Stephanie Papes is the CEO and Co-Founder of Boulder Care, a digital health platform aimed at changing the way we coordinate and deliver treatment for substance use disorders. She founded Boulder after spending time in investment banking and healthcare venture capital.
Dr. Amanda Wilson (MD, FASAM) is a board certified internal medicine and addiction medicine physician, focused on treating addictive disease. She is the Founder of a leading national group of outpatient addiction treatment centers, which have treated over 25,000 patients in 8 states.
Tim: The opioid crisis is now the leading cause of death for people under 50. The White House has called this a “health emergency.” How did we get here?
Amanda: It goes back to the early 90’s, to 3 concurrent events:
First, Oxycontin was heavily marketed to physicians. I personally remember a pharmaceutical representative providing “educational training,” saying, ‘finally, we’ve got an opiate that’s not addictive.’
Second, the joint commission deemed pain the new fifth vital sign. So all of the sudden, providers are rated and remunerated by how well they’re doing on pain management.
Third, the Mexican cartels became extremely skilled at delivering heroin. The architecture of what they’ve built for dispensing heroin across the country is actually pretty remarkable. Basic supply and demand economics brought about the rise of Fentanyl – a salt shaker of it is enough to wipe out Boston. So what’s about to happen to the country is actually scarier than what’s been happening.
Stephanie: We already see Fentanyl driving the next wave of the epidemic. It can be easily purchased online, in an e-commerce consumer shopping experience: websites offer 24/7 live support, assuring discretion and anonymity.
It’s simple and convenient to obtain illicit drugs from your own home. But the patient journey for obtaining drug treatment is just the opposite. There is the supply and demand dynamic, as well as a behavioral economics component: the current system makes it much harder to make the healthier choice. Boulder’s mission is to eliminate these barriers and deliver a frictionless experience to patients seeking treatment.
Tim: Taboos prevent people from seeking out treatment, or lead to a lot of external judgment. What are the sides of this disease that the average person assumes incorrectly or doesn’t really understand?
Amanda: What do they really understand? Unfortunately the vast majority of people really have no concept of the reality that patients who suffer from Opioid Use Disorder face, what they go through, and what addiction does to you. The single greatest thing is the absolute misperception of the nature, or root cause of this disorder. People assume that this is a human failing, that a weak person who just wants to spend most of their time high, who obviously doesn’t care about their family, isn’t interested in working, isn’t driven, lives under a bridge, and is using drugs because that’s all they care about. That’s the classic image that people have. And along with that image comes a whole heap of other judgments about how they should get better – that if they just rolled up their sleeves and prayed hard enough, and talked to someone who’s been there before and just pushed through, they’ll get better. It’s assumed if they aren’t getting better, the reason is they just don’t have enough moral turpitude to succeed. I think that’s the global picture, and it’s actually so very different from that.
Tim: How so?
Amanda: 15% of us are genetically inclined towards an addictive disorder, and the ones who are the most susceptible are at risk even if exposed to opioids for one week. On brain imagery, we see they’re lacking circulatory blood flow and delivery of dopamine to the frontal part of the brain once dependent. It’s this change in blood flow in the brain, and the disruption in the dopamine system that results in the behavioral changes that we witness in patients with advanced addictive disease. They are actually less and less capable of cogent, advanced decision making, and they are increasingly driven to replenish their brain’s neuro-chemicals or suffer severely. If you suddenly stop someone from taking painkillers, they start going into immediate withdrawal – sweating, nausea, vomiting – like the worst flu you’ve ever had. You’re functioning with a pre-adolescent thought process. Most of the symptoms of end-stage addictive disease are social: you may be homeless, your family won’t talk to you anymore, people lose their jobs. In this disorder, that’s what advanced disease looks like. They’re dying from their disease. And when you start treating it, guess what patients do? They get a job, and they take care of their kids, and they reestablish their relationships, their lives normalize.
Another misunderstanding is what treatment works for recovery. Families are told, ‘send him to Miami, and he’ll talk to other people with the same disorder in a group, and then in a month, he’ll come back cured.’ They’ll spend $35,000 on this. This is a chronic medical illness: we have to rethink the whole treatment model. It turns out medication treatment for addiction works 60% of the time, compared to rehab which on its own has never been proven effective for long term recovery for opioid use disorder. How about we try what works?
