Implementing telemedicine for opioid addiction amongst youth of Pakistan

Addiction to opioids including other illicit substances is a chronic, relapsing multifactorial disorder of the brain and, if left untreated, can become a cause of more complications. Substance addiction is among the most prevailing health issues faced globally including in Pakistan. Its effect on physical and psychological health and become a leading cause of other problems. Drug addiction, whether it is single or multiple drug addiction is a major problem in Pakistan. It is defined as a maladaptive form of drug or illicit use leading to clinically significant distress or impairment, while an individual may also suffer from withdrawal and tolerance. It is already known that drug addiction or abuse is a common problem worldwide, including Pakistan. Substances categorized as stimulants, sedatives, hallucinogens, and opioids exploited throughout the world including Pakistan1. Psychiatric facilities in urban settings across Pakistan are reportedly surging with cases of opioid misuse. It is estimated that one in every 20 people between the ages of 15 and 64 is dependent on these lethal drugs; heroin being the most popular opioid in use2. Dealing with addiction places a significant burden on families, consuming their time, finances, and energy. Accessing reliable information online helps individuals and families take effective measures, but quitting drugs usually requires attendance at rehabilitation centers or doctor appointments, resulting in high costs. Video chatting with doctors can save time and money. Parents bear the primary responsibility for helping addicts quit, spending more time on transportation and counseling. These processes involve substantial expenses, including travel costs and multiple visits. As counseling progresses, parents’ involvement decreases, while addicts continue physical visits, emphasizing the potential benefits of virtual counseling options3. Telepsychiatry has been proven effective across various age groups and clinical settings, providing equivalent or more efficient care compared to face-to-face sessions. It improves access to mental health services, particularly in rural areas, and is cost-effective by increasing psychiatrist productivity and reducing travel-related expenses. Telepsychiatry is an attractive option, especially for communities with limited in-person access to psychiatric services4. Telephonic consultations gather patient history and provide psychological interventions, while medication prescriptions are not allowed. Video consultation is recommended for various scenarios, but in-person consultation is necessary for detailed examination, severe withdrawal, and specific medication needs. Consultant psychiatrists are involved in complex cases and clinical discretion throughout the process5. Despite challenges, digital health is growing with contributions from the public and private sectors. The success of these approaches remains uncertain due to limited evaluation and reporting. To ensure effectiveness, an informed policy and business environment is crucial, promoting collaboration among healthcare and IT stakeholders. Implementing a cycle of policy, execution, and assessment at various levels can pave the way for impactful eHealth programs in Pakistan, benefiting both individuals and healthcare providers6. Telehealth presents challenges and opportunities in social work practice, including providing services across state lines, delivering substance use disorder therapy online, and ensuring secure electronic record transmission. Community partnerships, understanding client needs, and addressing technology barriers are essential for effective implementation. Technology-mediated services, accelerated by the COVID-19 pandemic, offer practical solutions for improving mental health interventions. Social workers can advocate, conduct research, educate on technology use, and collaborate with resources to bridge access gaps. With resilience and clinical skills, social workers can positively impact substance use disorder clients and enhance care delivery through innovation and technology7. Pakistan has witnessed a ʻyouth bulgeʼ since the 1990s. The most recent statistics show that about 64% of the population is below the age of 30, with individuals aged 15 to 29 years forming 29% of this fraction. With such a magnanimous number and representation, youth can add up to the much-needed human resource. However, if not taken care of, they can turn into an absolute demographic plight for the country8. However, the circumstances have been very unfortunate. With over nine million people who are not just abusing drugs but are also labeled addicts, about 2 million lies in the age bracket of 15 to 25 years, with a vast majority of this figure attending colleges and universities9. Low self-esteem, poor goal-setting skills and a lack of insight about the future and career, minimal monitoring and supervision with easy access to illicit drugs, and distance from the family fabric and religious values are some of the risk factors for drug abuse. Such high-risk youngsters are more likely to give into peer pressure and succumb to drug culture10. In Pakistan, the prevalence of drug addiction is increasing at an alarming rate. According to the United Nations Office on Drugs and Crime (UNDOC) and the reports of the United Nations (UN), Pakistan has 7.6 million drug addicts, where 78% are males and 22% are females1. The mean age of opioid users interviewed was 35.5 years, which ranged between 14 and 66 years. Within the provinces, the older opioid users were in NWFP and Baluchistan where the mean age was around 37 years and younger drug users in Punjab and Sind – mean ages 34.2 and 33.6 years, respectively. Moreover, countrywide up to one third of drug users were between 31 and 40 years old, while in Punjab and Sind up to 40% of the drug users were between 16 and 30 years old. Compared to the national adult literacy rate of 49.9%, countywide up to 62% of drug users were literate (38% had no education). One-quarter of the drug users had up to primary education and more than a third had up to high school, that is, up to 12 years of education. In Punjab