Year : 2020  |  Volume : 62  |  Issue : 5  |  Page : 606--607

Coronavirus disease 2019 pandemic: Ethical concerns for the treatment of individuals with substance use disorders in India


Tathagata Mahintamani, Abhishek Ghosh 
 Department of Psychiatry, Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Abhishek Ghosh
Department of Psychiatry, Drug De-addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
India




How to cite this article:
Mahintamani T, Ghosh A. Coronavirus disease 2019 pandemic: Ethical concerns for the treatment of individuals with substance use disorders in India.Indian J Psychiatry 2020;62:606-607


How to cite this URL:
Mahintamani T, Ghosh A. Coronavirus disease 2019 pandemic: Ethical concerns for the treatment of individuals with substance use disorders in India. Indian J Psychiatry [serial online] 2020 [cited 2020 Nov 25 ];62:606-607
Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/5/606/297757


Full Text



Sir,

The coronavirus disease 2019 (COVID-19) has been declared as a pandemic in March 2020. The contagious nature of the illness and the nonavailability of any specific treatment or vaccines compel the governments to impose preventive measures ranging from quarantine and social distancing to nationwide lockdown.[1] To adapt to this changing scenario, the healthcare system focused on limiting the public gathering, leading to various degrees of suspension of nonemergency services including treatment for substance use disorders (SUDs).[2] This created unforeseen ethical dilemmas.

Telemedicine is emerging as an alternative platform for virtual interaction between patients and clinicians. The limited ability to perform a physical examination during teleconsultation may affect the diagnosis of comorbid physical illness and management of the same. This may potentially breach the principle of nonmaleficence. If a patient uses someone else's audiovisual device for teleconsultation, privacy and confidentiality might also be at stakePsychotropics in the Schedule H1 List (Drugs and Cosmetics Act) and Narcotic Drugs and Psychotropic Substances Act cannot be prescribed through teleconsultation. Therefore, medications for opioid agonist treatment, i.e. buprenorphine and methadone fall under this prohibited category. This inadvertently affects the treatment of opioid use disorder.[3] It might be viewed as discrimination against people with SUD. The Substance Uses and Mental Health Services Administration of the United States has temporarily allowed the prescription of controlled substances (including buprenorphine and methadone) through telemedicine, without the need for a face-to-face consultationThe lockdown imposed unwarranted restrictions of patients' movement by the suspension of public transport, closure of state borders, and curfew.[2] As, in some cases, patients are unable to come for follow-up, medications are to be dispensed by proxy. This practice complies with the principle of beneficence, but it might result in a breach of confidentiality. One extreme form of such breach happens when a government official acts as a proxy collector of medication for a couple of villages/taluks (it is actually happening). While medications for some chronic noncommunicable diseases (like diabetes mellitus) could efficiently be dispensed this way, but for stigmatized and sometimes criminalized SUDs, this practice might lead to significant harm to patients. To impose stringent lockdown, everyone is routinely checked at several police posts on the way to and from the hospital. This certainly leads to a breach of confidentiality, and among patients with illicit SUD, fear of legal action may limit service utilizationThe lockdown caused an abrupt cessation of supply of substances, especially of alcohol, resulting in a sudden increase in patients with severe withdrawal symptoms, and possible intoxication with nonconsumable alcohols and suicide attempts.[4] During the third phase of the lockdown, the prohibition on alcohol was lifted, which might have resulted in increased rates of relapse. In spite of the increased treatment need, treatment provisions and opportunities are restricted. This is like an ethical “double whammy,” breach of both nonmaleficence and beneficenceInpatient treatment, too, is largely limited due to restriction of bed availability (e.g., conversion of various healthcare systems into COVID-19 hospitals) and also for the fear of nosocomial transmission of the infection.[2] This restriction interferes with the patients' autonomy to avail of inpatient treatment. At the same time, long-stay patients with dual diagnoses in the residential settings are at a higher risk of developing COVID-19 (due to overcrowding and poorer general health condition).[5] Despite the risk, it is difficult to discharge patients, because of their limited acceptance in the society, whereas there is a risk of the rapid spread of infection in the inpatient setups.

The basic tenets of medical ethics are beneficence, nonmaleficence, autonomy, and justice.[6] The Mental Healthcare Act, 2017 revolves around autonomy, which allows the patient's right for confidentiality, the right to choose or refuse a particular treatment modality, and the right to community living. The government must ensure these rights, but the psychiatrist is endowed with the implementation of the rights.[7] In this extraordinary situation of the pandemic, the state is not able to ensure these rights, but the psychiatrists stand at the crossroads. Here, beneficence conflicts with the patient's autonomy and confidentiality. It warrants a rational prioritization from the mental healthcare providers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. COVID-19: How doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020;368:m1090.
2Arya S, Gupta R. COVID-19 outbreak: Challenges for addiction services in India. Asian J Psychiatr 2020;51:102086.
3Telemedicine Practice Guidelines. Ministry of Health & Family Welfare: New Delhi; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 Jun 14].
4Narasimha VL, Shukla L, Mukherjee D, Menon J, Huddar S, Panda UK, et al. Complicated alcohol withdrawal-an unintended consequence of COVID-19 lockdown. Alcohol Alcohol 2020;55:350-3.
5Kavoor AR. COVID-19 in people with mental illness: Challenges and vulnerabilities. Asian J Psychiatr 2020;51:102051.
6Gillon R. Medical ethics: Four principles plus attention to scope. BMJ 1994;309:184-8.
7Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, et al. Mental Healthcare Act 2017 Aspiration to action. Indian J Psychiatry 2019;61:S660-6.