Standards › Standard 38 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · SUB-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 38.3
At a glance
- Harm reduction services are listed and available (SUB-REG-001).
- Naloxone is offered to every person at risk and supplied where accepted.
- Safer use information is given to each person who uses substances.
- A testing referral is offered and recorded.
- Stop and get help straight away if: a person at risk of overdose is not offered naloxone.
1. Purpose
To reduce the harm of substance use for people who use substances (38.3).
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
People who use substances face serious harm from overdose and infection. Harm reduction services save lives and bring people into care, and they should be available to anyone who needs them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for addiction services | Owns the harm reduction service and its stock | Clinical director |
| Any clinician or outreach worker | Offers naloxone, information and referral | 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. Offer.
- Offer naloxone, safer use information and a testing referral to each person at risk.
Key point: Offered.
Step 2. Supply.
- Supply naloxone where accepted and record the supply (SUB-REG-001).
Key point: Supplied.
Step 3. Refer.
- Refer for testing and record the referral.
Key point: Referred.
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 |
|---|---|---|---|---|
| People at risk offered naloxone | 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-REG-001 | Naloxone and harm reduction register | Register |
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)