The Workit Health model: evidence-based telemedicine addiction treatment
Despite knowledge that opioid addiction is an epidemic-level public health concern, there remain large treatment gaps. Care is limited where the need is often greatest and many traditional models of addiction care are neither accessible nor highly effective. These widening treatment gaps affect patients of all backgrounds and lived experiences and have taxed systems such as Medicare, Medicaid and Private Insurance.
There is substantial evidence supporting Medication Assisted Treatment (MAT) as the most efficient way to treat opioid addiction, but brick and mortar delivery of care has led to limited access and thus created demand for new avenues to provide clinical care. Workit employs telehealth to provide an alternative that overcomes barriers, enhances the efficiency of evidence-based recovery MAT, and reduces financial burden in the health system.
Workit Health’s response to the opioid crisis treatment gap is a disruptive solution that combines ease of access through telemedicine, online counseling, and evidence-based MAT through buprenorphine-naloxone (bupe-nx).
Opioid addiction in the U.S.
In the US, there are an estimated 2.1 million individuals diagnosed with opioid use disorder (OUD). Opioid abuse – mainly of heroin and prescription pain relievers – has been described as an epidemic by the US Department of Health and Human Services, with over 40,000 people dying from opioid-related drug overdoses in 2016. (1) The historical ease of access to opioids in the US has contributed to its risky use. Many are introduced to opioids through legally prescribed pain relievers such as oxycodone and morphine, of which a portion eventually misuse and/or exchange for inexpensive, illicit alternatives. (2)
The potential consequences of untreated substance abuse are numerous and varied. Other than death by overdose, which is more common for opioids than any other illicit drug, risky use of opioids has been linked to the following: (3)
• Tolerance, cravings, and severe withdrawal symptoms resulting in physiological dependence
• Health problems such as sleep disorders, heart failure, and increased risk of injury
• Deficits in working memory
• Onset of psychiatric disorders such as depression and anxiety
• Miscarriage, stillbirth, and birth defects, including neonatal abstinence syndrome
• Spread of infectious disease through needle sharing
• Chronic unemployment and financial/legal problems
A 2017 report by the US Council of Economic Advisors stated that accounting for the consequences of opioid use on mortality, productivity, and the healthcare and criminal justice systems, the total societal cost of the opioid epidemic is around $500 billion annually. (4)
In hospital costs alone, opioid overdoses account for nearly $11 Billion in utilization across non-emergency and emergency visits. In 2019, the average cost for an overdose patient who was treated and released totaled $504, but the average cost rose more than 20 times ($11,730) for patients treated and more than 40 times ($20,500) for those that required ICU care. (5)
This burden is overwhelmingly borne by insurers. About 66% of it is covered by Medicare and Medicaid, 16 percent by private payers, and 14 percent by the patient himself. (6)
Stakeholders across the continuum have advocated for Medication-Assisted Treatment (MAT) in conjunction with telehealth as a potential solution to the problem of treatment access. SAMHSA outlines MAT and telehealth as a tool to achieve the objective of tackling the opioid epidemic:
Leverage SAMHSA funding to expand access to MAT and recovery support services for individuals with opioid use disorder, including through efforts to increase the number of MAT providers and programs, the advancement of telehealth approaches and use of mobile technologies, and through the implementation of comprehensive delivery service models.
The Workit Health model
Workit Health began providing MAT In 2017, leveraging telemedicine, coaching, and counseling to provide holistic care for those with opioid use disorder (OUD). Since launching in Michigan, Workit Health has expanded to California and New Jersey with plans to enter additional markets in 2020.
The company utilizes technology, telemedicine and electronic messaging in particular, to overcome barriers to care. Workit’s digital platform allows us to provide addiction services to patients who may live hundreds of miles from addiction providers. By aligning evidence-based medicine, social and costreduction elements, Workit Health delivers Medication-Assisted Therapy (MAT) to a greater number of patients who would otherwise be without care.