Stephanie: These misperceptions are influencing where patients seek medical treatment, how the government allocates dollars and how payors reimburse providers. If you see a moral defect that can’t be cured, you look to the criminal justice system for solutions. But reframed as a chronic medical condition that has efficacious viable treatments, like diabetes or cardiac disease, you see the need for longitudinal outpatient care, integrated into daily lives.
If your diabetic patients need to be on a regimen which includes insulin indefinitely, if that’s keeping them well, that’s what the FDA recommends providers ought to provide – and it’s very much the same with medication-assisted treatment for opioid addiction. The FDA just recently announced that many patients will require and should be provided the option for indefinite medication assisted treatment because the efficacy is well understood. Patients achieve and maintain recovery much more successfully with medications compared to without, much like heart disease patients lead longer more productive lives with the right medication combinations and they may be needed lifelong.
Tim: This all feels like a powder keg…
Amanda: There are two huge concerns. One is that there are far more people dependent on opioids than is even understood, and they’re increasingly getting exposed to more and more potent opioids, placing them at increasing risk of overdose. The rates continue to climb. I fear that there’s also a pendulum swing happening. 100 million Americans are being treated for chronic pain, and a majority are on prescribed opioids right now. What’s going to happen when providers, motivated to prevent addiction and dependence, start saying ‘we’re just not going to prescribe opioids anymore?’ Already dependent people will continue to need opioids, and the cartels are going to meet the need with illicit opioids. This pattern has been seen in Massachusetts, where prescribers have decreased opioid prescribing by 15%, but the incidence of overdose continues to rise at a staggering rate.
Tim: So in trying to do the right thing, you actually end up creating an artificial spike in demand?
Amanda: The numbers show that these swift crackdowns increase heroin use. We need better emphasis on proper pain treatment, but also on how to properly wean patients off of opioids if they are no longer necessary and how to better identify patients who’ve developed addiction and get them into long-term treatment.
Stephanie: The system is fragmented and broken, so policies often result in unintended consequences. Current care is silo’d and so isolated that patients admitted to the ER are released with no follow-up; they cycle through detox and drug courts and cannot find quality care. Our prisons severely lack appropriate healthcare treatment for opioid use disorder. They have thousands of people each day suffering abrupt detox and not provided access to medication assisted treatment. When they are discharged, no follow up care is provided in the vast majority of cases for their addictive disease. The overdose rate after incarceration is 39 times higher.
Tim: I would imagine that care for this kind of patient population is trickier than most, because even if there’s a strong desire to get better, they’re being subverted at every turn by a brain that’s not theirs anymore, which makes it very difficult to keep track of them.
Amanda: Exactly. One of the key pieces then becomes care coordination, because they fall out of the system through cracks. Patients suffering with addiction get picked up by police for carrying substances, end up on probation or placed in detox, and there is absolutely zero connection between any of those things and long term treatment that’s effective. Addiction providers try to create as much of an ecosystem as we can, but it’s so much more limited. Digital solutions like Boulder are the hope for bridging some of those gaps using technology while treating this like the chronic disease that it is.
Tim: How big of an impact on awareness – how much of that in the public consciousness is a result of it finding its way from inner cities into affluent suburbs?
Amanda: Everyone I knew thought I was crazy to change my career trajectory, become an addictions specialist, to take care of ‘those people…’ Now most people I talk to have 1 degree of separation from addiction, someone close to them, family or friends, neighbors or close contacts are suffering.
There is still a broad lack of education around the disease. By modifying access to proper treatment we really could see a tide change where less drugs come into the country because people are getting proper care, and with the right medications the demand for illicit substances goes down. Every recognized health organization (World Health Organization, National Institute of Drug Abuse, National Institute of Health) has said that the first line of treatment should be medication-assisted therapy (MAT), but there are still many perceptual barriers and biased judgements not based in science that prevent people from accessing this effective care. Largely, patients still are sent to inpatient rehab treatment and never connected with a MAT provider. This care is upside down. We no longer admit patients with heart disease as first line therapy to the hospital. We shouldn’t be doing this in addiction care either.