and NWFP significantly 33 more drug users – 43 and 38%, respectively, had up to high school education. Overall, up to 3% of drug compared to the national adult literacy rate of 49.9%, countywide up to 62% of drug users were literate (38% had no education). One-quarter of the drug users had up to primary education and more than a third had up to high school, that is, up to 12 years of education. In Punjab and NWFP significantly 33 more drug users – 43 and 38%, respectively, had up to high school education. Overall, up to 3% of drug users, more in Punjab, had higher education11. Factors responsible for the opioid intake among youth in the first place: Drug addiction is also associated with many risk factors like aggression, violence, isolation, and emotion dysregulation. There are many established and significant psychosocial risk factors like parental relationship, lack of achievement and motivation, self-esteem, psychological stress, and attention seeking behavior that are found positively correlated with substance abuse or addiction in Pakistan1. The euphoric effect of opioids, seeking refuge from life’s stresses, lack of knowledge about these drugs and influence of peers are among the causes of the opioid crisis in our country. Students in medical schools have easy access to these drugs from their respective hospitals, and they are often the ones maintaining the supply chain. Physical and emotional trauma endured in a battlefield can also lead to addiction as injured soldiers when treated with potent opioids experience the drugs’ euphoric effects2. Poor self-esteem and little motivation to succeed, access to drugs and encouragement from peers to use them, poor ties with those social institutions, value of family, religion, and career and some of the factors that affect as well10. Telemedicine, the remote delivery of healthcare services through telecommunications technology, holds immense potential in combating opioid addiction among youth. By leveraging this innovative approach, we can overcome barriers and ensure timely, high-quality treatment, particularly in underserved areas. Through telemedicine, we can reach remote and marginalized communities, providing essential medical consultations, therapy sessions, and medication management. This transformative solution has the power to bridge gaps in addiction treatment access, addressing the needs of underserved populations and making a significant impact in the fight against opioid addiction among youth. Impact and challenges Since the youth of any nation is its ultimate asset, it is high time to actively tackle the issue of increasing drug addiction and opioid use in the youth. According to the United Nations Office on Drug and Crime 2013 report, over 76% of opiate users stated they wanted assistance and help for their dependence. The most common reason cited for not having done so was the inability to pay for the therapy12. Other obstacles include the presence of only a few specialists, distant locations, and inadequate infrastructure. The youth with addiction in remote areas where there is a lack of medical doctors and trained paramedics are obliged to travel a long distance even to the closest clinic or rehabilitation facility if they choose to get help. This all results not only in the apparent frustration of inconvenience and the nuisance of arranging doctors’ fees but also an unapparent, higher loss cumulatively with the individuals having to pay for the transportation costs; they are also forced to take a leave from their academic institutes as they travel, resulting in a loss of their prime study time6. The gravity of the situation further intensifies when it comes to the scarcity of methadone clinics and the paucity of addiction specialists and physicians trained to prescribe medication-assisted treatment (MAT) for opioid use disorder (OUD). The resulting frustrating delays and patient dissatisfaction can greatly discourage those trying to seek care, exacerbating the already detrimental condition4. Having the opioid endemic explained in the context of the Pakistani youth, telemedicine can serve a crucial role in eradicating opioid use and drug addiction. If adopted as one of the means of curbing the problem, it will transcend many of the mentioned hurdles in the way of addicts receiving help. Telemedicine includes the use of different modalities of distant communication to help facilitate the dissemination of basic health requirements to even the farthest and remotest rural areas. It attempts to give populations based in such underprivileged regions the same access to basic health knowledge, prompt diagnosis, and treatment as an urban population. Online monitoring via the internet, on-call patient-physician dialog for tailored diagnosis and treatment, and text or e-mail reminders are some of the interventions falling under telemedicine13. OUD treatment needs a multifaced approach and telemedicine has the potential to be one of the stakeholders. It can help by boosting the efficiency of the relevant specialists and experts while overcoming the logistical barriers to access to in-person assistance by physiatrists and MAT4. Despite the fact that Pakistan is still in the early phases as it tries to integrate telemedicine into its healthcare system, telemedicine has already shown fairly successful results so far6. Thus, it is quite reasonable to take the initiative of introducing telemedicine to beat the menace of opioid addiction rightly at this time. Improvements and enhancements can be made as the network expands and the healthcare infrastructure becomes more suited to get the most out of what telemedicine has to offer. There are certain challenges that will come with the implementation of telemedicine, such as technical and internet service issues, potential threats to breach in patient confidentiality, and legal restrictions to the prescription of drugs (for instance, for MAT). However, these can be dealt with very efficiently by developing a strategic plan and adopting a wise policy. This will satisfactorily address the ethical dilemmas and legal concerns5. The use of telemedicine for combating drug addiction and for the treatment of OUD has already been put into practice in