Standard 31: Substance Use and Addiction Treatment (Version 11)

Each person has a documented assessment of their substance use, using a validated screening or assessment tool, before a treatment plan is agreed.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.

Guidance

Treatment starts with knowing what the person uses, how much and how often. A validated screening or assessment tool gives a common starting point that can be compared over time, and the tool used is named in the record.

The assessment is dated before the treatment plan. It is repeated at the set interval, and each repeat is recorded so that progress or relapse can be seen.

What good looks like

• A validated assessment procedure (SUB-SOP-001) that names the approved tools.
• A substance use assessment record (SUB-FRM-001) completed for each person before the plan.
• The tool and score recorded for every assessment.
• Repeat assessments recorded against the set interval.

Common mistakes

• A plan agreed first and the assessment completed afterwards.
• An assessment with no named tool, so its result cannot be compared.
• Repeat assessments done only when the person asks.
• Assessment records held in separate files and not linked to the plan.

Questions the surveyor asks

• Each person has a substance use assessment dated before the treatment plan. The surveyor checks each record for an assessment dated before the plan.
• The assessment uses a validated screening or assessment tool, and the tool is named. The surveyor checks each assessment for the tool named and the score recorded.
• The assessment is repeated at the set interval. The surveyor checks each record for the repeat assessment dates against the interval.

How the surveyor verifies this criterion

References

1. WHO (2023). Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. https://news.gmj.ge/guideline/mental-health-gap-action-programme-mhgap-guideline-for-mental-neurological-and-substance-use-disorders/
2. World Health Organization (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: WHO. https://news.gmj.ge/guideline/guidelines-for-the-psychosocially-assisted-pharmacological-treatment-of-opioid-dependence/

Each person has an individual treatment plan. Where medicines are part of treatment, they are prescribed and monitored by a qualified clinician, following WHO guidance on the treatment of substance use.

Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.

Guidance

Treatment for substance use must fit the person. The individual plan sets goals and interventions specific to that person, and it is reviewed with them.

Where a medicine is part of treatment, a licensed clinician prescribes it and records the monitoring for each prescription, following WHO guidance on opioid dependence. Monitoring is checked against the monitoring plan.

What good looks like

• An individual treatment and prescribing policy (SUB-POL-001).
• An individual treatment plan record (SUB-FRM-002) for each person.
• Monitoring recorded for every prescribed medicine.
• Prescribing limited to licensed clinicians.

Common mistakes

• The same plan copied for everyone.
• An opioid medicine prescribed by telephone with no assessment or monitoring.
• Monitoring entries missing for weeks.
• Prescribing delegated to staff who are not licensed to prescribe.

Questions the surveyor asks

• Each person has an individual treatment plan. The surveyor checks each plan for goals and interventions specific to the person.
• Monitoring is recorded for each prescribed medicine. The surveyor checks each record for monitoring entries against the monitoring plan.

How the surveyor verifies this criterion

References

1. WHO (2025). Opioid agonist maintenance treatment as an essential health service: implementation guidance on mitigating disruption of services for treatment of opioid dependence. https://news.gmj.ge/guideline/opioid-agonist-maintenance-treatment-as-an-essential-health-service-implementation-guidance-on-mitigating-disruption-of-services-for-treatment-of-opioid-dependence/
2. World Health Organization (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: WHO. https://news.gmj.ge/guideline/guidelines-for-the-psychosocially-assisted-pharmacological-treatment-of-opioid-dependence/

Harm reduction services are available to people who use substances, including access to naloxone, information on safer use, and referral for testing for blood-borne infections.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.

Guidance

People who use substances face serious harm from overdose and infection. The harm reduction services offered are listed in the procedure (SUB-SOP-002), so that anyone who needs them knows what is available.

Naloxone is offered to people at risk and each supply is recorded in the naloxone and harm reduction register (SUB-REG-001). Each testing offer and referral for blood-borne infections is recorded in the same register.

What good looks like

• A harm reduction and naloxone procedure (SUB-SOP-002) listing the services offered.
• A naloxone and harm reduction register (SUB-REG-001) kept for each person.
• A naloxone offer and supply recorded for each person at risk.
• Testing offer and referral recorded for each person.

