Telepsychiatry in addiction treatment: Evaluating India’s telemedicine guidelines

Abstract

Telemedicine has improved healthcare delivery by enhancing treatment access and convenience. India’s telemedicine adoption was limited before COVID-19 due to legal ambiguity and judicial barriers, but the pandemic prompted the development and implementation of Telemedicine and Telepsychiatry Operational Guidelines. The telemedicine guideline established ethical frameworks, consultation protocols, and medication categories for tele-consultation. This viewpoint article examines the advantages and limitations of current telemedicine guidelines in the context of addiction treatment. Given India’s high substance uses prevalence, rural healthcare disparities, and a huge substance use disorder treatment gap, telepsychiatry offers a path to improve treatment access and thereby, reducing stigma and improve treatment outcomes. Even though the current telemedicine guideline is a good first step, it is severely limiting addiction treatment. The major limitations are restrictive medication lists, lack of evidence-based recommendations, privacy concerns, and regulatory gaps. Key recommendations include reclassifying non-abusable medications and adequately addressing legal and privacy concerns.

INTRODUCTION

The World Health Organization (WHO) defines telemedicine as “The delivery of health care services, where distance is the critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.[1]”

Before the COVID-19 pandemic, India had not widely adopted telemedicine, as it was not yet a recognized legal practice. Numerous judicial orders hindered its practice, leading the public to question its effectiveness, especially after a case of criminal negligence was upheld involving a phone consultation.[2] However, the pandemic has highlighted telemedicine as a crucial method of healthcare service delivery. During those challenging times, it proved beneficial, offering opportunities while minimizing risks for both patients and healthcare providers.[3]

TELEPSYCHIATRY OPERATIONAL GUIDELINES 2020

In response to the pandemic, the Ministry of Health and Family Welfare, Government of India, issued the Telemedicine Guidelines in March 2020. Subsequently, the Indian Psychiatric Society and the Telemedicine Society of India, in collaboration with NIMHANS, released the Telepsychiatry Operational Guidelines—2020 in May 2020.[4] These documents promote wider discussion about telemedicine in psychiatry and validate it as a credible method of treatment delivery. By issuing these guidelines, an effort was made to address a significant gap: the absence of legislation and a framework for ethical practice.

The telepsychiatry guidelines are the first of their kind. These telepsychiatry guidelines aim to assist, educate, and guide psychiatrists in India in establishing, implementing, administering, and delivering telepsychiatry services nationwide. They outline teleconsultation methods, various consultation types, and post-consultation procedures, including online prescription services and consent protocols. The Registered Medical Practitioner (RMP) determines whether consultations will be conducted online or in person, with emergencies requiring in-person visits. Consultations can be initiated by family members or healthcare workers, benefiting rural access. The guidelines also permit and detail provisions for online psychotherapeutic interventions. Registered medical practitioners must adhere to ethical regulations, IT laws, state, and national laws related to medical practice, as well as the necessary registrations to perform consultations.

Prescriptions fall within specific drug categories. This list likely intends to discourage indiscriminate prescriptions by mental health professionals while providing legal protection when a medication is not prescribed.

NEED FOR TELEPSYCHIATRY IN ADDICTION TREATMENT

Substance use disorders (SUDs) is highly prevalent in India, with tobacco use at 38% in men and 8.9% in women according to the National Family Health Survey-5,[5] alcohol use at 14.6%, cannabis use at 2.7%, and opioid use at about 2.1%[6] yet a large proportion of individuals with these disorders do not receive the necessary treatment. India faces a significant challenge in providing equitable healthcare to a population exceeding 1.2 billion. According to the 2011 census, the healthcare infrastructure is primarily concentrated in urban areas, while 68.84% of the population resides in rural regions.[7] The urban-to-rural doctor ratio is 3.8:1, with 60% of doctors serving only 30% of the population residing in urban centers.[8] India has 0.75 Psychiatrists per 100,000 population, while the desirable number is anything above three Psychiatrists per 100,000.[9] This skewed distribution of resources creates a barrier to accessing treatment, particularly for individuals suffering from SUDs. The treatment gap was found to be 91.1% in the National Mental Health Survey, 2015–16, particularly in rural areas. A field survey conducted in Punjab also demonstrated a higher treatment gap in rural areas compared to urban counterparts.[10] Additionally, low affordability, massive information asymmetry, and poor health awareness further compound the issue.[11]

