Fighting addiction in a pandemic: Is telemedicine the key?

• Services for addiction treatment in South Africa have been restricted by the pandemic.
• Recovery centres are also taking financial strain.
• Telemedicine might be the way forward, but it faces some challenges.

Addiction – or substance use disorder (SUD) – is a tough, exhausting fight even under normal circumstances.

But throw a pandemic into the mix, and accessing support becomes a lot harder. Isolation has become the new reality for the world as we try to curb the spread of Covid-19, but it can become a trigger for relapses or even new addictive habits.

"Addiction is a disease of disconnection as it isolates you from the people you love, and physical distancing contributed to addictions flourishing during lockdown," says Adrie Vermeulen, the national coordinator for the South African National Council on Alcoholism and Drug Dependence (Sanca).

In South Africa, certain services shut down at the start of lockdown, and those still open took no new admissions. Even hospitals couldn't provide detox services to patients suffering from severe, potentially deadly withdrawal.

And, to make matters worse, addiction is also considered a comorbidity for the novel coronavirus. 

READ: Looking for ways to protect against pandemic PTSD 

What it takes to recover from addiction

Recovering from addiction is a painful journey – and without professional support an even tougher dragon to slay.

The recovery process is very much dependent on the type of substance abuse, how long the patient has been addicted and other underlying health and mental conditions. Mild to moderate SUD can be treated in an outpatient setting, but severe withdrawals, like from alcohol and nyaope, requires medical supervision at for example a Sanca centre.

The physical detox can take anything from five to 15 days, but only after that does the real work begin. Rewiring the brain so that the patient doesn't relapse can take up to 12 months with the help of psychological methods like cognitive behavioural therapy.

"Treatment is only the first step in 'discovering' yourself, and the real work in 'recovery' starts once you leave the treatment centre," Vermeulen says.

"Success depends on the client's understanding that this is a lifelong disease that they have and that they will need continued care and support to really change their lifestyle."

Aftercare support groups are extremely important, but in a pandemic many recovering addicts are cut off from these vital resources.

ALSO READ: Ex-smokers who take up vaping are more prone to relapse 

Limited access to resources

During just the first week of lockdown, Sanca's WhatsApp line had 500 messages from people requesting help.

When more Sanca centres reopened during lockdown Level 4, their inpatient admission had decreased considerably due to a fear of Covid-19 infection. Their bed capacity had also been slashed in half to adhere to physical distancing regulations.

Prevention services were also suspended, with only social media campaigns being launched, aimed at the youth and other high-risk groups. 

And, like so many businesses, these vital centres might financially not survive the lockdown.

"[Physical distancing] has had a severe effect on the income of the centres and threatens their sustainability. The centres incurred extra costs to ensure compliance with Covid-19 regulations, financially placing more strain on limited funds," Vermeulen adds.

One glimmer of good news, though, was that 25 temporary and established shelters across South Africa's cities provided Sanca with the opportunity to treat nayope addicts, where withdrawal symptoms are severe. 

READ: Coronavirus crisis could help trigger relapse among those fighting addiction 

Impact of cigarette and alcohol bans

But another reason people could be avoiding treatment during lockdown is that many turn to cigarettes, which are currently still banned in South Africa, to curb their cravings.

"Although SANCA National agrees with the ban on the sales of alcohol and tobacco during lockdown by the government to protect public health and prepare the under-resourced medical services for the pandemic, we recognise that the situation is more complex than originally expected," Vermeulen says.

The alcohol ban also had some negative implications when it was in effect.

"The concerns are that people with a severe alcohol use disorder were not properly warned about the lockdown and that they lacked access to treatment services and medical services to deal with severe withdrawal symptoms."

READ: Why the cigarette ban during lockdown? Five medical experts weigh in 

Is telemedicine the way forward?

Around the world, healthcare unrelated to Covid-19 has started moving online, including certain services for former addicts.

In the US, experts from the University of Michigan Addiction Centre and VA Ann Arbor Healthcare System reviewed how telemedicine policy changes have had a major impact on addiction care, according to an article in JAMA Psychiatry.

They found that allowing clinicians to prescribe higher schedule medications for patients they have not seen in person through telemedicine meant they could more easily provide medicine to handle withdrawals to outpatients, especially in crisis situations.

Telemedicine also helped break down barriers for addicts who want to kick the habit in rural areas where services are non-existent.

However, telemedicine has some limitations. For example, it's dependent on the patient's access to technology, reliable, affordable connectivity, and the information needed by the healthcare professional can be tinged by patient bias. Certain bio-information may also need to be assessed by a professional via tests.

There's also an ethical consideration. Group therapy is an important part of addiction recovery, but they rely heavily on anonymity. This is a problem because you wouldn't know if someone were recording a virtual group session.

Unfortunately, South Africa is still far way from utilising telemedicine to the same extent as other parts of the world.

OPINION: Coronavirus intensifies the need to embrace telemedicine

Hesitance to use telemedicine

Before the pandemic, the Health Professions Council of South Africa (HPCSA) defined telemedicine as follows:

The practice of medicine using electronic communications, information technology or other electronic means between a healthcare practitioner in one location and a healthcare practitioner in another location for the purpose of facilitating, improving and enhancing clinical, educational and scientific healthcare and research, particularly to the under-serviced areas in the Republic of South Africa.

A patient was, however, not permitted to consult a healthcare professional from their home virtually or via telephone.

But with the coronavirus pandemic, regulations were relaxed, permitting telemedicine only where there was an existing patient relationship, except for psychiatrists. However, many healthcare bodies, like the South African Medical Association, opposed this, and in April the HPCSA no longer banned telemedicine outright.

"We should, therefore, caution all practitioners that the clinical interest of the patient must be of the utmost importance when deciding on the mode of contact and that the ethical rules and guidelines of good practice as enforced by the HPCSA should guide the profession to still deliver the highest possible standard of care to the people of South Africa under these difficult circumstances," is SAMA's current official stance on telemedicine.

For the South African Society of Psychiatry (SASOP), an established relationship alongside video communication is also preferred, according to its president Professor Bonginkosi Chiliza. He adds new patients should be first seen face-to-face unless crisis management is needed.

Sanca centres had facilitated some online support during levels 4 and 5 of lockdown, including hosting Zoom meetings for self-help groups like Narcotics Anonymous, as well as providing counselling over WhatsApp.

But Vermeulen feels it should be a supplement to treatment rather than a replacement.

"[Telemedicine] could change how we do things, but we believe that human connection is the key to any treatment programme and that you would use technology to complement a treatment programme rather than to replace it."

Who you can contact to help fight addiction:

• The Department of Social Development has a 24-hour helpline 0800 12 13 14. Alternatively, you can send an SMS to 32312 for online counselling and referrals.
• Sanca National can be contacted on 011 892 3829, or on WhatsApp on 076 535 1701 during office hours for referral to Sanca centres for emergency treatment options.
• Alcoholics Anonymous South Africa on 0861 435 722.
• Narcotics Anonymous is hosting 10 Zoom sessions per week that you can join. You can phone 083 900 6962 for more information.
• If you are not one for a 12-STEPS programme, try www.smartrecovery.org for a free online recovery programme.
• Family members or loved ones can contact Al-anon on 0861 252 666 for guidance.
• If people don't have access to the internet, they can download free applications on their cellphone such as Sober Grid, Nomo-sobriety Clocks, SoberTool, WE Connect, AA Big Book and 12 STEPS Meditation Daily Reflections and Strides.

READ: Video doctor visits gain ground during coronavirus pandemic

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