Stephanie: We know this modality is clinically effective, but finding good care is still challenging. There are providers offering buprenorphine prescriptions for cash, without proper medical oversight… some methadone clinics look more like a warehouse than a doctor’s office…
Tim: There’s one not far from my apartment in Manhattan – it doesn’t look particularly inviting…
Amanda: Would you tolerate that if you had any other medical illness? If you had Crohn’s Disease, would you tolerate it if your doctor told you that you were going to have to stand in a line at 6am for your meds every day?! We’re going to look back on this in 50 years and think like we think now about the way we treated psychiatric patients, about the way we hospitalized them, like in One Flew Over the Cuckoo’s Nest, and we won’t believe we were doing this to human beings with a chronic disease.
Stephanie: High-quality centers also face hurdles. The ‘not in my backyard’ mentality is pervasive. We think digital solutions are a way to overcome this, and so is getting addiction treatment integrated into primary care offices: settings where patients can be in the waiting room without anyone needing to know why they’re there. The only way to combat a disease of this scale is to help more providers be willing – and able – to treat patients. We see tremendous opportunity for technology to help achieve this.
Tim: What else can we do to change the narrative in addition to those things? Can we even talk beyond that – or is there so much ground-level work that needs to be done before we can get to anything creative?
Amanda: We have to change the way we think about treatment, focusing on medication assisted therapy, and the things we know work. Insurers are finally recognizing this is the proper treatment. So there’s been a shift there, but it’s just the start of the curve. This was thought of as a criminal problem, and that people who use heroin are people you should put away. That is also shifting because there are judges and politicians who are losing kids. It’s so rampant, and I think that unfortunately that has probably caused most of the perceptual shift, the movement of this disease into suburban and rural America. It’s insane. Every 3 weeks, the same number of people die from overdose as died on 9/11. 142 people die every single day, as reported by the Opioid Commission’s Interim Report in August, it’s a travesty.
Stephanie: The education about the medical treatment is really important, and what Boulder is trying to do is marry proven clinical modalities with community and social networks. This is a social disease, it’s truly in communities, in families and in friend groups. So if you really want to make a change and start seeking treatment, you might start rebuilding your social network and changing who you’re hanging out with and who your kids are playing with. It’s a major progression in life, and we think there’s such opportunity to be connecting people so they can talk about what they’re going through. We can harness digital technology to integrate the ongoing peer support with the medical treatment.
Tim: Stephanie, I know this is something you’ve been passionate about for a while now… first as a VC, and now as the Founder of Boulder Care. Want to tell us a bit about what you’re building?
Stephanie: Boulder Care harnesses the accessibility and privacy of mobile technology to deliver a proven approach for treating opioid addiction.
Through a personalized combination of behavioral therapies, medication, and psychosocial support, Boulder empowers patients to achieve the goals that matter most to them, all delivered through a mobile device.
For payors and providers responsible for patient health, Boulder’s digital solution enables compassionate, team-based care that can scale to meet unprecedented need.
We’re working with exceptional partners to ensure our solutions serve patients end-to-end.
Tim: Amanda, from the provider’s side, how do you see marrying a digital solution like Boulder Care with some of the more traditional clinical care delivery mechanisms, to be greater than the sum of those parts?
Amanda: There are many potential digital solutions, first starting with enabling visits by telehealth. Getting medications in an easier way – if the cartels can deliver heroin to your door, we should be able to deliver medication. Let’s make it that easy. Many services can be delivered seamlessly, and privately through a virtual platform.
From the primary care doctor’s perspective, if all of their patient’s care is getting managed virtually by a team of allied and digitally interconnected professionals, then addiction patients are no longer complex patients to follow and prescribe for. Right now the level of complexity in managing someone who’s got end-stage addictive disease without that wrap-around care is just too overwhelming for most physicians. So are the regulatory concerns. The barriers have been too high.
Tim: So it’s not just barriers for patients, it’s barriers for everyone involved; every stakeholder that wants to participate actively, can’t right now.