Telepsychiatry presents a potential solution to these challenges by improving access to mental health care in underserved regions, overcoming geographical barriers, and ensuring privacy, which may help reduce stigma. Given the significant treatment gap in addiction care, telepsychiatry can play a crucial role in bridging these disparities, especially for rural populations where traditional face-to-face consultations are often unattainable.

KEY ADVANTAGES OF THE GUIDELINE IN ADDICTION TREATMENT

Telemedicine offers scalable solutions to long-standing barriers related to accessibility, stigma, and continuity of care. One of the primary benefits is its ability to overcome geographical barriers, making addiction treatment more accessible to patients in remote or underserved areas. Patients in outlying areas no longer need to travel long distances to receive treatment, as they can consult with healthcare professionals from nearby medical facilities or directly through digital platforms. RMPs can provide consultations to patients across India, ensuring equitable access to specialized addiction care nationwide. This universal access is even more critical in a country like India, where healthcare infrastructure is often concentrated in urban areas, leaving rural populations underserved. A systematic review conducted by Kruse et al.[12] assessed the effectiveness of telemedicine in managing alcohol abuse and addiction, revealing substantial improvements.

The stigma attached to seeking treatment for SUDs frequently prevents individuals from asking for help. Telemedicine presents a confidential and private alternative for patients to obtain care, enabling them to receive treatment without anxiety about social repercussions. This is especially vital in communities where addiction carries a substantial stigma. By facilitating consultations from the comfort of one’s home or through a nearby healthcare center, telemedicine helps reduce the negative views often associated with conventional in-person treatment visits. Study by Couch et al.[13] emphasized that telemedicine can effectively encourage individuals who might otherwise avoid treatment due to social or cultural stigmas to seek help.

Current provisions in telepsychiatry’s operational guidelines facilitate addiction treatment in the following ways:

Consultations for routine follow-up and continuous monitoring

Addiction treatment frequently necessitates extended follow-up, which can be challenging for patients since, it often requires regular in-person visits. Telepsychiatry guidelines alleviate this burden by enabling consultations for follow-up care and monitoring without requiring patients to attend in-person appointments, particularly within the first 6 months. This approach is crucial because reintegrating individuals into society can be obstructed by the frequent visits required by conventional treatment methods.

Telemedicine improves flexibility by enabling patients to access care from home or local healthcare facilities, thereby minimizing disruptions to their work and daily routines. This level of adaptability results in decreased waiting times, lower transportation costs, and fewer logistical hurdles, which enhances adherence to treatment plans. Studies by Treloar et al.,[14] Young[15] support these conclusions, indicating that telemedicine facilitates continuous addiction management by boosting accessibility, enhancing treatment compliance, and decreasing missed appointments.

The recent National Medical Commission Registered Medical Practitioner (Professional Conduct) Regulations, 2023, have introduced rules that have significant implications for telemedicine and telepsychiatry practice in India. Two major changes pertinent to telemedicine include: first, the follow-up teleconsultations are now defined more precisely, permitting continuation of care within 6 months of a previous in-person consultation, or up to one year if the RMP has explicitly advised a longer review interval; second, when the same RMP is unavailable, a different RMP may conduct the follow-up consultation only if they are satisfied that adequate clinical information is available to ensure continuity and safety of care.[16]

Provides legal recognition to the practice of telepsychiatry in addiction services

The 2018 case of Deepa Sanjeev Pawaskar v. State of Maharashtra highlighted the legal challenges associated with remote healthcare.[2] The Telepsychiatry Guidelines have played a significant role in establishing a legal framework. These guidelines guarantee that telepsychiatry for addiction treatment is practiced lawfully, while preserving ethical standards and protecting both patients and healthcare providers. They emphasize the principles of informed consent and confidentiality. As the legal framework continues to evolve, it is essential to strike a balance between regulatory oversight and flexibility, ensuring that individuals in need of addiction care can access timely treatment without unnecessary barriers.

