Should addicts get paid for staying sober?

Shakespeare once asked where is fancy bred, in the heart or in the head? In this newsletter, we might reframe the question as where does innovation start, in a group or apart?

After COVID forced many people to work apart, the question remains whether remote work hinders the flow of new ideas sparked by serendipity. In the case of a Boston medical-tech startup called DynamiCare Health, it was a chance encounter between a father and son that sparked an idea that could ultimately help thousands of recovering addicts stay sober.

David Gastfriend, the dad, is an addiction psychiatrist who spent 25 years on the faculty of Harvard Medical School, directed addiction research at Mass General, and worked at Waltham drug company Alkermes running trials for the generic form of Vivitrol, used to help addicts avoid relapsing. His son, Eric Gastfriend, has had a different career path, working at a gaming technology startup in Cambridge and then attending Harvard Business School.

About six years ago, a member of the Gastfriends’ extended family was struggling with addiction. Eric wanted to know why David’s field was so ineffective at preventing relapses. “Listen,” David retorted. “We have an approach that would be the envy of modern medicine, it’s so effective. But nobody will use it.”

Known as contingency management, the approach tries to short-circuit an addict’s need for constant hits by delivering small monetary rewards when an addict stays sober. It sounds hard to believe, but multiple studies have found that the small rewards can trigger the same part of the brain that releases dopamine from drug or alcohol abuse and thus satisfy an addict’s cravings.

In the past, however, running such a program was expensive, as recovering addicts had to check in with counselors and be tested for sobriety frequently. There were also concerns about how addicts would spend even the few dollars a day they earned in a program. Insurers weren’t convinced there was enough accountability, and the federal government considered the rewards a potential violation of rules intended to prevent Medicaid fraud.

As David explained these problems, a light bulb went off for Eric. Using smartphones, connected devices, and telehealth practices could overcome the challenges, he told his dad.

“My jaw just hit the floor,” David recalled in a recent interview. “I said, Eric, if you could integrate that stuff, you could revolutionize my field.”

Together they founded DynamiCare and started developing a smartphone-based contingency management program for recovering addicts. It’s taken six years, but after multiple successful trials that have won over some insurers, they’ve even convinced the Feds to change course.

The Office of Inspector General for the Department of Health and Human Services last month issued a new opinion that app-based contingency management programs would not violate Medicaid’s anti-kickback rules. That means Medicaid will be able to reimburse health care providers offering DynamiCare’s service.

“We’ve broken the sound barrier of reimbursement,” David said.


Aaron Pressman can be reached at aaron.pressman@globe.com. Follow him on Twitter @Ampressman.

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