Workit provides web-based psychotherapy to individuals in all of our programs. The Workit Health psychotherapy curriculum, which is intended to supplement direct contact with a coach or counselor, is comprised of six modules based on the following evidence-based practices for substance use:
1. Mission: Solution-focused therapy, motivational enhancement therapy (7)
2. Body: Holistic harm reduction, psychoeducation
3. Mind: Cognitive behavioral therapy, relapse prevention (8)
4. Heart: Supportive-expressive therapy, dialectical behavioral therapy (9)
5. Spirit: Acceptance & commitment therapy, mindfulness-based therapy, narrative therapy, existential therapy (10)
6. Community: Family systems therapy, assertiveness training, 12 step facilitation (11)
Web-based psychotherapy for substance use disorders is a relatively new but rapidly expanding model. Preliminary evidence supports the effectiveness of web-based programs targeting SUDs, (12) though the majority of platforms available are limited in scope, abstinence-focused, have limited personalization, and/or are directed at aftercare following discharge from an inpatient program. (13) In contrast, Workit Health delivers personalized psychotherapy to individuals in varying stages of opioid use disorder. A recent review concluded that psychotherapy is a generally effective addition to MAT, but results are dependent on intervention type and subpopulation, suggesting the need for tailored and flexible intervention approaches. (14)
In addition to the online curriculum, Workit counselors provide real-time support through text messaging, video calls, or phone calls – an approach found to be generally effective for web-based psychosocial treatments. (15) Counselors receive training in empirically based counseling modalities, including motivational interviewing and trauma-informed care. (16) Telephone support has been found to be an effective addition to alcohol and drug use treatment, as well as buprenorphine-naloxone treatment specifically. (17) Recent studies have additionally demonstrated that text messaging, while a newer form of therapeutic online communication, has been found to be an acceptable and useful method of communication for individuals with substance use disorders. (18)
SAMHSA recommends group therapy for substance use as a means of engendering a supportive environment, reducing isolation, facilitating the exchange of feedback, and highlighting positive examples of recovery. (19) Group therapy can also meet the preferences of individuals who find it to be more effective and comfortable. (20) Accordingly, we provide online group sessions that are guided by a social worker in order to facilitate community and recovery.
Patients in our MAT program also receive medical care. To begin teleMAT, all patients must attend their first appointment in person at a designated Workit location. We currently have clinics in Ann Arbor, MI; Lafayette, CA; Bakersfield, CA; and Trenton, NJ. Workit Health providers typically prescribe buprenorphine/naloxone, which decreases withdrawal symptoms or cravings and ideally eliminates use of illicit opioids. Workit leverages a home induction model in which patients are sent home with their initial dose. (21) Patients are seen by an NP, PA, or MD on a weekly basis for the first 4-6 weeks of treatment before transitioning to monthly appointments. When providers are confident patients are maintained on the medication, they can be transitioned to bimonthly appointments. Prior to each provider appointment, patients are required to conduct a presumptive drug test in the Workit platform. These tests are performed on our telemedicine platform with a 10-panel urinalysis or oral swab test provided to them at their initial in-person appointment or through the mail. This process is monitored by a medical assistant or social worker and is an additional moment of intervention in which the Workit staff member can check in with the patient.
The Workit difference: designing a better solution
Workit Health was built out of a need for more accessible and effective addiction care, and subsequently overcomes several of traditional models.
Fear of medication misuse has hampered rapid expansion of life-saving interventions. As a scalable telemedicine provider, Workit Health enables individuals otherwise unable to access care to receive the gold standard of buprenorphine-rx. After a legally-required initial in-person induction with a DEA-waivered medical professional, patients can receive ongoing buprenorphine/naloxone maintenance therapy via our phone or web-based apps.
Psychotherapy for addiction treatment is scarce, and that which is available often requires frequent in-person appointments. In contrast, Workit Health’s licensed counselors and self-guided, personalized psychotherapy curriculum are available anytime, anywhere. Patients can access psychosocial support in the medium most convenient for them, wherever they are.
Traditional addiction care is expensive. By leveraging telemedicine to deliver MAT and psychotherapy, Workit Health can deliver improved clinical outcomes at a lower cost. Neither patients nor payers have to sacrifice the benefits of inpatient or intensive outpatient treatment when choosing Workit.
Traditional addiction care is based on a one-size-fits-all model which limits the effectiveness of SUDs care. Workit’s digital-first approach enables providers to provide precision care in real-time, thereby allowing each patient to receive personalized care in the setting most comfortable for them. A combination of active (user-set preferences), passive (clicks on an audio share), and progressive (mid-program surveys) personalization strategies are used to help meet the unique challenges faced by each user.(22) Individuals often struggle with polysubstance use or concurrent alcohol/drug abuse and behavioral, processbased addictions, which when left untreated, can increase a patient’s overall risk. (23) Our licensed counselors and tailored curriculum can be leveraged to ensure the entirety of an individual’s needs are met.
There exist a myriad of social and logistical barriers to accessing traditional models care even when available. These include: stigma, privacy concerns, patient beliefs that treatment is unnecessary or not beneficial, as well as logistical difficulties such as coordinating transportation and work schedules that may prevent an individual from seeking care in traditional in-person settings. Workit’s model enables individuals to receive care in an environment where and when they feel comfortable. This model also works well for individuals who do not have the resources or time to access continuous care in-person. This may be due to factors such as unreliable transportation, homelessness, job security, and/or domestic violence – among others. By meeting patients where they are – whether that’s at home, in a public bathroom, or while on a work break – we open up access to effective, low-cost treatment that individuals might have otherwise avoided.