HYBRID MODELS AND TELEPSYCHIATRY GUIDELINES

The operational guidelines for telepsychiatry in India suggest a “hybrid” model for addiction treatment, combining regular in-person consultations with telemedicine sessions. This approach provides a balanced care strategy, ensuring crucial face-to-face interactions, while leveraging the convenience and flexibility of telehealth platforms. A longitudinal study by Gliske et al.[17] showed that patients receiving hybrid care reported greater overall health and satisfaction compared to those in the fully virtual care group.

The discussion about the necessity of in-person meetings continues to be a significant topic in telemedicine policy debates. Advocates for telemedicine in addiction treatment argue that the hybrid model effectively combines the benefits of both methods, allowing for ongoing care through virtual appointments while also providing essential in-person sessions as needed.

PRINCIPAL DRAWBACKS OF THE GUIDELINE IN ADDICTION TREATMENT

A good clinical practice guideline is based on a systematic review of evidence, developed by a multidisciplinary panel, considers patient subgroups and preferences, uses a transparent process that minimizes bias, clearly links care options to outcomes with evidence ratings, and is updated with new evidence. It is best when it offers clinical flexibility and undergoes scheduled reviews.[18] The current telemedicine guideline came at the beginning of COVID-19, and the telemedicine guideline does not provide a systematic review of evidence to support the guideline recommendations. It also does not disclose details about the members involved in the guideline formulation. Although current telemedicine medicine guidelines or the Telepsychiatry operational guideline are a good first step toward increasing access to the unreached, they have certain limitations and are very restrictive for substance use disorder treatment.[19]

From an addiction treatment perspective, it severely limits the scope for medical management of various substance use disorders such as Opioid, Alcohol, and Tobacco. The primary reason behind this difficulty is because of the classification of medications into the A, B, and Prohibited List without any scientific basis for such a classification. List B and prohibited medications may need to be started at the first consultation for maximum patient benefit, and delay may even cause harm in some situations. These may affect the right of the patient to effective treatment.[3]

Addiction treatment often involves prescribing controlled medications. Commonly prescribed medications such as Lorazepam, Diazepam, Chlordiazepoxide, Tramadol, Buprenorphine and Methadone are placed under the prohibited category [Table 1]. Some other commonly used uncontrolled medications or medications with no abuse potential like Acamprosate, Naltrexone, Disulfiram, Baclofen, Topiramate, Bupropion, Varenicline are put on List B without any rational or scientific evidence. This leads to limiting various treatment options for substance use disorders such as alcohol use disorder and tobacco use disorder via telemedicine. Putting all Narcotic and Psychotropics on the Prohibited list appears to have the implicit assumption that these medications will be abused instead of used for treatment. This may further stigmatize the substance using population. The NDPS Act of 1985 is not restrictive; it promotes the treatment of substance use disorder.[3]

Table 1.

Categories of medications as per telemedicine guidelines

Categories of medicine	Medications (generally used in treatment of substance use disorder)
O (over-the-counter medications)	Nicotine gum, Nicotine patch, Nicotine lozenge
A (relatively safe psychiatric drugs and requires a video consultation for the initial prescription)	Clonazepam, Clobazam
B (adjunct medications aimed at optimizing treatment)	Naltrexone, Acamprosate, Baclofen, Topiramate, Disulfiram, Bupropion, Varenicline
C Prohibited list (prohibited by the NDPS Act of 1985 and Schedule X of the Drugs and Cosmetics Act of 1940, which cannot be prescribed via teleconsultation)	Other benzodiazepines (e.g., Diazepam, Lorazepam, Nitrazepam, Chlordiazepoxide), Methadone, Buprenorphine, Tramadol, Methylphenidate, Amphetamines

OPIOID USE DISORDER

Treatment of opioid use disorder becomes almost impossible to treat because narcotics and psychotropics are not allowed to be prescribed online. Because of this, both short-term detoxification and long-term management such as Agonist maintenance are not possible using Buprenorphine, Methadone. Tramadol-based detoxification is also not possible. For the maintenance of the antagonist of the Opioid Use Disorder using Naltrexone, withdrawal management cannot be performed using Buprenorphine or tramadol through telemedicine, and if the patient has been abstinent for an adequate duration, you can prescribe Naltrexone only when the patient had a visit in person before. This may lead to treatment dropout or relapse leading to poor treatment outcomes.

