Standard 38: Substance Use and Addiction Treatment

Why it matters. Substance use treatment starts with knowing what the person uses, how much and how often. A validated screening tool gives a common starting point that can be compared over time.

Sample. Review assessment records for 20 people who started treatment in the last 6 months.

1. Each person has a substance use assessment dated before the treatment plan.

Method. Check each record for an assessment dated before the plan.

Evidence to show. Substance use assessment record (SUB-FRM-001).

Pass when. Every sampled person has an assessment before the plan.

2. The assessment uses a validated screening or assessment tool, and the tool is named.

Method. Check each assessment for the tool named and the score recorded.

Evidence to show. Validated substance use assessment (SUB-SOP-001).

Pass when. Every assessment names a validated tool and records a score.

3. The assessment is repeated at the set interval.

Method. Check each record for the repeat assessment dates against the interval.

Evidence to show. Substance use assessment record (SUB-FRM-001).

Pass when. Every sampled person has repeat assessment at the set interval.

Immediate fail (any one means the criterion is not met)

• A person starts treatment with no assessment of substance use on file.

Why it matters. 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.

Sample. Review treatment plans and prescribing records for 20 people, including any given medicines for substance use.

1. Each person has an individual treatment plan.

Method. Check each plan for goals and interventions specific to the person.

Evidence to show. Individual treatment and prescribing (SUB-POL-001).

Pass when. Every sampled person has an individual plan.

2. Medicines are prescribed by a licensed clinician and reviewed at the set interval.

Method. Check each prescription for the prescriber and the review dates.

Evidence to show. Opioid prescribing review record (MNP-FRM-001, existing, reused).

Pass when. Every prescription is by a licensed clinician and is reviewed.

3. Monitoring is recorded for each prescribed medicine.

Method. Check each record for monitoring entries against the monitoring plan.

Evidence to show. Individual treatment plan record (SUB-FRM-002).

Pass when. Every prescribed medicine has monitoring recorded.

Immediate fail (any one means the criterion is not met)

• A person prescribed an opioid medicine by phone with no monitoring and no individual plan.

Why it matters. 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.

Sample. Review harm reduction records for the last 6 months, including naloxone supply and testing referrals.

1. Harm reduction services are available to people who use substances.

Method. Check the service list for the harm reduction services offered.

Evidence to show. Harm reduction services and naloxone access (SUB-SOP-002).

Pass when. Harm reduction services are listed and available.

2. Naloxone is offered and supplied to people at risk, with the supply recorded.

Method. Check the register for each naloxone supply against the offer recorded.

Evidence to show. Naloxone and harm reduction register (SUB-REG-001).

Pass when. Every person at risk has a naloxone offer and supply recorded.

3. Referral for testing is offered and recorded.

Method. Check each record for the testing offer and the referral.

Evidence to show. Naloxone and harm reduction register (SUB-REG-001).

Pass when. Every testing offer and referral is recorded.

Immediate fail (any one means the criterion is not met)

• A person who uses opioids is not offered naloxone or a testing referral.

Why it matters. A person who uses substances may fear arrest or stigma if their information is shared. Keeping it confidential, and sharing it only with consent or where the law requires, keeps them coming back to care.

Sample. Review information-sharing records for 15 people, including any request for information from a third party.

1. Information about substance use is kept confidential.

Method. Check each record for the confidentiality status and the access controls.

Evidence to show. Confidentiality of substance use information (SUB-POL-002).

Pass when. Every record is held under confidentiality controls.

2. Information is shared only with consent or where the law allows.

Method. Check each sharing event for the consent or the legal basis recorded.

Evidence to show. Shared record access check (PHC-FRM-001, existing, reused).

Pass when. Every sharing event has consent or a legal basis recorded.

3. Each disclosure is recorded with the person, the reason and the date.

Method. Check the disclosure log for each entry.

Evidence to show. Confidentiality of substance use information (SUB-POL-002).

Pass when. Every disclosure is recorded with its reason and date.

Immediate fail (any one means the criterion is not met)

• A person’s substance use disclosed to an employer without consent.

Why it matters. Leaving treatment without a link to community support is a common reason for relapse. A planned discharge with referrals keeps the person connected after the service ends.

Sample. Review discharge and transfer records for 15 people who left treatment in the last 6 months.

1. Discharge or transfer is planned in advance.

Method. Check each record for the plan dated before the discharge date.

Evidence to show. Discharge, community support and relapse plan (SUB-SOP-003).

Pass when. Every sampled discharge has a plan dated before it.

2. Each person is referred to community support.

Method. Check each record for the referral and the receiving service.

Evidence to show. Referral criteria and referral tracking (PHC-SOP-003, existing, reused).

Pass when. Every sampled person has a community referral recorded.

3. A relapse plan is agreed with the person and recorded.

Method. Check each record for the relapse plan and the person’s agreement.

Evidence to show. Discharge, community support and relapse plan record (SUB-FRM-003).

Pass when. Every sampled person has a relapse plan agreed and recorded.

Immediate fail (any one means the criterion is not met)

• A person discharged from treatment with no community referral and no relapse plan.