The Private Addiction

America currently has a heroin problem, and those of us on the front lines have seen it firsthand. It is glaring at us with a doubling of the population using heroin, as well as an increase in hospital admissions for complications resulting from substance abuse.^1,2 With the Institute of Medicine’s (now the National Academy of Medicine) recent publication calling for the development of evidence-based standards for mental health and substance abuse disorders, there is renewed interest in understanding how best to curb this disturbing trend.³

Beyond the individual and public health benefit, I have gained a new appreciation for the impact of substance abuse on healthcare expenditures and services. Although the government has borne the greater share of substance abuse treatment in the last few decades, limited state and local funding has necessitated a recent increase of private insurance and out-of-pocket spending for substance abuse treatment.⁴ Furthermore, patients with drug dependence are likely to present to the hospital with severe medical conditions²—heroin abuse in particular leads to skin, respiratory, and cardiac conditions that require costlier and longer hospital stays.

While some benefit managers may view this increase in substance abuse treatment spending as another expense that must be managed, I view this as an opportunity. The prior year-to-year pattern of spending unintentionally favored treating substance abuse patients once they had costly complications.⁴ With an increased share of the spending with the private sector, there is room for innovative models that can prevent those costly complications from even happening. The suburban mother with a new broken bone and a susceptibility to addiction will be monitored more closely for her narcotic prescriptions. No longer will the asthmatic who inhales heroin present to the emergency department with chest pain and an asthma exacerbation, and he can also be remotely monitored for worsened breathing before it becomes an acute issue.

In fact, there are many start-up companies that intend to change the face of mental health and substance abuse. 1DocWay, which aims to provide telepsychiatry and in-person services to increase access to underserved communities in a cost-effective model, recently received funding from Village Capital, a venture firm, to grow their services. Additionally, Wellframe, a care management platform, has created a mental health product that allows clinicians to engage with patients and to provide a touch point at their time of need. The program Joyable provides coach-supported cognitive behavioral therapy, an evidence-based psychotherapy treatment for mood disorders, which is frequently associated with substance abuse. Ginger.io tackles the mental health issue using big data, claiming to use self-reported information to identify those who need assistance in the population. Perhaps new innovative primary care models will integrate mental health services to ensure appropriate prescription opiate drug use and encourage strong monitoring of those who are predisposed to substance abuse.

However, the demographics of patients with substance abuse are changing. In the last decade, there has been a 60% increase in the prevalence of heroin abuse among people with private insurance.¹ Although substance abuse still represents a small fraction of private spending, this sector will need to take a leadership role in identifying and treating at-risk and vulnerable patients before they become dependent on public funding sources.

There is no question that we are in the midst of an innovation burst in healthcare. Let's continue to encourage the brightest minds to solve our toughest problems, including those within mental health.

1. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR. 2015;64(26):719-725.

2. Choi H, Krantz A, Smith J, Trick W. Medical diagnoses associated with substance dependence among inpatients at a large urban hospital. PLoS ONE. 2015;10(6):e0131324.

3. IOM. Psychosocial interventions for mental and substance use disorders. Institute of Medicine; 2015.

4. National expenditures for mental health services and substance abuse treatment, 1986-2009. Substance Abuse and Mental Health Services Administration; 2013. [HHS Publication No. SMA-13-4740.]