Opioid use disorder patients can be helped by telemedicine as treatments such as agonist maintenance entails long term treatment and frequent follow-ups. Once the dose is stabilized, the follow ups can be done via telemedicine also. Two Indian studies highlight the potential of telemedicine in opioid therapy. Bhad et al.[20] conducted a trial (N = 110) on Telemediation-assisted methadone treatment (TMAT), showing increased retention rates, longer retention duration, and more follow-up visits. Participants found TMAT accessible, with privacy and cost benefits. Ghosh et al.[21] reviewed charts (N = 60) of telemedicine-assisted buprenorphine induction, noting high retention rates.

In the United States, Frost et al.[22] conducted a study involving 17,182 patients and discovered that those who participated in telehealth visits, particularly through video sessions, exhibited better 90-day retention rates in buprenorphine treatment. Hailu et al.[23] analyzed 11,801 patients with opioid use disorder (OUD) and found no significant differences in the initiation of medication-assisted treatment or OUD-related clinical events between clinicians with varying levels of telemedicine use. Research from both India and other countries confirms the effectiveness and practicality of using telemedicine to treat opioid use disorders. Opioid use disorder involves various other challenges such as medication storage, dispensing. More clarifications regarding such matters are required. Pharmacy based dispensing can be solution to such issues.[24] As the guideline does not let Buprenorphine and Methadone to be dispensed via telemedicine, such progress in the field become further limited.

ALCOHOL USE DISORDER

For alcohol use disorder, commonly used anti-craving agents such as Naltrexone, Acamprosate, and the deterrent agent, Disulfiram, cannot also be prescribed in the first telemedicine visit and can only be prescribed after an in-person visit. Withdrawal management becomes almost impossible via telemedicine, as most of the benzodiazepines come under a prohibited list of medications. Clonazepam and Clobazam are placed in list A, while the same class of medications and more important medications for addiction treatment, Lorazepam and Diazepam, are placed in the prohibited list. Clonazepam and Clobazam were added to List A on April 4, 2020, in an amendment.[19] The rationale for placing Clonazepam and Clobazam was not mentioned, and the logic behind not placing other more commonly prescribed Lorazepam and Diazepam is not understandable. A medication like Lorazepam may become necessary when the liver impairment is present or when the status is unknown as recommended by major treatment guidelines.[25] This gives the impression that the current telemedicine treatment guidelines are not in line with most current treatment guidelines.[26] One argument about not allowing these to be prescribed online is the lack of physical examination, but this can be bridged with already available provisions in the guidelines such as collaborative consultation where, for example, a nurse can do the physical examination, and a registered medical professional can prescribe the medication. Such new models are useful where inpatient management or close supervision is required.[27] These guidelines show a shut-the-door approach towards the prescription of such medications which may not lead to further improvements in the tackling of its limitations.

Huskampt et al.[28] studied AUD treatment starting in the US from January 2019 to September 2023 (n = 19,121), focusing on telemedicine’s role in medication prescriptions. Telemedicine accounted for 13.9% of initiations, with variations by medication: naltrexone (14.6%), topiramate (11.8%), disulfiram (12.8%), and acamprosate (13.5%). Western countries have adopted the use of telemedicine in AUD, but Indian guidelines limit its utilization to the full extent. A systematic review of 22 studies by Kruse et al.[12] found tele-health interventions to be effective to reduce risky drinking, improve accessibility, decrease cost, improve quality of life and increased patient satisfaction.

