Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal

Ann Intern Med. 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.


Background: Opioid overdose is a leading cause of accidental death in the United States.

Objective: To estimate the cost-effectiveness of distributing naloxone, an opioid antagonist, to heroin users for use at witnessed overdoses.

Design: Integrated Markov and decision analytic model using deterministic and probabilistic analyses and incorporating recurrent overdoses and a secondary analysis assuming heroin users are a net cost to society.

Data sources: Published literature calibrated to epidemiologic data.

Target population: Hypothetical 21-year-old novice U.S. heroin user and more experienced users with scenario analyses.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Naloxone distribution for lay administration.

Outcome measures: Overdose deaths prevented and incremental cost-effectiveness ratio (ICER).

Results of base-case analysis: In the probabilistic analysis, 6% of overdose deaths were prevented with naloxone distribution; 1 death was prevented for every 227 naloxone kits distributed (95% CI, 71 to 716). Naloxone distribution increased costs by $53 (CI, $3 to $156) and quality-adjusted life-years by 0.119 (CI, 0.017 to 0.378) for an ICER of $438 (CI, $48 to $1706).

Results of sensitivity analysis: Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity and scenario analyses, and it was cost-saving if it resulted in fewer overdoses or emergency medical service activations. In a "worst-case scenario" where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the ICER was $14 000. If national drug-related expenditures were applied to heroin users, the ICER was $2429.

Limitation: Limited sources of controlled data resulted in wide CIs.

Conclusion: Naloxone distribution to heroin users is likely to reduce overdose deaths and is cost-effective, even under markedly conservative assumptions.

Primary funding source: National Institute of Allergy and Infectious Diseases.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Drug Overdose / prevention & control
  • Heroin / poisoning*
  • Heroin Dependence / drug therapy
  • Heroin Dependence / economics
  • Hospital Costs
  • Humans
  • Markov Chains
  • Naloxone / economics*
  • Naloxone / therapeutic use*
  • Narcotic Antagonists / economics*
  • Narcotic Antagonists / therapeutic use*
  • United States
  • Young Adult


  • Narcotic Antagonists
  • Naloxone
  • Heroin