Amanda: That’s right. So we need to connect everybody. And that’s really what has to happen. So how do we create a safe place – and that’s the other piece too, because of all the stigma we alluded to earlier – there is a very large cohort of people who probably want treatment and won’t get it, because they don’t want friends and family or anybody to know they suffer with this disease, they’re too embarrassed. So what if you can just get on an app, navigate, and get connected to providers, physicians, nurses, counselors, peers… that simply, and privately? How incredible would that be?
Stephanie: Patients seeking recovery are cycled through an entrenched system mired in myth and misconception, multiple episodes of rehabilitation or detox, and they don’t make sustained progress. Even if they are referred to a long term MAT provider, if they can find good care, they’re asked to physically go to a clinic and their pharmacy and counseling upwards of 130 times per year in aggregate. Virtualizing many of those touch points makes care much more accessible and sustainable. Our goal is to eliminate barriers for both sides – patients and providers – and strengthen the patient-provider dyad, by increasing their contact and enhancing the services offered.
In the short term, Boulder can meet a lot of these clinical needs and expand access. Then we increasingly integrate community and social aspects –building engagement and introducing patients to peers in recovery, nonprofits and patient advocacy groups.
Amanda: If you think about it– if I had to go 130 times in a year anywhere for a medical problem that I have, that would be really difficult, especially if you have transportation barriers, or employment, or children to think about. So how many people typically stay engaged in treatment? On average, unfortunately, insurers have shared that when someone is written a prescription for Buprenorphine (medication assisted treatment for opioids), they end up filling it for, on average, only 9 months. We need to make care more accessible and more patient-centric so that they can stay engaged with their providers which increases their chances of long term continuation and therefore improved success.
Tim: That feels like a long time.
Amanda: It’s a horribly short time.
Tim: So what happens at 9 months?
Amanda: They’re so frustrated.
Tim: With the whole process?
Amanda: With the system, yes. I mean the system we’ve created around them is such a steep barrier; after they’ve stabilized on medications, they’re trying to work now, they’ve gotten their lives back to a great degree, they’re reestablishing their family relationships and they’re taking care of their kids. The understandable time constraints make it very difficult to stay engaged in treatment (medical, behavioral health, peer support visits, etc.) Even though they know that this treatment is how they got their lives back on track in the first place.
Tim: They just feel like they’re not making progress because the system isn’t helping, it’s just getting in the way?
Amanda: The system has such a high threshold for patients to just continue to remain engaged. Medication Assisted Treatment providers lose a large percentage of patients – more than half are gone by 3-6 months, putting the patients at grave risk of relapse, and that’s a dreadful shame. Our hope with Boulder is, make this such an engaging virtual tool and so easy, that the patients are doing their monthly check-in with their doctor for 15 minutes, and when they need additional support their nurses are there for them, and their care coordinators help them get their lives, housing, insurance set up, and peer support is available. This way they don’t have to be given so many hoops to jump through, so many in-person appointments to attend.
Tim: So keep it high touch, but make it less disruptive.
Stephanie: And to your point, 9 months is long enough to stabilize most patients, but not generally long enough for them to significantly reduce the risk of relapse without the meds. What is it that’s taking them off track at that point? You’ve gotten to a place where you’re stable enough, you still need the frequent touch and the lifeline, but not necessarily a one-size-fits-all kind of program, that requires frequent in-person clinical encounters.
Tim: So if each of you were going to leave people reading this with what they can do, or how they can think a bit differently, I’d be curious to hear what you’d tell them.
Amanda: I think the biggest message I would send is to debunk the myth that this is a moral failing: being compassionate and getting patients into long-term monitored medication assisted treatment with psycho-social support is the best way for success.