TOBACCO USE DISORDER

Treatment of tobacco use disorder is limited to the use of Nicotine replacement in the first telemedicine visit, as it is over the counter and Bupropion and Varenicline cannot be prescribed in the first telemedicine visit. These medications are neither controlled nor have any addiction potential to be limited to prescribed in person only. An easy access to tobacco cessation treatment through telemedicine can contribute to reducing the current treatment gap for tobacco use disorder treatment. Existing remote programmed such as quit lines and text-based interventions have demonstrated efficacy in reaching underserved areas. A meta-analysis of 22 text-based cessation interventions showed these interventions significantly improved the 7-day and continuous abstinence rates compared to controls.[29] Incorporating the availability of medications into the already available telephone-based intervention would further improve the access to tobacco cessation efforts. Multiple studies have shown telemedicine interventions are effective for tobacco cessation treatments.[30,31,32,33]

OTHER SUBSTANCE USE DISORDERS

For the treatment of sedative dependence and dependence on stimulant use disorder, the limitation of benzodiazepines prescription also poses similar limitations.

Comorbid substance use disorders are a norm rather than an exception in addiction treatment.[34] Patients with comorbid substance use would also have different availability of treatments in person and via telemedicine, leading them to take treatment in person which may beat the purpose of the telemedicine.[3]

DUAL DIAGNOSIS

Dual diagnosis, which is having a psychiatric disorder and substance use disorder in the same patient, also becomes more difficult due to limitations in prescription choices. Approximately 1/3 to half of the patients with substance use disorder have comorbid psychiatric diagnoses The distinctive problems faced by patients with dual diagnoses have also not been adequately addressed.[35,36,37] The restricted or differential availability of medications can hamper recovery in this population.[3] List A antidepressants are Imipramine, Escitalopram, and Fluoxetine. The guidelines of the Indian Psychiatric Society suggest choosing an antidepressant based on the response to previous treatment, the history of side effects, cost, comorbidity, patient/family preference, and availability.[38] This will force the clinician to call the patient for an in person visit if they want to prescribe other medications that are equally effective or more suitable for the patient, which beats the purpose of telemedicine.

Similarly, List A antipsychotics are haloperidol, risperidone, and olanzapine. It is not understandable on what basis the list of medications was categorized; it does not appear to be based on the safety or efficacy of medications. IPS guidelines here choose an antipsychotic based on past treatment response, past history of side effects, cost, comorbidity, patient/family preference, preferred route of administration, availability, current metabolic profile, past history of compliance, treatment resistance.[39] This again shows how this guideline is not in line with clinical practice and evidence-based treatment, but it reduces the choice of prescription of the clinician and the patient in choosing the best medications for them. In this situation, evidence-based treatment, which has three components, the clinician, the patient, and the evidence, is also difficult to follow based on the current classification of medications in the Telemedicine Guideline and associated prescription limitations. In mood stabilizers, Sodium valproate is in List A but Divalproex is in List B. Placement of the two preparations on different lists may not be warranted.[40] ADHD, which is a comorbidity often encountered in SUD treatment, also becomes difficult to be treated via telemedicine, as the first line and most effective medication, Methylphenidate cannot be prescribed.[41] Injectable psychotropic classification also does not appear to be based on any evidence. Injectable haloperidol, fluphenazine, or promethazine are in list A, while safer medications such as Zuclopenthixol, flupentixol, paliperidone, and aripiprazole are in list B. Depot olanzapine, considering its cost-benefit analysis, could be a list A medication.[42]

GLOBAL SCENARIO

Examining the global situation, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 in the United States originally required patients to have at least one face-to-face evaluation before physicians could prescribe controlled substances like buprenorphine and benzodiazepines.[43] During the COVID-19 pandemic, the Drug Enforcement Administration lifted this requirement, allowing for telemedicine-based prescribing, a decision that has been extended repeatedly, with the latest extension until December 31, 2025.[44] In the UK, the GMC guidelines (2021) allow remote prescribing of controlled substances with additional safeguards in place to ensure patient safety.[45] Canada’s CRISM guidelines allow telemedicine-based renewal or re-induction of opioid agonist treatment (OAT) when clinically appropriate, and initiation of OAT remotely if delays pose a significant risk to the patient’s condition[46]. Western guidelines are more permissive and flexible, prioritizing benefit and avoidance, increasing access to treatment, and reducing harms like relapse and dropout in addiction treatment.

