Standards › Standard 38 › Policies
Policy · SUB-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 38.2
At a glance
- Each person has an individual treatment plan (SUB-FRM-002).
- Medicines are prescribed and monitored by a licensed clinician.
- Opioid prescribing follows the stewardship policy (MNP-POL-002).
- Monitoring is recorded against the plan at the set interval.
- Stop and get help straight away if: a medicine is prescribed to a person with no individual plan or no monitoring.
1. Purpose
To make sure treatment is individual, prescribed safely, and monitored (38.2).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Treatment for substance use must fit the person. A plan built for them, and medicines prescribed by a licensed clinician, keep the treatment safe and effective.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for addiction services | Owns the treatment and prescribing standard | Clinical director |
| Prescribing clinician | Writes the plan, prescribes and monitors | Clinical lead for addiction services |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Plan.
- Write the individual treatment plan with goals and interventions (SUB-FRM-002).
Key point: Planned.
Step 2. Prescribe.
- Prescribe any medicine as part of the plan, under the stewardship policy.
Key point: Prescribed.
Step 3. Monitor.
- Monitor the person and the medicine against the plan at the set interval.
Key point: Monitored.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Plans with monitoring recorded at the set interval | 100% | Monthly | Clinical lead for addiction services | Escalate to the clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SUB-FRM-002 | Individual treatment plan record | Record |
| MNP-POL-002 | Opioid stewardship (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (2009), the WHO Guidelines on HIV and harm reduction for people who inject drugs, and the ASF Ambulatory standard for addiction services. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Narcology & Addiction Treatment (AMB-21)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)