[Corrected 5/22/19, 4:27 pm ET. See below.] Eric Gastfriend was looking for his next tech startup idea after leaving his video game startup Happy Cloud and finishing an MBA at Harvard Business School when the inspiration came from a source close to home.
A relative was entering rehab for alcohol abuse for the second time, he says. Gastfriend asked his father—David Gastfriend, former director of addiction research at Massachusetts General Hospital—why treatments sometimes don’t seem to stick and people with substance disorders relapse. [Paragraph corrected to indicate David Gastfriend no longer works at MGH. We regret the error.—Eds.]
“My dad said, ‘Well, we have treatments that are as effective as any modern medicine, but people don’t use them.’ I was like, ‘What are you talking about, if it works, why wouldn’t people use it?'” Gastfriend says.
The treatment method he referred to is contingency management, and it has been lauded for its positive effects in numerous peer-reviewed studies. It involves incentivizing people to stay sober—creating a sort of gamified reward system that speaks to the same part of the brain that’s lit up by the short-term effects of drug use.
Gastfriend found that the approach hadn’t been put into practice on a large scale for a number of reasons. The logistics behind a system that monitors and rewards sobriety was rather complex. There’s also the sticky financial question.
“How do you get it paid for, who’s going to put up the money for the incentives?” he says.
Trying to address those questions is DynamiCare Health, Gastfriend’s latest company that operates out of MassChallenge’s office in South Boston. The business raised $4.1 million in seed funding last week from Hyperplane Venture Capital and other investors, including former U.S. Rep. Patrick J. Kennedy, a mental health advocate who was one of six members of President Trump’s commission to address the opioid crisis. David Gastfriend is the company’s chief medical officer, and its head of medical affairs is Paul Earley, the incoming president of the American Society of Addiction Medicine.
DynamiCare fits into a growing corner of the health tech sector developing digital responses to disorders traditionally treated with drugs. Boston-based startup Pear Therapeutics has an FDA-cleared digital platform built around addiction recovery, and Akili Interactive, also based in Boston, has developed a mobile video game currently seeking regulatory clearance for treating attention deficit hyperactivity disorder. Bay Area startup Addicaid has developed a behavioral science-based app that provides digital support to those in a recovery program.
The DynamiCare app prompts users to record results of random drug tests, facilitated either by a Bluetooth-connected breathalyzer or drug-specific saliva test strips that change color when substances like opioids, cocaine, amphetamines or PCP are present. In both cases, members take the tests on camera to confirm they were the ones who took the test. The results are recorded and confirmed by the startup’s staff. The app also lets members record attendance at recovery meetings by confirming their location using the cellphone’s GPS.
Rewards are issued to a reloadable debit card, which can be used like a traditional debit card in most cases except that this one is blocked from use at ATMs and places like bars and liquor stores. The value of the sobriety rewards escalate as the member maintains sobriety, and they reset back to the beginning if a member skips or fails a test.
Finding organizations to supply the incentives came surprisingly easy, Gastfriend says. Insurers stepped in because they know the exact costs of addiction, one telling Gastfriend it pays out $500 a month in claims for an average policyholder but pays out $1,400 in claims on average for a member with a drug or alcohol addiction.
“We found that actually, payers like health insurance companies are fairly willing to try this out because addiction, in addition to massive human suffering that it causes, is also a huge economic burden to any health insurance plan or company.”
The insurers also told Gastfriend they knew about the same research that led him to develop DynamiCare, but they never saw a good enough technology to implement it.
Gastfriend says building the technology to pull off the random testing and rewards system has been a challenge, but the biggest obstacle for the startup is finding its place in the complicated, constantly changing US healthcare system.
“In healthcare, you could sell directly to consumers, you could sell to treatment providers like addiction rehabs, you could sell to hospitals, which is a whole different type of treatment provider, you can sell it to the health insurance companies, health plans, which are overseeing all the claims but not providing healthcare correctly, but they control the pocket book,” he says. “You can sell it to employers, because most health insurance in the US is employer sponsored, and because the employer is like the ultimate checkbook, they make the final decisions.”
Also complicating the issue is whether DynamiCare’s system should be an FDA-regulated device, a wellness program, or a treatment provider itself.
“All that is fairly complicated,” Gastfriend says. “It’s hard for a lot of digital health companies to figure out where in that world they fit.”
DynamiCare currently has 15 employees and is up and running at seven treatment centers across the US. Gastfriend declined to share how many people in treatment are using the system. He says the incentives are currently paid by insurers and treatment centers.
Next month, the startup is launching a direct-to-consumer option where people can purchase subscriptions to the service that fund the incentives and also pay for a remotely connected recovery coach, Gastfriend says.
The sobriety rewards app ran into its share of challenges with investors that were skittish about putting money into healthcare due to its complexity and long sales cycles, Gastfriend says. But the idea also generated some pushback from potential users.
“The biggest objection people have is a philosophical one,” he says. “Just against the idea of incentivizing people to stay sober or stay in treatment in general. They’ll say it’s something they should already be doing.”
The chasm between the video game industry and substance abuse treatment is not as wide as it would seem given both video games and drugs speak to the reward system in the brain known as the limbic system, Gastfriend says, adding that comparing the two is more than apt.
“It’s all driven by the limbic system in the brain, kind of like the ‘lizard brain’ or the rewards center, which is pursuing things that feel good, that give you those dopamine bursts, and avoiding pain,” he says. “Video game developers are really good at doing this, and I think there are MRI scan studies that show that video games, when you win, it actually released dopamine in your brain. It’s working on the brain in a similar way that substances do, which is that, everyone knows that substances are bad for you in the long term. But in the short term, the substances have a chemical reaction that leads to a release of dopamine in your brain, which you perceive as reward.”
That “lizard brain” can often win the power struggle between short-term good and long-term good, resulting in addiction that spirals out of control. Gastfriend says DynamiCare tries to hack that system.
He adds: “We’re taking all the long-term benefits of recovery, and putting it into a short term, the immediate gratification that the limbic system can understand.”