NON-PHARMACEUTICAL MANAGEMENT

Non-pharmacological management of addiction treatment also becomes more difficult to access as a detailed in-person psychiatric assessment must be carried out before initiating teletherapy according to the guidelines. Motivational enhancement treatment (MET) and Brief intervention (BI) may be required to be done in the first tele-visit. Telemedicine-delivered MET and BI have been shown to have positive outcomes related to AUD and other substance use disorders.[47,48] This restriction may encourage psychiatrists to prescribe List A medications instead of giving psychotherapy.

Other Concerns

The current telemedicine guidelines do not address protecting patient privacy in much detail. Due to the close-knit nature of Indian families, with small living areas and digital devices often being shared, keeping treatment information confidential can be quite challenging. Although Section 23 of the Mental Health Care Act, 2017 advocates a patient’s right to confidentiality, the Telemedicine Practice Guidelines mandate that a diagnosis be written in prescriptions.[49] This may lead to unintentional privacy breaches Additionally, the responsibility for protecting patient data and records falls on the treating doctor, which may enhance further burden on the doctor. A review by Venkataraman et al.[50] highlighted that the most cited barrier to telemedicine in India are concerns about data privacy and security. It is essential to protect data privacy, especially in addiction treatment where sensitive information is often shared. A centralized digital health record system, like those in Western countries, could potentially resolve these issues.[51]

The legal framework for teleconsultations in India currently raises several concerns. There is a lack of clarity regarding whether a doctor is required to hold a medical council registration in the patient’s state to conduct a teleconsultation as all the regulations and rules applicable to in-person consultations under the Indian Medical Council extend to teleconsultations, thus requiring practitioners to adhere to the same standard of care. Additionally, the jurisdiction of state medical councils in cases of professional misconduct during inter-state teleconsultations remains inadequately defined, requiring further clarification.[52]

Another important concern within the current guidelines is that requiring psychiatrists to routinely enquire about whether patients conflict with the law during telepsychiatry consultations. As the substance using population has more legal involvement, this further reduce accessibility and more importantly, may further stigmatize individuals with SUD even if the aim of such a precaution is to protect clinicians against unwanted legal involvement.[40,52]

Other welcome additions to the guideline include addressing insurance and reimbursement issues, which are not currently discussed. The absence of clear guidelines in this area may encourage patients to opt for in-person consultations due to uncertainties about coverage and cost. The guidelines require psychiatrists to complete a compulsory online training course within 3 years of notification by the Board of Governors (in supersession of the Medical Council of India) to provide online consultation, there is uncertainty regarding the current availability of such a course. In addition, the guidelines do not address the crucial aspects of monitoring and evaluating teleconsultation practices Incorporating these elements would further improve the overall framework for telepsychiatry in India.[4]

RECOMMENDATIONS

We propose that a List B category of medications is unnecessary, as the classification lacks a scientific basis. Eliminating List B would not restrict the selection of the optimal antidepressant, antipsychotic, or mood stabilizer, and would allow clinicians and patients to choose the most appropriate agent in accordance with treatment guidelines. Antic raving agents such as naltrexone, acamprosate, topiramate, and baclofen should be reclassified under List A, since they are neither addictive nor subject to legal regulation. Disulfiram may also be placed in List A, provided that appropriate informed‐consent procedures are followed. Similarly, non‐abusable medications for tobacco use disorder such as bupropion and varenicline should be included in List A, as they are not addictive or legally regulated. We further recommend incorporating lorazepam, diazepam, and chlordiazepoxide into List A, considering their demonstrated advantages and efficacy. Finally, there is a critical need to address opioid use disorder treatment via telemedicine, encompassing not only prescribing practices but also the secure storage and dispensing of regulated medications.

Conflicts of interest

The authors declare no conflicts of interest.

Funding Statement

No external funding was received for the preparation of this manuscript.