This study did not consider the quality of life of drop-out heroin users, thus the incremental quality of life gained might be overestimated or underestimated.
In this study, most of the incarcerated heroin users were sentenced for less than 6 months during methadone implementation time period; however, while the period of non-methadone
implementation, we applied the interval of prison term which was in the criminal law. Therefore, the estimate of the incarceration costs might be overestimated.
Penalties for criminal cases after implementation of methadone maintenance treatment were calculated in Table 15. We
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collected the criminal offenses from the Ministry of Justice which had been completely investigated; however, the criminal offenses provided by the Ministry of Justice were only property crimes which the
drug-related crimes were not included. This is because that the
first-use of heroin were placed on probation which most individuals in this methadone maintenance program were placed on probation, thus the criminal offenses of the drug-related crimes might be
underestimated.
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