We have a problem with addiction and it’s something far more sinister than tapping your phone every 2 minutes to check for a dopamine hit from a flashing notification. Too many individuals living with substance use disorders (SUDs) have fallen through the cracks of the traditional healthcare systems due to lack of access to appropriate diagnostics and treatment, the stigmatisation of their condition or sheer lack of human resources for health to support their needs.

Dr Lipi Roy (Clinical Assistant Professor at NYU Langone Health and Kingsboro Addiction Treatment Center specialist) flagged a number of key considerations to keep in mind as we strive for better care for those living with, and being affected by, SUD:

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• Addiction is a chronic medical disease of the brain, relapse is expected (as it is with *every* chronic disease, e.g. diabetes, heart disease, lupus). It is NOT a sign of moral weakness or failure.

• Cost savings are massive: every dollar put towards addiction treatment saves $4 in health care costs and $7 in criminal justice costs.

• We need to widely implement harm reduction strategies, as well as other innovative methods including digital technologies, creative therapies, mindful practice, etc.

So, is digital a possibility for somewhat alleviating this burden? We think it just might be. However, we have some way to go before these solutions are seen at scale. It will ultimately take maturing of the evidence behind these solutions, the building out of reimbursement pathways, the buy-in of public health bodies and a shift in public perception - to name a few. But when has tech alone ever stood to make true change in healthcare?

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There’s no denying that the effort would be worth it whatever angle you’re coming from. The SUD burden globally is instrumental in determining the global disease burden with injectable drugs being linked to Hepatitis and HIV, smoking intrinsically linked to lung cancer, and alcoholism tied to other non-communicable diseases such as hypertension and stroke. It goes without saying that in order to tackle some of the most prevalent causes of mortality, such as the aforementioned, it will be critical to develop more effective diagnostics, treatments and supports for people struggling with addiction - things we have been largely unable to achieve with conventional efforts.

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In this week’s HealthXL blog we break out some of the most pressing SUDs, digital therapeutic and digital health companies attempting to impact their negative effect on public health, and some insights into what has worked in practice to date.

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Smoking cessation - Evidence based DTx stubbing out the habit?  

Smoking is the leading risk for premature death and disability globally. Despite striking mortality and morbidity rates, individualised support for smoking cessation has remained relatively unexplored with the majority of smokers foregoing proactive cessation support and resorting to seeking care when they become symptomatic.

Telehealth solutions and DTx represent a novel, accessible platform for helping smokers quit that really had no robust non-digital alternative to date and the evidence is mounting as highlighted by some of the studies produced by smoking cessation related startups below. Many of the solutions below fit under the prescription digital therapeutic (PDT) pool requiring a smoker to be recommended into the programme through their health plans or providers raising the question of how we can enable the scale of solutions that have been shown to work? This also applies to direct to consumer smoking cessation interventions. Ultimately this will take public health buy in to support consumers to access these applications. In addition to this prescription platforms, such as the Express Scripts digital health formulary, that can integrate into will likely be central to motivating clinical buy-in.

The value pool for smoking cessation has been clearly realised by investors who are pumping $$$ into the solutions that are focused on clinical efficacy but the real proof will be getting it into the hands of those who need it.

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Opioid addiction - A bitter pill to swallow: CBT, Prescription Platforms and Objective Pain Assessment

A turning point for realising the value of these digital to support the efforts against the opioid epidemic occurred with the landmark regulatory approval of Pear Therapeutics reSET-O app allowing clinicians to prescribe the solution alongside required medications. The reSET-O solution, specifically designed for opioid use monitoring, allows for more transparency in the patient-clinician interaction with patient-reported buprenorphine adherence connected to a Clinician Dashboard in addition to interactive treatment modules, CBT and other behavioural support features.

A number of years ago opioid prescribing was out of kilter in the US (to say the least) largely due to cases of misplaced trust and political sway however physicians are now very seriously questioning whether opiates are the appropriate course of treatment. One challenge for physicians was the worry that they were under-prescribing for painful recoveries or conditions which would leave patients in the lurch. With new remote monitoring solutions, and prescription platforms this worry is slowly diminishing - albeit in its infancy. Adjunctive pain management tools are also being explored such as musical therapy which was highlighted in a 2017 study from Harvard Medicals Brigham and Women's Hospital exploring personalised music as a smartphone-based mHealth intervention for acute and chronic pain management.

Beyond the direct treatment it will also be interesting to see how the underlying causes of the opioid epidemic may be addressed using digital levers. For example one core unknown in the prescription environment for pain management is how to actually measure pain. Despite many attempts at setting out frameworks for the clinical assessment of pain evaluation remains largely subjective. Digital tools, such as PainChek by ePAT, are now being explored to more objectively quantify levels of pain in order to arrive at increasingly valid prescriptions. However, for the time being this appears to be a more future gazing approach.

Another arena where technological advances may stand to support SUD is in advanced analytics such as those helping to identify users who need immediate help through data from first responders and helplines. One example developing in the US worth noting is the Overdose Detection Mapping Application (ODMAP) allows for real time mapping of overdose cases onto a centralised database allowing for insights that can help inform more effective responses.

Whatever avenue proves to be most promising, it is clear that compassion will have to be woven into the fabric of the approach with human coaching interactions, patient reported insights and a disregard for stigma around this genuine neurological condition.

Alcoholism - Identifying a hidden fault line

Conversely to opioid use disorders and the stigma associated, alcoholism has been excessively normalised in Western societies causing a challenge of diagnosis and identification - both by the health systems and individuals.

It’s estimated that upwards of 90% of those identified with alcoholism fall prey to relapse following treatment flagging a need for long term care that can be tailored to the individual needs, help identify triggers and provide motivation to stay on course.

For alcoholism the power of online communities, private telecoaching, and objective tracking of consumption are emerging as some of the most hopeful applications. Ria Health is one noteworthy solution who are working to address alcohol use disorder (AUD) claiming the ability to reduce drinking by 70% within the first 6 months through their app based coaching.

Others are taking a more objective monitoring approach such as BACtrack who are integrating a wrist based wearable sensor (currently only available for pre-order) with push notification to keep users motivated.

Ultimately however if a person living with AUD of other substance use disorders is not enabled by their environment to change their lifestyles these solutions will be at odds with forces far too great for any app, advanced analytics or sensors. It will require public health bodies to both be aware of and work in conjunction with these emerging solutions, clinicians and end users to determine what the best route to take may be in creating facilitative ecosystems.

Making digitised addiction management a reality

Once connected to the appropriate treatment and recovery services people living with addiction have a high likelihood of getting better but as we have flagged it is our own biases, lack of empathy and lack of resource allocation has failed all too many within this population to date. Digital technologies promise an accessible and potentially low cost alternative or adjunctive intervention for previously high-touch demands - we just need to figure out who the cream of the crop are and how to sufficiently retrofit our current system to enable true progress.