The gradual move towards telemedicine for the care and service provided to patients with addictive disorders [1], has been accentuated during the pandemic [2, 3, 4]. Telemedicine facilitates expert medical care to those situated at distant locations, and reduces the indirect and direct healthcare costs. While the benefits of telemedicine have made it an exciting opportunity, some ethical concerns still remain [5]. Here, we discuss some of the ethical challenges in providing treatment to patients of addictive disorders through telemedicine.

First, assessment of the patient’s physical condition becomes challenging in the telemedicine framework as important clues can be missed. For example, for a patient with alcohol dependence, examination of the central nervous system and palpation for enlarged liver might not be possible. Similarly, for patients on opioid substitution, the corroborative withdrawal signs of dilated pupils may be difficult to assess. Beneficence maybe compromised if the treating physician finds it difficult to take an informed decision. Dose optimisation of medications like buprenorphine may be deferred pending closer examination and evaluation.

Adherence to medication is a related issue. In opioid substitution treatment, supervised dosing is preferred. While such supervision may be possible online, autonomy may be curtailed in favour of better adherence. This is especially true of medications like disulfiram and naltrexone, where supervised administration may have better outcomes. Current restrictions on prescription of certain medications through telemedicine may compromise provision of adequate help to patients [6].

Telemedicine does offer an opportunity to contact patients who have dropped out of treatment or are likely to drop out, but this will impinge upon autonomy and free choice regarding treatment. Of course, when patients dropping out are contacted through telemedicine, they have the choice on whether to go through with the consultation or terminate it.

Provision of equitable care is difficult as telemedicine requires the availability of a device (eg, a smartphone), internet connection, understanding of video conferencing applications and dispensable medications, absence of which may create barriers for those seeking care through telemedicine. However, it needs to be weighed against the benefits of greater access in difficult times and wider geographical reach.

Another issue is provision of urgently needed care; eg, if a patient with poor motivation indicates an intention to use a substance during the consultation (or is seen taking a substance). In face-to-face consultations, the treatment provider aims to provide a “holding environment” till the intoxication subsides, or makes repeated efforts to urge the patient to continue the treatment, providing breaks to contemplate outside the consultation room, or may offer involuntary admission when a patient’s behaviour indicates significant risk to self or others. In a telemedicine consultation, should the mental health professional try motivation enhancement to help quit substance abuse (at the discretion of the patient), or initiate the process of coerced treatment, or just end the case consultation process? On the other hand, if the therapist finds that a patient of alcohol withdrawal is slipping into delirium, should the therapist arrange for a treatment team to be despatched in the interests of beneficence, but at the risk of interfering with autonomy and confidentiality? The answer to this question may vary with the clinical situation, presence of psychiatric comorbidity, and availability of such community teams — though such teams that can be sent home are not available in India in the formal healthcare system.

Privacy and confidentiality concerns are also challenging. Digital media adds another device/agent in the care process, which may be susceptible to breach of confidentiality by intermediaries or even hackers. This is not under the control of treatment providers and the data might be stored internationally. Systems and policies are required to ensure confidentiality and restrict access to the data. Telemedicine may also facilitate easier referral to other professionals (with due consent of the patient) for related conditions through mail, instant messaging or other services/softwares. Care needs to be taken to maintain protocols of confidentiality throughout and after the referral. This could be through defining a data safety policy and implementing it.

Specific ethical concerns besides those in the regular healthcare system apply to the care of patients with addictive disorders — like privacy, autonomy and coerced treatment, surreptitious treatment, and weighing beneficence and harms while dispensing opioid agonists [7]. These have to be balanced with the benefits of telemedicine, using the lens of ethics. Also, the recent guidelines offer clear suggestions and expectations of the enforcement of privacy and confidentiality concerns [6]. Telemedicine has the potential of wider reach and reduced costs of medical care delivery, thus serving the ethical tenets of justice and beneficence. It is a valuable tool, which should continue to be used expeditiously, in a responsive manner, in the treatment of substance use disorders. As telemedicine has become, an important part of healthcare, more discussion will help in shaping its use as a responsible, effective, and efficient mode of delivering healthcare.

Siddharth Sarkar (corresponding author — sidsarkar22@gmail.com), Associate Professor, Department of Psychiatry and NDDTC, AIIMS, Ansari Nagar, New Delhi 110 029 INDIA; Yatan Pal Singh Balhara (ypsbalhara@gmail.com), Additional Professor, Department of Psychiatry and NDDTC, AIIMS, Ansari Nagar, New Delhi 110 029 INDIA.

Conflicts of interest and funding: None to disclose.

Previous related work: Parmar A, Patil V, Sarkar S. Ethical management of substance use disorders: the Indian scenario. Indian J Med Ethics. 2017 Oct-Dec;2(4):265–70.