About the authors: Dr. Sofia Noori (@sofianoori) was a member of the 2019 Flare Capital Partners Scholar Class and is currently a psychiatry resident at Yale School of Medicine. She is the curriculum lead for Innovation to Impact, a substance use entrepreneurship program funded by the National Institute for Drug Abuse.
Dr. Dan Gebremedhin (@dangebremedhin) is a partner at Flare Capital Partners, a healthcare technology and services-focused VC Firm. Prior to Flare Capital, he served as a practicing physician at the Massachusetts General Hospital, a medical director at the Harvard Pilgrim Health Plan and an entrepreneur in the health IT industry.
Substance use disorder (SUD) has reached historic proportions with significant consequences. In the United States, roughly one out of every 12 adults has suffered from substance use disorder in the past year alone. When considering the impact from crime, lost productivity, and healthcare, SUD costs the U.S. over $740 billion annually. With the ongoing trauma of the coronavirus pandemic and social isolation, Americans are struggling now more than ever with substance use.
Given these startling numbers, it's surprising that obtaining effective and lasting treatment for SUD is still a challenge. The reasons for this systematic underperformance in diagnosing and managing SUD are not dissimilar from the challenges in treating broader behavioral health conditions – which we’ve previously written about extensively. Our current system struggles with inadequate screening, unaffordable and limited access, and poorly tailored treatment form factors. The significant unmet need in managing SUD has many calling for an overhaul as demand for innovation from payers and employers is reaching a fever pitch.
Thankfully, there is a growing cadre of passionate entrepreneurs who are utilizing innovative technology and service models to rebuild our SUD treatment system from the outside in. In our review of the landscape, we’ve highlighted five keys we believe are crucial for new entrants to effectively impact this population. We’ve also highlighted notable early-stage companies employing these techniques to improve the quality, outcomes and overall cost of substance use treatment.
Access the population
The access problem in U.S. behavioral healthcare is well documented, as a staggering 89% of people who require SUD treatment do not receive it. A surprising and often overlooked statistic is that an overwhelming 95% of this population, 17 million Americans, do not receive SUD treatment, because they are in denial about having a substance use disorder. The vast majority of Americans with SUD don’t identify with needing treatment. Thus simply providing access to SUD services is likely not enough to tackle this challenging behavioral health condition.
We encourage new tech driven entrants to not be overly passive in waiting for patients who need SUD treatment to access their services. To be clear, it is paramount to respect patient confidentiality and anonymity when managing a SUD diagnosis. That said, we are starting to see SUD-focused digital health companies working with payers, providers and employers to proactively market their services and increase awareness of SUD management programs. We anticipate startup companies will increasingly leverage available population health data and analytics while respecting confidentiality, in order to selectively engage patients at highest risk for SUD.
For populations who do seek SUD treatment, roughly 40% of the population, or 351,000 Americans, cannot find appropriate treatment. Long wait times to rehabilitation programs, high costs and variable quality of existing treatment have plagued the SUD treatment industry for years. Solutions that can increase access to high-quality treatment by shortening wait times and increasing convenience for both urban and rural populations stand a better chance to add value in the industry.
Multiple innovations have emerged to increase access and offer intermediate levels of treatment, including treatment programs that people complete from their homes. Companies such as WorkIt Health, Boulder Care and Bicycle Health provide substance use counseling and treatment through telehealth or online modules. These tech-forward new entrants are also experimenting with innovative ways of reaching potential patients through both direct-to-consumer and enterprise-facilitated channels.
We believe this new class of digital-first treatment programs, combined with respectful targeted marketing, will begin to solve our decades-old access and utilization problems.
Minimize Stigma, Offer Respect
Stigma, specifically with respect to SUD, is defined as an attitude, behavior or condition that is socially discrediting. Several studies have shown the language used when describing patients struggling with SUD creates a stigma that serves as a hidden barrier to accessing treatment. As many as 37% of people do not disclose a SUD for fear of social stigma, which likely contributes to the huge proportion of adults who are unwilling to acknowledge they may need help.
Society at large is not alone in its negative perception of people with SUD: Healthcare professionals also perpetuate harmful stigma toward SUD patients. Doctors have been observed to avoid populations labeled with SUD for fear of unwarranted "dangerous and unpredictable” behaviors.
Our perception is that sources of stigma are rooted in the archaic notion that substance use disorder is a "moral failing," In order to effectively treat SUDs, we believe innovators must also educate relevant populations regarding the defined physiological, psychological and social reasons why substance misuse and use disorder occur. By offering solutions that minimize stigma and create treatment environments that promote client dignity, innovators can dissolve a hidden barrier to care and increase reach and engagement.
Innovative companies like Groups and Tempest are designing person-centered solutions that target stigma head-on. Groups operates freestanding opiate-use-disorder clinics that are a safe space for patient populations. Peer support and group therapy, which have been shown to reduce self-stigma, is a main component of the Groups treatment model. Tempest, formerly known as Hip Sobriety, is a web-based treatment platform, complete with blog and podcast, that normalizes open SUD discussion and promises to “put people at the center of their recovery.”
