This week, the Centers for Disease Control and Prevention released a stunning report that showed drug overdose deaths shot up 30% in 2020. While the pandemic has led to increased distress among Americans, it’s also opened the door for innovation in certain aspects of mental healthcare, especially around addiction. Rehabilitation programs—ranging from 12-step programs to medication-assisted therapy—all went online. Now, a cadre of startups are thinking about how they can leverage the boom in telehealth to deliver better addiction care.
Historically, in-person substance abuse treatment has been a jumble of 12-step programs, religious residential centers, luxury sober houses, cognitive behavioral therapy, group therapy, detox centers, medication clinics, and peer support. Programs are not standardized, and relapse rates among people with addiction who try to stay clean is high. About 30% of people in substance abuse programs drop out. The question is, can apps help people stick with their treatment programs?
Affect Therapeutics, a company founded in 2020 amid the pandemic, is using game-design thinking to tackle methamphetamine addiction. During the pandemic, psychostimulant-related overdose deaths, including those from methamphetamines, went up 34.8%, according to CDC data. The Affect app isn’t live yet, but in a prototype version, a home screen lists challenges and tasks that a person can choose to complete. For example, if you complete a drug screening test, the app rewards you with 5,000 gems (an in-app currency) and $25 cash. Alternatively, a person might rack up extra points by finding a community meeting for former methamphetamine users.
“The core of what we’re focusing on in this app is around engagement and being able to create compulsion loops [that make users] return to this app day after day and again and again,” says Rachel Lin, head of product at Affect and a former product manager at Uber. She says the app uses the same mechanisms that keep people invested in a game to keep them progressing in their treatment. The app itself is paired with out-of-app care. Affect users are assigned a care coordinator as well as a psychiatrist and a licensed recovery coach or peer advocate—often someone who has been through addiction care themselves.
Neither Lin nor the company’s chief technology officer, Russell Osborne, have experience in healthcare or addiction treatment. However, Osborne says the work he’s done engineering various e-commerce products is highly relevant to the work he’s doing now. “A lot of tools we’ve created for the e-commerce world around retention, engagement, and conversion management, retargeting, are directly applicable to helping people through a recovery journey.”
Online addiction care is growing
Affect is one of three tech companies involved in addressing addiction that were cofounded by Jeff De Flavio, a doctor and entrepreneur-in-residence at Alley Corp, an early stage venture fund and incubator in New York. Tempest is a sobriety platform for women who have struggled with drinking. It’s stickiness factor is that its curriculum and support system is lifestyle-driven, meant to easily integrate into a person’s life. The company offers a mix of online peer support, skill development around emotional regulation, workshops on friendship building, and one-on-one counseling. Its four-week intensive program costs $300, and its core membership is $59 per month.
Flavio’s other company is Groups Recover Together, an opioid recovery network that gives patients at-home access to Suboxone, an opioid alternative used to supplant an addictive opioid, along with care coordination and group therapy. It’s available in 11 states with two more on the way and offers both in-person and online care.
During the pandemic, while substance abuse was proliferating, people were seeking help online.
“There was so much concern over really guarding these medications and [making] these programs so regimented, and we saw that we don’t need to do that,” says Stephanie Strong, founder and CEO of Boulder Care. It’s now in 10 states, with Medicaid coverage in Washington and Oregon. Strong has been working to get her program into prisons to reach incarcerated individuals. Other relatively new entrants offering Suboxone inside of a largely digital experience include Ophelia and Bicycle Health. These apps also offer responsive help—they can get in touch with patients if they think they’re heading toward relapse.
There’s evidence that reaching people where they are works. During the pandemic, while substance abuse was proliferating, people were seeking help online. Sober Grid, a social app for people with substance abuse issues that’s been around since 2015, saw a 30% spike in use during the pandemic. Today, some 350,000 people use the sobriety social network in 170 countries.
It’s no secret that investment in virtual health has skyrocketed in the wake of COVID-19-related lockdowns. Last year, investors spent $4.9 billion on the category, according to Pitchbook data. Already this year, they’ve invested $4.37 billion. Addiction care is a small slice of that pie, but there are indications that it too is poised to grow. Boulder Care recently raised capital, bringing its total funding to date to $20 million. Bicycle Health raised $27 million in January, and Ophelia raised $15 million in April.
In its 2022 Medical Cost Trend report, PricewaterhouseCoopers wrote that healthcare spend is expected to be up 7% in 2021 and 6.5% in 2022. It highlighted the growth in substance abuse as part of the rise, not only for acute medical needs such as overdose but also for long-term negative health impacts from substance use disorders. For example, in its report, PwC says that between 2019 and 2020, hospitals in the U.S. saw as much as a 50% increase in admissions for alcoholic liver disease.
People who have achieved sobriety often cite strong support networks as part of the key to their own recovery.
Another opportunity in apps is the ability to create a sticky experience, as Lin describes. A bigger question is whether these apps can also integrate social experiences and facilitate a broader support system among people who are trying to get sober.
One of the most effective methods of helping people remain abstinent is Alcoholics Anonymous (and 12-step programs in general). It meets regularly, often multiple times a week, and recommends finding a sponsor, someone to call for no-shame conversations about getting sober. AA and other similar 12-step programs also recommend inviting family to celebrate milestone events like a person’s first 30 days or first year of sobriety. Family and social support is generally thought to improve outcomes for people with substance use disorder. Certainly, people who have achieved sobriety often cite strong support networks as part of the key to their own recovery. Many of these apps have social aspects to them or help patients connect to in-person meetings, though there’s a question of how far tech can go to replicate human connection.
“I have not seen any application right now that has aimed to actually provide a surrogate of that physical contact,” says Dr. Nora Volkow, director of the National Institute on Drug Abuse.
Volkow says that where apps really excel is in affordability and flexibility. NIDA and the National Institutes of Health have grant-funded several of the startups in this space, including Sober Grid and Boulder Care. She says apps can be especially helpful as a way of providing follow-up care after intensive in-person addiction treatment. She agrees that for substance abuse programs online and offline, the biggest challenge is keeping people engaged for the long haul. It’s a difficult problem to tackle, she says, because it can be so multifaceted.
To try and better understand the issue, she met with the manager of a well-run Baltimore clinic that provides methadone—another opioid alternative used to treat opioid addiction—and asked if she could speak with some of its patients. “I said, ‘Let me ask the people: What is making it difficult for them to stay in treatment at the methadone clinics?'” says Volkow. “Every single one of them said, ‘I don’t have a place to live.'” Instead of going to treatment, she says, these people had to figure out where they were going to spend the night. With many shelters, that means showing up at 1 or 2 in the afternoon and waiting in line to ensure they’ll get a bed that evening. “That becomes your priority,” she says.
Over the long term, according to Volkow, treating relapse and retention will require more integrative care that takes into account mental and physical health status as well as other environmental factors like housing. Nearly half of all people with a substance use disorder suffer from a co-occurring illness, according to 2018 data from the Substance Abuse and Mental Health Services Administration. Overcoming those obstacles will require more than a new app.