Common mistakes

• Naloxone available on the shelf but not offered to people at risk.
• Supplies given with no entry in the register.
• Testing referrals made verbally and not recorded.
• Services listed on paper that the service does not actually provide.

Questions the surveyor asks

• Harm reduction services are available to people who use substances. The surveyor checks the service list for the harm reduction services offered.
• Naloxone is offered and supplied to people at risk, with the supply recorded. The surveyor checks the register for each naloxone supply against the offer recorded.
• Referral for testing is offered and recorded. The surveyor checks each record for the testing offer and the referral.

How the surveyor verifies this criterion

References

1. World Health Organization (2025). Opioid agonist maintenance treatment as an essential health service: implementation guidance on mitigating disruption of services for treatment of opioid dependence. https://news.gmj.ge/guideline/opioid-agonist-maintenance-treatment-as-an-essential-health-service-implementation-guidance-on-mitigating-disruption-of-services-for-treatment-of-opioid-dependence/
2. World Health Organization (2026). Consolidated guidance on hepatitis B and C prevention, testing, treatment, service delivery and monitoring. https://news.gmj.ge/guideline/consolidated-guidance-on-hepatitis-b-and-c-prevention-testing-treatment-service-delivery-and-monitoring/

Information about a person's substance use is kept confidential. It is shared only with consent or where the duty of confidentiality allows, and each disclosure is recorded. This criterion adds to the record-keeping and confidentiality rules in Standard 1.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.

Guidance

A person who uses substances may fear arrest or stigma if their information is shared. Information about substance use is held under confidentiality controls, and access is limited to the staff who need it for care.

Information is disclosed only with the person's consent or where the law requires it. Each disclosure is recorded with the person, the reason and the date in the disclosure log, under the confidentiality policy (SUB-POL-002).

What good looks like

• A confidentiality policy for substance use information (SUB-POL-002).
• Access controls on every record of substance use information.
• A disclosure log with the person, reason and date of each disclosure.
• Staff trained in confidentiality (T-11).

Common mistakes

• Information shared with an employer or family without consent or legal basis.
• Disclosures made by telephone and not logged.
• Records left open to staff who do not need them for care.
• Requests from third parties answered without checking consent.

Questions the surveyor asks

• Information about substance use is kept confidential. The surveyor checks each record for the confidentiality status and the access controls.
• Each disclosure is recorded with the person, the reason and the date. The surveyor checks the disclosure log for each entry.

How the surveyor verifies this criterion

References

1. WHO (2025). Global standards for quality health care services for adolescents. https://news.gmj.ge/guideline/global-standards-for-quality-health-care-services-for-adolescents/

Discharge and transfer are planned in advance, with referral to community support, and with a relapse plan agreed with the person.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: home care, fitness and wellness, dental clinic, aesthetic and procedure clinic.

Guidance

Leaving treatment without a link to community support is a common reason for relapse. Each discharge or transfer is planned in advance, and the plan is dated before the discharge date.

A relapse plan is agreed with the person and recorded on the discharge and relapse plan record (SUB-FRM-003), together with the community support the person has been referred to.

What good looks like

• A discharge, community support and relapse plan procedure (SUB-SOP-003).
• A discharge and relapse plan record (SUB-FRM-003) for each person.
• Referral to community support recorded before discharge.
• Relapse plan agreed and signed with the person.

Common mistakes

• A person discharged with no referral and no plan.
• A relapse plan written by staff and never discussed with the person.
• Plans dated after the discharge.
• Referral letters sent but not followed up.

Questions the surveyor asks

• Discharge or transfer is planned in advance. The surveyor checks each record for the plan dated before the discharge date.
• A relapse plan is agreed with the person and recorded. The surveyor checks each record for the relapse plan and the person's agreement.

How the surveyor verifies this criterion

References

1. World Health Organization (2025). Opioid agonist maintenance treatment as an essential health service: implementation guidance on mitigating disruption of services for treatment of opioid dependence. https://news.gmj.ge/guideline/opioid-agonist-maintenance-treatment-as-an-essential-health-service-implementation-guidance-on-mitigating-disruption-of-services-for-treatment-of-opioid-dependence/
2. World Health Organization (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: WHO. https://news.gmj.ge/guideline/guidelines-for-the-psychosocially-assisted-pharmacological-treatment-of-opioid-dependence/