Treat the Whole Person
The umbrella diagnosis of “substance use disorder” is a not a one-size-fits-all condition. A simple SUD diagnosis can obscure the breadth of triggers, causes, comorbidities or risk factors that affect unique populations. Given the diversity of complicating factors, research suggests an individualized, person-centered SUD treatment approach is most effective. A person-centered treatment strategy incorporates associated behavioral health or medical conditions, relevant social and economic factors, and shared decision-making to engage patients in their care.
A key leap in person-centered SUD treatment is the development of medication-assisted treatment (MAT). Medications such as buprenorphine, which prevents withdrawals and cravings for opiates, have redefined evidence-based treatment for SUD by targeting biological causes of dependence.
As support for medication-assisted treatment grows, there has been a marked tendency to distribute these medications as treatment alone, when they should be prescribed in concert with therapy or counseling. By opening high-volume, cash-only “suboxone clinics," some providers are ironically mimicking the practices of the original “pill mills" – freestanding clinics with irresponsible and illegal opiate prescription practices. Although MAT is an important component of treatment, models that overly focus on it may inadvertently cause more harm than good.
Early-stage companies such as Eleanor Health and 180 Health Partners are pioneering models of care that tailor treatment to specific needs of their populations. Eleanor Health has launched tech-enabled SUD clinics in North Carolina and New Jersey, and deployed multidisciplinary, integrated care teams designed to deliver “whole person care.” Nashville-based 180 Health Partners focuses on pregnant women struggling with substance use. The company’s treatment protocols include traditional SUD care combined with wraparound services and peer support tailored to each woman’s specific circumstances, with the common goal of a healthy, successful pregnancy.
Minimize harm from ongoing use
Statistics suggest as many as 85% of patients undergoing SUD treatment will experience relapse within a year of treatment. Despite the dogmatic belief that “abstinence only” is the correct approach to SUD treatment, the practical reality suggests patients will use again, and this discrepancy can undermine effective long-term recovery and safety. Stemming from this understanding, we’ve seen increased adoption of harm reduction: the practice of anticipating and working to reduce risk associated with continued substance use.
The benefits of incorporating harm reduction principles into a treatment protocol are threefold. First, harm reduction is an evidence-based approach shown to reduce morbidity and mortality. Second, these practices align with actual patient experience, which is marked by potential continued substance use or relapse. Finally, harm reduction solutions are inclusive; populations who are early in their understanding of their substance use disorder can be targeted, leading to awareness and potential enrollment into a treatment protocol.
Provider and industry views on harm reduction are rapidly evolving as we continue to deal with the dramatic epidemic of substance use disorder. Some public health examples of harm reduction are the increasingly widespread adoption of naloxone kits to help bystanders reverse opiate overdoses and needle exchange programs that reduce the spread of serious infections associated with intravenous drug use.
There are also clinical examples of harm reduction, where providers incorporate treatments and monitoring to temper ongoing substance use. One example is naltrexone, an FDA-approved medication for alcohol use disorder that reduces cravings and lessens the pleasurable effects of alcohol. The aforementioned tech-first SUD treatment company WorkIt Health offers naltrexone with appropriate therapy and coaching to help reduce a person’s alcohol use over time. Dynamicare Health is an early-stage digital-treatment platform that combines substance testing to monitor for risk of relapse with coaching and incentive rewards to support and motivate users through recovery.
We anticipate demand for solutions that preempt cravings, monitor for risk of relapse, reverse overdose and test for substance impurity. We expect early-stage companies to incorporate these strategies into their treatment paradigms for maximal impact.
Support the Lifelong Journey
Substance use disorder is a relapsing and remitting disease. The reality of living with a SUD means avoiding triggers, managing cravings and struggling through relapse. Like that of a chronic medical disease, treatment and recovery are often a lifelong journey.
There exists, however, a mismatch between the current treatment system that operates in acute “episodes of care,” and the long-term support that most people need for lasting recovery. Our existing treatment options – like a stint in rehab – are almost entirely time limited. There remains significant unmet need for long-term support services.
Opportunities abound to fill the gaps in the treatment continuum. Some specific examples of these services are patient navigation, on-demand support and fostering a lifestyle and community around recovery. SoberGrid, an app-based product, helps people in recovery create a community that supports one another in their journey. The Phoenix is a remarkable network of nonprofit gyms that bills itself as an active sober community, charging a membership “fee” of 48 hours of sobriety. Through fitness, the Phoenix helps its community abstain from substances while improving their health and well-being.
We anticipate early-stage companies will design solutions for a lifestyle of recovery. By providing continuous support and treatment, market entrants can drive long-term engagement and customer lifetime value.
Substance use disorder is a centuries-old problem, now reaching epidemic proportions in the U.S. The current coronavirus pandemic will only increase the existing need and demand for SUD treatment. As we address needs for innovation, there is an opportunity for new entrants to disrupt traditional models of care. By creating thoughtful, person-centered approaches to recovery, early-stage companies can reverse epidemic trends and begin to heal our communities. We believe these new tech-driven approaches will be key to creating impact and positively disrupting our status quo.