Digital Health Technologies to Address the Social Determinants of Health in context of Substance Use Disorders (SUD) (R43/R44 Clinical Trial Optional)

Purpose

The taking of drugs of abuse is a high-risk behavior associated with immediate and long-term health consequences. Understandably, multiple initiatives to address the opioid crisis in the United States aim to improve pain management, access to medication-assisted treatment, and use of overdose-reversing medications. Moreover, public health experts have also long recognized the impact of social determinants on health outcomes. According to the World Health Organization (WHO), the social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. Growing research is demonstrating that social determinants of health (SDH) play a far greater role in health outcomes than expected.

The health of people who use drugs of abuse is inextricably bound to their social environment. Drug-taking and drug-use risk behaviors are affected by social processes, and health, in this situation, is a product of both drug-use behaviors and social determinants. Social determinants can directly shape health risk behaviors. SDH can be manifested in the living conditions and resources that indirectly exacerbate the consequences of drug use. For example, inadequate housing can increase the likelihood of infectious disease transmission, while the stable social relationships can offer protective financial and emotional resources, and more cohesive neighborhoods can have a greater likelihood of providing appropriate support and care.

Although illicit drugs are used by people of all income ranks, drug-related morbidity and mortality are disproportionately higher among lower income groups. Numerous studies have shown the existence of a social gradient, in which rates of morbidity and mortality decrease directly and proportionately with each increase in level of income or education.  Factors such as poor access to risk-reduction information and differences in quality of information received may play a role in stratifying the health risks. People with lower socioeconomic status experience difficulties with receiving the appropriate preventive care, have limited access to medical care, and frequently receive substandard medical care.

People affected by SUD or drug use make up a significant proportion of the homeless in the United States; 10%-20% of homeless people are estimated to abuse drugs, with estimates of lifetime prevalence of 25%-50%. Homelessness influences the well-being of this population because of their high-risk behavior, inadequate access to medical care, and failure/inability to comply with treatment regimens. In general, regular attendance of a drug treatment program, such as methadone maintenance treatment, is associated with significant reductions in drug use. The lack of basic information about the drug treatment program locations, treatment options, and access to the program, both in terms of logistics and financial literacy, severely limits their access to medical care. Enrollment in methadone programs is thus inversely associated with homelessness.

Effects of incarceration on health relate to the cycle of incarceration (release and reentry), which increases morbidity and mortality for incarcerated drug users and limits their access to health resources. Injection drug-use rates for prisoners are about 20 times higher than for the general population, and the risk of injection-drug use in prison increased by 17% for every year of imprisonment. Limited availability of housing, benefit programs, and preventive and treatment services in these communities upon release compounds their health problems. Incarceration is thus a risk for disease amplification both within prisons and in the communities that inmates come from and go to. Research evidence warns about a high likelihood of drug-related death immediately after prison release, with mortality from overdose that is 7 times higher in the first 2 weeks after release than in the next 10 weeks. Overall, the mortality of former prisoners during the first year after release was four times the age-adjusted rate in the general population. The likely factors associated with this high mortality include loss of tolerance to opiates while in prison, the increased opportunity for drug use and other high-risk behavior but also the psychological stress associated with re-entry into the community.

Research Objectives

A full spectrum of interventions encompassing both social determinants of health and individual-level factors (behavioral interventions, MAT) should be considered in order to fully address the drug use epidemic in the Unites States. Digital technology-based solutions can offer a new path forward in addressing SDH in drug addiction, as these solutions focus on providing evidence-based, continuous and accessible experiences for individuals affected by drug use or living with SUD. The advantages of digital technology also lie in its capacity to accommodate the changing context and environments that contribute to the 21st century SDH: new communication means, mobility, cultural contexts, new consumer behaviors, family and community dynamics, etc.

NIDA supports the research and development of the tech-forward solutions to provide evidence-based medical care and treatment through multiple funding opportunities published elsewhere. Through this FOA, NIDA solicits the research applications for commercializable digital health-based products that aim at positively influencing the fundamental social and environmental conditions that are risk factors for the populations affected by the use of drugs, including opioids. In the context of this FOA, product is any source of value for the end users and customers. Services, subscriptions, software as a service (SaaS), physical/tangible products (e.g. apps, digital platforms), aggregations, and similar could all provide value and thus be considered the eligible products. The proposed product could be the result of novel scientific research, repurposing an existing technology for a new use, extending a research observation into SUD area, devising a new business model or distribution/delivery channel that unlocks value currently concealed, or simply bringing a product or service to previously underserved set of customers. This FOA focuses on development of digital solutions for the states, families, schools, employers, landlords, and patients, especially, the 90% of people with addiction who do not seek treatment. The FOA's aspiration is to incentivize the small businesses and startups to explore the digital tech's great opportunity of reaching the disenfranchised populations: the unemployed, the uninsured, the incarcerated, etc.   

The eligible small businesses can submit the grant applications focusing on transforming family, housing, employment, justice and educational determinants of drug addiction. The proposed products should offer the most far-reaching and promising opportunities for the intended customers and end-users to meaningfully contribute to addressing the drug addiction and opioid crisis.

Illustrative topics could include, but are not limited to:

See Section VIII. Other Information for award authorities and regulations.

1. • Research, design and validate novel tools and approaches to address food and housing insecurities;
   • Research and design of novel tools to enable impactful housing programs that promote health (for example, the innovative housing programs that can co-locate employment, education, and behavioral health services);
   • Design and validation of curriculum for “soft skills” development for addiction treatment providers;
   • Novel educational tools/novel educational delivery systems to foster compassion and eliminate stigma associated with SUD;
   • Research and design of preventive systems for families to promote healthy behaviors, social skills, community opportunities, and productive social involvement;
   • Novel educational tools/novel didactic delivery systems focused on social stability (community, tradition, faith, family), and self-regulation and resilience;
   • Novel educational tools/novel didactic delivery systems to focus on happiness, wellbeing, belonging, positive and fruitful communal life; 
   • Design and validate technologies that help create and enhance productive social support networks that facilitate recovery, engagement with care, and/or access to needed services;
   • Research and design tools and technologies to help facilitate continuity of care, access to services, and successful community reintegration for people re-entering communities following a period of incarceration;
   • Development of technology to facilitate data sharing among organizations that serve justice-involved individuals with the goal of increasing coordination of services, enhancing service quality, and/or increasing engagement with effective services;
   • Research, design and validation of novel approaches for job training (e.g. in entrepreneurship, financial literacy, IT skills), especially, delivered in recovery housing or while incarcerated;
   • Develop and validate the best approaches for employer education and support to allow employers to hire, retain, and facilitate treatment for employees seeking help for SUD.