Cost-Effectiveness of Transcranial Magnetic Stimulation for Methamphetamine Use Disorder during Pregnancy.

BACKGROUND

Methamphetamine use disorder (MUD) during pregnancy is associated with adverse maternal and perinatal outcomes, including increased risk of preterm birth, cesarean delivery, neonatal intensive care unit admission, placental abruption, and maternal or perinatal death. For the few evidence-based treatments for MUD, including transcranial magnetic stimulation (TMS) and injectable naltrexone with bupropion combination, there are few data available for pregnant individuals.

AIMS OF THE STUDY: We completed an exploratory model applying existing knowledge in clinical practice and available research to examine the potential cost-effectiveness of TMS compared to the combination of injectable naltrexone with bupropion or care as usual in a population of pregnant individuals with MUD. We aim to utilize the outcome of this analysis to inform future trial designs that examine TMS efficacy and safety in MUD during pregnancy.

METHODS

A decision tree model was developed to evaluate the direct medical costs and clinical outcomes of TMS compared to injectable naltrexone with bupropion or usual care for pregnant individuals with MUD. The analysis included three strategies from the start of pregnancy through delivery, focusing on mode of delivery, gestational age, and infant birth weight. The primary outcome was the percentage of full-term vaginal deliveries of infants with normal birth weight. The analysis was conducted from a third-party payer perspective, considering only direct medical costs, and used a $50,000 willingness-to-pay threshold to determine cost-effectiveness.

RESULTS

In this experimental model, TMS demonstrated the lowest overall cost and highest effectiveness, yielding 76% full-term vaginal deliveries with normal-weight infants, compared to 44% for injectable naltrexone with bupropion combination and 39% for no intervention. Sensitivity analyses confirmed the robustness of TMS as a cost-effective intervention.

DISCUSSION: Our exploratory model found that TMS was cost-effective compared to injectable naltrexone and bupropion or usual care, potentially improving outcomes at low costs. This study provides preliminary data supporting TMS being a promising cost saving option for MUD during pregnancy. The study's limitations include absence of direct TMS efficacy data in pregnant populations, necessitating the use of extrapolated data, small sample size, and short-term nature of efficacy data in non-pregnant populations. Additionally, there was insufficient data on the adverse effects of the interventions on fetuses and infants, highlighting the need for studies to confirm safety and efficacy.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Both TMS and the combination of injectable naltrexone and bupropion show potential for treating pregnant individuals with MUD. However, neither treatment is FDA-approved or extensively studied in this population. If TMS proves to be a cost-effective and safe treatment option, it could significantly improve maternal and perinatal outcomes.

IMPLICATIONS FOR HEALTH POLICIES: Excluding pregnant individuals from MUD clinical trials limits evidence on treatments for this population. Funding large clinical trials focused on pregnant individuals with MUD is crucial.

IMPLICATIONS FOR FURTHER RESEARCH: Limited data exist on the safety of TMS and injectable naltrexone with bupropion for fetuses and infants. Future research is crucial to update this model, confirm safety and efficacy, and explore perinatal outcomes for MUD in pregnancy, ensuring optimal care for this population.