not only developed countries like the USA4 or Canada14, but also in developing nations like some in our very own region, India5 and Bangladesh3. Hence, by putting a little effort into laying down a strategy or adopting a model being utilized in these countries with adjustments for our own system, we can start right away. Efforts and recommendations Multiple efforts have been made to rehabilitate people suffering from drug addiction in Pakistan. The Anti-Narcotics Force has been set up, which is responsible for running the Model Addicts Treatment and Rehabilitation Centers in various cities of Pakistan, such as Karachi, Islamabad, Sukkur, and Hyderabad15. These are run mainly for rehabilitation, as most hospitals have a detoxification facility but no rehab center. However, these present a few problems; they are only present in a few cities, and therefore not accessible to those in remote areas. Another organization is the IRADA Clinic, also known as the Institute of Rehabilitation and Drug Addiction16. IRADA focuses on providing programs tailored for specific individuals’ needs. It also provides extended care to help patients transition to everyday life with ease and a lower chance of relapse. In this way, it helps treat addiction at its root cause. A more recent effort is the establishment of the Center for Drug Addiction and Rehabilitation at Sheikh Zayed Medical College in Rahim Yar Khan in 202017. The center provides multiple facilities for patients of substance use disorders, such as a psychiatric ICU and ketamine clinic. There is also a 21-days inpatient detoxification service after which they provide rehabilitation. Up till now, there have been only a few telemedicine clinics in Pakistan, and most of these do not provide telepsychiatry. Aga Khan University Hospital has introduced a telepsychiatry program for northern Pakistan, which is beneficial to the people living there, as the region is very remote18. Another teleclinic is telepsychiatry.pk19, which lets patients ask for help anonymously. However, none of these programs are targeted specifically towards rehabilitation for patients of substance use disorders, and there are multiple problems regarding the use of telemedicine, which will be covered in the following section. Multiple telepsychiatric clinics focusing on treating drug addiction have been set up all over the world, and Pakistan can follow in their footsteps in order to treat this problem more effectively. One example is the Thikana Telepsychiatry Clinic in Bangladesh20. While telepsychiatry is relatively new in Bangladesh as well, there has been a positive response to telemedicine3. The Drug De-addiction & Treatment Center of the Postgraduate Institute of Medical Education & Research in Chandigarh, India, is another example of a telepsychiatric clinic focused on treating substance use disorders5. It employs a step-wise approach, by first performing a teleconsultation call to conduct a basic clinical assessment and determine the intensity of the treatment required. After that, the patient is either prescribed a video call in order to ensure that there is no discrepancy regarding patient identity, and get to know further details about the patient, or an in-person consultation so that the patient can begin treatment or rehabilitation. This model reduces the cost and time of traveling to a clinic to get information about substance abuse. Project ECHO is a notable telemedicine program targeted towards treating OUD in the USA, based in New Mexico21. This has been met with a positive response, with project ECHO reporting that it has reduced waiting times for patients. Another treatment program is the Eastern Shore Mobile Care Collaborative (ESMCC) at Caroline County Health Department22. It aims to provide services in rural regions using synchronous forms of telehealth. In San Francisco, the Citywide Case Management Program is in function, with 170 staff members and four teams focused on different groups, namely, the Hong Ling team which is Chinese, Cross Currents Team (LGBTQ and women), Kujichagulia team (African- and European-American) and Senderos team (Latino and Korean). They provide multiple behavioral therapies, such as cognitive behavioral therapy and cognitive processing therapy. Citywide also distributed cellphones to clients who did not own one to keep them engaged in treatment. Lastly, the REACH Project, Inc. based in Ithaca, New York State was established in 2018, but shifted to entirely online services in 2020 due to the COVID-2019 pandemic. Since many clients do not have consistent access to WiFi, REACH also uses landline calls and texting to get in touch with them. In order to combat opioid addiction in Pakistan effectively, we will need programs modeled similar to the ones listed above. The use of mobile vans can help spread awareness to remote regions where rehab facilities are not available, while text and landline or cellphone-based telemedicine can improve the reach of teleclinics to areas where WiFi is not consistently available. In urban regions, teleclinics which allow the user to stay anonymous will reduce barriers as more people will reach out for help without worrying about the stigma associated with substance abuse. Conclusion Combating opioid addiction among Pakistani youth and adolescents requires a multifaceted approach that combines awareness, prevention, and comprehensive treatment. Telemedicine has the potential to revolutionize addiction care delivery by overcoming barriers of accessibility and stigma. By advocating for its implementation, we can pave the way for a brighter and healthier future for our nation’s youth. Ethical approval Ethical approval was not required for this correspondence. Consent Consent was not required for this correspondence. Sources of funding None. Author contribution All authors made substantial contributions to the manuscript. Conflicts of interest disclosure The authors declare that they have no financial conflicts of interest with regard to the content of this report. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Abdullah Malikzai. Provenance and peer review Not commissioned, externally peer reviewed.

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