When individuals don’t know where to access treatment, they can be mismatched with out-of-network, high cost care through online and TV advertising. Workit’s own acquisition funnel offers members a digital screening, brief assessments, and referrals (SBIRT), that members are able to schedule anytime through our website. Our licensed counselors, combined with our program’s proprietary algorithms, match members to the right level of quality, innetwork care, either with Workit or another preferred provider.
Our learnings and results
At Workit, we strive to measure outcomes holistically while incorporating empirically tested measures, including aspects of recovery that are not always tracked in traditional care settings. Depending on the specific needs of the user, we track:
• Addictive behavior frequency
• Self-defined goals
• Motivation levels
• Quality of life
• Health-promoting behaviors
• Psychosocial context
• Employment performance
• Biometric data (mandatory for Clinic users)
• Issues of interest for employer clients and investors; made available in aggregated form monthly
This data is used to ensure continued safety for medication users, inform the process of care escalation or de-escalation, and improve program quality overall. Our most recent longitudinal study of over 450 safety-net patients in our MAT program demonstrated improved clinical outcomes over traditional care models.
1. Our offering reaches a diverse population across a variety of ages, genders, geographic locations, and socioeconomic background. Our nearly 50/50 split between men and women is impressive considering that typically men are much more likely to seek treatment or addiction. We attribute Workit’s even gender ratio to the product’s privacy and convenience which are two of the biggest barriers to treatment. We also have users of all ages and continue to see a rise in the number of older patients who access Workit. In addition, 20.4% of Workit’s patients come from a rural zip code, indicating that telemedicine is a powerful tool for overcoming a lack of providers in less dense parts of the country. Lastly, 42.5% of all Workit patients have experienced at least one period of housing instability, indicating the convenience of Workit as an important tool for enrollment and retention. When an individual is concerned about housing or transportation, they are less likely to attend in-person care.
2. Patients quickly reduce use of their substance of choice. A longitudinal analysis of drug testing results from the Workit program over a 9-month period found that 82.29% of Workit members who remain in the program achieve adherence to Workit’s use guidelines after one month in the program. This is in stark contrast to the 28.85% of users who demonstrated adherence at the time of intake. Workit members are able to maintain this adherence over time. The proportion of adherent members remains steady after month one, with similar numbers at two and and three months. Workit members who have been in the program for 6 months or more are abstinent from their drug of choice 90% of the time.
3. Patients are much more likely to remain in the program because Workit overcomes many barriers to care. After one month, 84.51% of Workit members are still engaged in the program (n=381). Multiple studies have shown that retaining clients for three months is associated with improved outcomes. At three months, Workit’s retention is 73.95%, and retention remains high in later stages of recovery, with 67.69% of members still retained in the program at 6 months. Moreover, nearly all of these members are actively engaged in the program outside of their medical appointments.
4. Workit’s harm reduction model leads to a higher rate of truthful self-reports of use. One criticism of telehealth medically-assisted treatment is that remote drug testing encourages “cheating.” We find the opposite to be true. Because our members trust that we will not discharge them because of a relapse as long as they are engaged in their recovery, they are truthful in their reports of their drug use. Across nine months of drug testing, we find that members truthfully report whether they will test positive for an illicit drug 90.3% of the time.
5. Workit members rarely leave Workit Health’s offering for other providers or methods of care. High levels of retention demonstrate that Workit’s members are highly satisfied with the Workit program. Further, very few Workit members leave Workit for another recovery program. Only 8% of all clients discharged in the last year from the Workit program left because they wanted to change to another provider or method of care. Of these, most left to switch to another provider who took their insurance, while a small number left in order to enter an inpatient program or because they did not like buprenorphine-rx.
6. Workit members report an improvement in quality of life. Every week, Workit members are asked to fill out a “gut check” quiz that assesses quality of life. A majority of Workit members show a higher quality of life now Workit Health | 2019 compared to when they first entered the program, in an analysis of the past year of assessments (55%). Compared to their first assessment in the program, members report lower anxiety, more participation in enjoyable physical activity, and more conscious spending. In total, members show improvement in five factors measured in the quality of life assessment. Two factors measure members’ own perceptions of their progress in recovery; importantly, members show improvement in both of these factors. One is a reduction in self-reported addictive behavior). Members also report increased success in fulfilling their “mission,” a self-defined goal related to their recovery such as repairing relationships with family members or avoiding triggers.