Stephanie: First, we need to reframe how we talk about the disease without the pejorative tone. Second, we need to be sharing data around MAT success and solutions that work, get patients into treatment instead of incarceration. Currently we punish people instead of helping them. Lastly, from a policy-perspective, the $45 billion the government has committed to this crisis to meet a $200 billion need is woefully inadequate. We need to think of cost-effective ways to increase access to proper treatments. One way would be to empower and enable entrepreneurs and providers to expand access with telemedicine and other digital solutions
Amanda: I’ll mention one barrier that I think is relevant: You may not know this, but there is a limit on how many patients a doctor can prescribe MAT for. That doesn’t exist anywhere else in medicine. A pain doctor can prescribe for an unlimited number of patients. They can have 3,000 pain patients and be prescribing an unlimited number of milligrams of morphine or Fentanyl. But a doctor managing patients with addiction – in their first year they’re only allowed to care for 30 of them, in their second year they’re allowed to submit a waiver request (which you have to submit and get approval from the government to do) to go up to 100 patients, and then in your third year of practice only then can you possibly go to 275 patients and that’s the cap for any doctor. And you can only get to that level if you’re board-certified in addiction as I am, or if you’re a part of a group practice that has several regulatory requirements for quality. So 275 patients is the maximum number that I could prescribe for – as an addiction doctor.
Tim: No limits on the root cause of the problem, but the people that want to fix it – we’re going to handicap so severely?
Stephanie: We have expanded prescribing rights now to NPs and PAs, and as you know firsthand, nurses are some of the most highly-skilled and probably the best people to be combatting this, so there have been changes. Recently the FDA also said that Buprenorphine is safe for life, and have reevaluated the way that we’re able to administer the medication. We still have a long way to go from a policy perspective, and we’re just thinking about ways to make it easier from a provider’s perspective to administer care.
Amanda: They keep asking, ‘how are we going to drive access to treatment?’ And they only just last year raised the prescribing limit per doctor from 100 to 275. I was in DC for weeks going to all these representatives to explain it, and it was like combat. There was a huge cohort of people who say, ‘you’re just replacing one drug with another,’ and ‘why don’t they just pull themselves up by their bootstraps and go into AA? I know people who did it that way, and if they can do it, so can the rest of them.’ There’s just so much discrimination.
And then they say, ‘this medication gets diverted and they’re selling it on the street!’ They’re selling it on the street because there’s a street value! Why? Because there’s a high demand for this treatment and there’s not enough supply because of the prescribing limitations and because of the inherent challenges in treating this population without sufficient support. So we’ve created the problem actually. If you just allowed doctors to be treating this like they treat any other disease…
Tim: You’re artificially messing with market dynamics, and then using the result as an excuse not to think differently.
Amanda: Exactly. The regulatory burdens are incredible. Before 2016, a doctor could only have 100 patients and none of the NPs could prescribe.
Tim: So, you have an awful lot of people that need this help…
Amanda: And nowhere near enough doctors. There’s only about 30,000 doctors in the country today who have gone through the 8-hour course you need to get the waiver to prescribe. You don’t need to be an addiction doctor to get the waiver, but in order to prescribe at all you need a special waiver. And here’s the kicker: Buprenorphine is a Schedule 3 medication. There are 5 schedules, in order of severity of risk. And it’s level 3. Oxycontin is level 2, a higher risk medication. Buprenorphine is safe: the likelihood of overdose is really low, its drug-drug interaction profile is really low. But NPs and physicians can prescribe all the level 2’s that they want, despite the risks, to as many patients as they deem appropriate. Meanwhile the curative medications are limited, because of bias. So—it’s crazy right?
Tim: It makes you worry a bit, because it stands to reason that it’s going to get worse before it gets better, if we don’t start being smarter about this.
Amanda: Well that’s where we can leverage technology to give people the right kind of access. To treat 100,000 patients, you need about 350 physicians – and that’s only 100,000 patients – if we just get that number we’re making a tiny dent in this crisis. There are 2.6 million people with this disease according to the National Institute of Drug Abuse.
Tim: Well hopefully some of the regulatory barriers come down in the near future.
Amanda: There’s some good movement. They went to 275. Now you can prescribe without having to do an in-person physical exam – that’s great because it enables telehealth prescribers to get care to patients in rural areas where there are no providers available to help. So it’s moving in that direction, just slowly.
Stephanie: But technology can make the rest of it go a lot faster.
Tim: Makes Boulder Care very necessary – very timely – I would think. Thank you both for sharing.