In-Depth: How digital health technologies can help the United States address the opioid epidemic

By Laura Lovett

Although generations of Americans have struggled with opioid addiction, what was once seen as a peripheral drug problem has lately hit the American public with force. Opioid overdoses have become so common that they are the number one cause of injury-related deaths in the United States, according to CDC reports. In 2015 alone opioids were involved in 33,091 deaths, according to the agency. The nation has also seen a rise in fentanyl, a particularly potent opioid.

The US government has begun to take notice. In the fall President Donald Trump declared the epidemic a “National Public Health Emergency.” The announcement brought the epidemic to the forefront, however, it only meant $57,000 in new funding towards solving the crisis.

But the government and innovators at large could be looking to digital health technologies as a promising approach to addressing the crisis.

Executive branch efforts

In November, the White House released The President’s Commission on Combating Drug Addiction and the Opioid Crisis report. The report encourages more digital technologies to address the crisis. It goes on to specifically mention wearables that could automatically inject naloxone when blood oxygen levels become low as well as apps that function as behavioral coaches.

Other departments within the government have began to address the crisis as well. In December, the Department of Health and Human Services hosted a code-a-thon to address the opioid crisis. Innovators from across the country were invited to compete for one of three $10,000 prizes and contribute ideas towards solving the epidemic.

“We are teaching the department that there are all these people around the country that are willing to help out and it is was important for us to address this problem with humility,” Bruce Greenstein, chief technology officer at HHS, told MobiHealthNews. “Basically we are saying we need help and we reached out to the tech, innovation, and data community.”

The code-a-thon was born out of an HHS Enterprise Strategy initiative, which sought to “unleash the silos of data from across departments,” according to Greenstein. From that, Greenstein and his team were tasked with using the data to work on the opioid epidemic.

HHS hosted more than 50 innovator teams from across the nation, with participants competing in three categories: prevention track coding, treatment track coding and usage track coders.

The products developed by competitors ranged from a tool that identifies illicit online pharmacies and reports them to authorities to a tool that predicts where there is an opioid outbreak.

“We are not only bringing together the winners,” Dr. Mona Siddiqui, chief data officer at HHS, told MobiHealthNews, “but other solutions we found promising at the state level and local community [level] to help facilitate those connections so they can get further.”

The Origami Innovation team won first place in the treatment category for its system that tracks overdoses in real time, which allows first responders and health authorities to prepare for outbreaks, according to the HSS webpage.

“For us the trend surfacing was using information in a consumable and actionable way that allows people to change their behavior,” said Siddiqui.

The other winners included the Opioid Prescriber Awareness Tool, which allows physicians to see their opioid prescribing habits compared to their peers. The Visionist Inc.’s Take Back America, focuses on take back programs at pharmacies where opioids can be returned, won in the prevention category.

Startups focus on prevention

Prevention tools have been one of the focuses in solving the epidemic. Social venture startup The Edification Project is among those working on prevention tools. The team plans to bring virtual reality into schools to help teach children and teens about the dangers of addiction — think in-school programs like D.A.R.E but with virtual reality and a different methodology.

The project is still in its infancy and the startup is figuring out what the experience will look like. One idea the team has is for students to use the technolgoy to virtually make decision and that leads them to a certain outcome, said founder David Murray.  For example, the experience may put teens in a virtual house party situation where they can either choose to virtually try drugs or not. Then the experience will lead them in a new direction based on that choice.

“It is almost like the ghost of Christmas future,” Murray said.

In its first phase the startup plans to pilot and test a theory-driven, evidence-based prevention program teaching students how to handle situations where they may have to say no to drugs.

The Edification project was selected as part of the PULSE MassChallenge class of 2018, which gives digital health startups access to free office space, partnerships, $200,000 in prize money and $50,000 in need-based scholarships.

But that isn’t PULSE MassChallenge 2018's only startup  focusing on the opioid epidemic. Epidemic Solutions is currently developing a wearable that detects when someone is overdosing. The wearable then contacts a family member or friend so that they can either get narcan to the wearer or call first responders.

Narcan has frequently been called a “miracle drug” because it reverses the dangerous effects of an overdose.

“The problem with narcan is it requires someone to administer it,” Dr. Joseph Insler, cofounder of Epidemic Solutions, told MobiHealthNews.

That is where Epidemic solutions comes in. Eventually the team wants to develop a wearable product that could actually administer the narcan after detecting an overdose.  

“With opiates it just takes one [time overdosing] and it is such an incredible loss of life at a young age,” Insler, who is also a psychiatrist specializing in addiction, said. “We thought about how can we solve this increased risk and give them a chance to recover.”

Insler described the device as more of a preventative measure until the patient could get treatment, which should include behavioral therapy, medication assistance, and overdose prevention.

