The behavioral health industry generally isn’t as entwined and reliant on the pharmaceutical industry as the rest of the health care industry.
This creates a wide open space for innovative approaches to care. But there are powerful reasons behind why that space exists. Even so, as things stand today, the addiction treatment industry has the greatest direct interaction with the pharmaceutical industry.
With those strong connections — illustrated by opioid treatment programs (OTPs), which are centered on the oversight of methadone — there are gaps that aren’t being filled from a pharmaceutical perspective that operators need to address.
For example, there are no approved pharmaceuticals meant to specifically treat stimulant abuse, such as methamphetamine use disorder. However, there isn’t exactly a flood of new pharmaceutical solutions into the space. And the new pharmaceuticals that have come to the forefront have been rife with troubles.
Relative to several behavioral health conditions combined, other chronic conditions simply impact wider swaths of the population and are more attractive for the health care and pharmaceutical industries to address.
“The population size relative to other disease states is so small,” Brad Eckmann, CEO of Louisville, Kentucky-based St. Matthews Pharmacy, told Addiction Treatment Business. “When you think about heart disease, oncology — those are the major focuses for health care and behavioral health is, while really important, a small piece. When you think about big pharmacy and pharmaceutical players, they direct most of their attention to big disease states.”
St. Matthews Pharmacy offers retail and specialty pharmacy services with a specialty in behavioral health. It operates in Indiana, Kentucky, Ohio, Oklahoma and West Virginia.
For example, about 2 million people will face a new cancer diagnosis in 2024. More than 22 million adults have severe obesity. Heart disease is the top cause of death in the U.S. About 38 million Americans have diabetes, while 53 million have arthritis.
About 7 million people in 2023, ages 12 years and older, were identified as having a substance use disorder and received treatment. That’s about 15% of all people identified with an SUD, according to federal survey data.
The closest interactions between pharma and behavioral health
OTPs, often called methadone clinics, sometimes act as their own miniature pharmacies, Nick Stavros, CEO of Scottsdale, Arizona-based addiction treatment and mental health provider Community Medical Services, told ATB. These entities will buy certain medications in bulk from the manufacturers and prescribe and administer them as needed to patients.
Community Medical Services also operates office-based opioid treatment (OBOT) clinics, which cannot administer methadone. Yet they often prescribe and administer buprenorphine, another medication used to treat opioid use disorder. Generally, this approach to care is called medication-assisted treatment (MAT).
On top of buying from manufacturers, addiction treatment providers will need partnerships with specialty pharmacies for certain medications. For example, Community Medical Services sometimes works with the specialty pharmacy company Genoa Healthcare, which also focuses on behavioral health, to get patients long-acting injectables for buprenorphine (like Sublocade or Brixadi) or naloxone (Vivitrol).
Doing more for patients with pharmaceuticals
Addiction treatment providers have to consider other aspects of their patients’ health that are relevant to their condition.
For example, this could include helping to address bloodborne pathogens that are associated with drug use, such as human immunodeficiency virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV). The National Institute on Drug Abuse finds that rates of new cases of HCV have been on the rise in relation to injection drug use. Certain types of pharmaceuticals for these conditions require specialty pharmacies.
“That’s something that we’re most bullish on,” Stavros said of scaling up testing and treatment across the company’s clinics. “A lot of people don’t know [HCV] is treatable. … When we do strategic planning and we look from a patient-value perspective and payer-value perspective, HCV is a huge one.”
Often, patients in treatment aren’t tested or treated anywhere else.
And the HCV treatment requires daily dosages, something that Community Medical Services is already providing.
Stavros imagines this being a growing part of the company’s wrap-around services to help ensure patient success and accountability.
Where there are gaps
Retail pharmacies represent the largest area of intersection between the behavioral health industry and the pharmaceutical industry. But its influence is not felt directly by operators. For the most part, the impact is directly on the patients, who may face medication shortages or stigma when seeking to fill a prescription for a specific behavioral health condition.
Still, the volume of behavioral health-related medications that are received every year is worth noting.
In 2022, Americans filled 158 million prescriptions of sertraline, escitalopram, bupropion, trazodone, mixed amphetamine salts, according to an analysis of federal data. All of those medications are common antidepressants, with the exception of mixed amphetamine salts, which treat ADHD.
Often, co-occurring mental health issues are not well addressed by front-line pharmaceuticals. People frequently fail to find relief from depressive symptoms across multiple medications. Most people don’t get better on their first medication. In part, this is because it’s not yet clear what causes conditions like depression or why certain medications do or don’t work.
Increasingly, providers are introducing alternatives to pharmaceuticals such as digital therapeutics or transcranial magnetic stimulation (TMS). TMS, which requires repeated, daily sessions of magnetic fields generated near and through a patient’s brain, has become more accessible over recent years.
For methamphetamine treatment, incentive-based programs, called contingency management, are the only validated care option. Digital addiction treatment and mental health treatment provider Pelago launched such a program earlier in the year. The former assets of Pear Therapeutics are another example of digital therapeutics delivering contingency management. They have been acquired by PursueCare.
Outside of these existing treatments, it’s not likely that there will be too many more pharmaceuticals to become relevant to the space.
“When it comes to new drugs, there’s very little competition in psychiatry,” John Minahan, CEO of Mindful Health Solution, told ATB. “It’s not at all as dynamic as cancer drugs.”
Minahan notes that most antidepressants, for example, were developed decades ago. Methadone was invented in the 1940s and was implemented as a maintenance therapy for opioid use disorder in the 1960s. Buprenorphine was approved for use in addiction treatment in 2002.
Alternative pharmaceuticals such as ketamine, an anesthetic whose off-label uses include treatments for several mental health issues, and psychedelics have not made the triumphant entrance that was perceived to have happened in the last few years. In fact, they have fallen on their faces.
The FDA recently rejected Lykos Therapeutics’ MDMA-therapy intervention. In the wake of that, the company cut 75% of its staff. And there are several examples of practices that tried to bring intravenous ketamine therapy to the forefront that have folded.
Ultimately, pharmaceutical companies and behavioral health companies alike are looking for new opportunities to address the ever-increasing need for behavioral health support. At least on the psychedelics and ketamine fronts, there is plenty of latent momentum to keep those interventions moving forward until the next big thing enters the fray.