Treatment and telemedicine

Many in the field are talking about the role of telemedicine in treating the opioid crisis — particularly for people who live in rural communities. In fact, even the President has discussed turning to telemedicine to treat the epidemic. When Trump declared a public health emergency in the fall he pledged to allow for the expansion of telemedicine services, including services involving remote prescribing of medicine commonly used for substance abuse or mental health treatment, according to a statement issued by the White House. However, the announcement did not include any of the specific logistics.

It is commonly agreed upon that replacement medications such as Buprenorphine and methadone are key to treating opioid addiction. However, most patients are required by law to at least meet face to face with their doctor before being prescribed the medication. Telemedicine policies such as these vary state to state.

In November telemedicine came into the spotlight again when a Maryland doctor broke the federal law and prescribed suboxone to recovering addicts living in a remote part of Appalachia, Politico reported. While doctors can treat addicts through telemedicine, a 2007 federal law requires doctors to see patients in person before starting telemedicine, according to Politico.

Still, many see telemedicine as the way of the future for addressing the epidemic. Jamey Lister, a social worker and assistant professor at Wayne State University, said it could be particularly useful for treating patients in rural areas where there are fewer doctors — and of them only a small amount of whom treat opioid addiction.

Lister said that isolated parts of Michigan, for instance, are a good example of where a telemedicine program could work.

“Where it could really help is Upper Peninsula in Michigan, where there are roughly 300,000 people and a just handful of providers in the whole area,” Lister told MobiHealthNews. “So what could happen there is you might be able to have a doctor there from lower Michigan who could consult with someone in the upper peninsula. That might open up more possibilities for people.”

Often when people are using telemedicine for substance abuse treatment, the patient still goes to a clinic to talk to the provider but communicates with the provider via a video communication platform like Skype.

Lister, who recently published an essay in The Conversation about the role of telemedicine, said that many people struggling with opioid addiction may even prefer telemedicine,noting that in small town there is less privacy. But it isn’t just rural areas that could benefit,  — it could also be helpful to people who don’t have access to transportation, particularly people living with poverty.

One app is now looking to actually treat opioid addiction remotely. Pear Therapeutics is currently working on a prescription digital therapeutic to treat individuals recovering from opioid addiction.

Pear Therapeutics’ reSET, which treats various addictions with cognitive behavioral therapy, was the first software-only digital therapeutic the FDA cleared with claims to improve clinical outcomes in a disease.

In October reSET-O, which is specifically designed to treat individuals recovering from opioid addiction, received an Expedited Access Pathway (EAP) designation from the FDA.

“What Pear does and the origin behind the name, is pairing drugs with therapeutic software,” Dr. Yuri Maricich, chief medical officer and head of clinical development at Pear, told MobiHealthNews.

reSET-O combines cognitive therapy with a prescription for Buprenorphine, a drug used to assist people addicted to opioids recover. Patients receiving Buprenorphine are required attend cognitive therapy while taking the drug. But that can be difficult for some patients because limited number of doctors and the distance to facilities, especially in rural areas.

“While there are multiple reasons why a patient might not be getting their behavioral therapy the fact of the matter is many don’t,” Maricich said. “reSETt-O allows patients to not only get access to that therapy but if provides it in a way that is on demand. So rather than only getting behavioral therapy when they are able to get to a medical provider, they are able to get their therapy at any time, particularly when they are experience a craving.”

The product also allows patients to report triggers and cravings, as well as report and test for substance use. The information is then shared with the medical provider. Both reSET and reSET-O are designed with a patient and provider interface to reinforce doctor-patient relationships and help extend and support the clinician, according to Maricich.

“It encourages open communication and effective dialogue with the clinical provider to support the clinical provider in providing better care,” Maricich said.

Another company, emocha, is using video and mobile technology to help physician remotely monitor adherence of opioid substitutes.

“The therapies that exist for opioid addiction, for example methadone, only work when they are taken,” Sebastian Seiguer, CEO of emocha, told MobiHealthNews. “By securing medication adherence, in this particular population, we can see patients retaining care and help make sure they are successful.”

Patients using this system login with a smartphone application. They can enter any side effects that they encounter and record a video of themselves taking the pill on camera. This is then sent to the provider.

“Being a clinician myself I think there is value in the system,” Dr. Bob Bollinger, an advisor at emocha and professor at Johns Hopkins University, told MobiHealthNews.  “It can identify a patient that is having difficulty taking their medication and also provide a provider with additional details about what time of day, where they were, and how they were feeling at the time they missed their does. And with that information … [doctors] can help identify what that individual patient’s issues are and [it] can help us design outcome interventions.”

The company started out focusing on tuberculosis adherence but, like so many digital health companies, has begun to look for ways to fight the opioid epidemic.

Digital health technologies can intervene at many points to prevent opioid- related deaths whether its preventing users from starting at all, like the Edification project, or administering lifesaving Narcan, like Epidemic Solutions. While the United States struggles to control the epidemic, digital health endeavors like these could prove to be an important part of the solution.