Drug And Alcohol Treatment Guidelines For Residential Settings
Drug and alcohol treatment guidelinesfor residential settingsFebruary 2007SHPN (MHDAD) 070010
NSW DEPARTMENT OF HEALTH73 Miller StreetNORTH SYDNEY NSW 2060Tel. (02) 9391 9000Fax. (02) 9391 9101TTY. (02) 9391 9900www.health.nsw.gov.auThis work is copyright. It may be reproduced in whole or in part for studytraining purposes subject to the inclusion of an acknowledgement of the source.It may not be reproduced for commercial usage or sale. Reproduction forpurposes other than those indicated above requires written permission fromthe NSW Department of Health. NSW Department of Health 2007SHPN (MHDAO) 070010ISBN 978 1 74187 042 8For further copies of this document please contact:Better Health Centre – Publications WarehouseLocked Mail Bag 5003Gladesville NSW 2111Tel. (02) 9816 0452Fax. (02) 9816 0492Further copies of this document can be downloaded from theNSW Health website www.health.nsw.gov.auFebruary 2007
AcknowledgementsThese guidelines draw heavily on the works of:n Msn SigginsI, Miller M. Draft “First cut” Treatmentguidelines for drug and alcohol residential rehabilitationtreatment services. 2004 [a report commissioned byNADA and a precursor to this document].n GowingL, Cooke R, Biven A, Watts D. Towards betterpractice in therapeutic communities. AustralasianTherapeutic Communities Association, 2002.www.nada.org.au/downloads/TBPTC.pdfn AustralasianTherapeutic Communities AssociationQuality Assurance Peer Review 1995Maggie Bradyn Odysseyn Kamiran TedHouse – NSWFarmNoffs Foundationn KedeshRehabilitation Servicesn WeHelp Ourselves – NSW.The guidelines were compiled and edited by Barry Evans,Director, The Buttery, with the editorial assistance ofCraig Bingham, Australasian Medical PublishingCompany, Sydney.NSW Health Drug and alcohol treatment guidelines for residential settings PAGE
Contents1Terms of reference. 41.1Aims of the guidelines.41.2What is treatment?.41.3 What is a drug and alcohol residentialtreatment service?.41.4Residential treatment modalities.52 brief history of residentialAtreatment in NSW. 62.1Introduction.62.2Range and type of service provision.62.3 Residential services provided byArea Health Services.75Induction. 146Treatment. 156.1Best practice.156.2Duration of and retention in treatment.166.3Harm reduction.177 Assessment during and aftertreatment. 187.1Assessing progress during treatment.187.2 Common/consistent assessmentforms and outcome measures.188 ompletion of treatment andCcontinuing care. 198.1Continuing care and support programs.198.2Social rehabilitation.208.3Follow-up after treatment.209 Management issues for treatmentprograms. 219.1Organisation, policy and procedures.214.1 Assessing the needs of peopleseeking treatment.119.2Philosophy and approach.219.3Quality assurance mechanisms.214.2Treatment matching.129.4Evaluation of treatment programs.214.2.1 Suitability for shorter termresidential programs.129.5Case management.229.6Risk management.229.7Duty of care.239.8Clients with HIV or hepatitis.233Effectiveness of residential treatment. 83.1Evidence of effectiveness.83.2Principles for effective treatment.83.3 Minimum standards for residentialtreatment programs.104 Who should receive residentialtreatment?. 114.2.2 Suitability for longer termresidential programs.134.3 Administrative requirements forassessment procedures.134.4Non-acceptance into a program.13PAGE NSW Health Drug and alcohol treatment guidelines for residential settings
10 uidelines specific to therapeuticGcommunities. 2411.3 Young people.3110.1 Definition and theoretical basisof a therapeutic community.2411.3.2 Towards more effective treatment.3111.3.1 Treatment outcome studies.3111.3.3 Assessment.3310.2 Ethos of the therapeutic community.2511.3.4 Interventions for young people.3310.2.1 Nature of substance abuseand recovery.2511.3.5 Treatment matching.3311.3.6 A model of residential treatment.3410.2.2 Broad concept of therapeuticcommunity approach.2511.3.7 After treatment.3410.2.3 Dimensions of socialisation.2511.4 Mental illness and substance abuse.3510.2.4 Psychological/behaviouraldimensions.2511.4.1 Definition of dual disorder/comorbidity.3510.3 Aspects of program delivery.2611.4.2 Issues in service delivery.3510.3.1 Ensuring a safe environment.2611.4.3 Continuum of interventions.3510.3.2 Encouraging community spiritand a sense of belonging.2611.5 Aboriginal and Torres Strait Islander peoples.3810.3.3 Program structure.2611.6 People from culturally and linguisticallydiverse backgrounds (CALD).3910.3.4 Encouraging behavioural change.2711.7 Pharmacotherapies in residential programs.3910.3.5 Treatment planning.2711.7.1 Prescribed medications.3910.3.6 Treatment components.2711.7.2 Pharmacotherapies for drugdependence.3910.3.7 Staffing dimensions.2811.7.3 Residential treatment with the use ofantagonist pharmacotherapy.4010.4 Quality assurance.281111.7.4 Residential treatment of people onmethadone or buprenorphinemaintenance treatment.40Groups with particular needs. 2911.1 Women .2911.1.1 Overcoming barriers to treatment.2911.7.5 Residential treatment of peopleseeking to discontinue methadoneor buprenorphine maintenance.4011.1.2 General clinical issues.3011.1.3 Sexual and physical abuse.3011.1.4 Psychological and medical concerns.3012References. 4211.1.5 Childcare.3011.2 Men or women with children.3011.2.1 Child development program.3011.2.2 Parent effectiveness training.3011.2.3 Accomodation.3111.2.4 Play equipment.3111.2.5 Safety.3111.2.6 Visits.3111.2.7 Discharge from program.31NSW Health Drug and alcohol treatment guidelines for residential settings PAGE
SECTION 1Terms of reference1.1Aims of the guidelinesThese guidelines provide recommendations for residentialtreatment of people with drug or alcohol dependence.The intent of the guidelines is to increase theeffectiveness of treatment and to improve treatmentoutcomes. They are based as far as possible on theevidence reported in peer reviewed literature.The guidelines differentiate between services whichprovide residential care and those which provideresidential treatment and make a further distinctionbetween residential treatment services andtherapeutic communities.1.2What is treatment?According to the NSW Health Department TreatmentData Collection Guidelines, a treatment episode is:a period of contact, with a defined date ofcommencement and cessation, between a clientand a provider or team of providers that occursin one setting and in which there is no majorchange in either the goal of intervention or thepredominant treatment activity.A National Campaign Against Drug Abuse working partydefined treatment in a drug and alcohol context as:any person to person intervention which is designedto identify and minimise hazardous, harmful ordysfunctional drinking/drug taking behaviour.(Ali et al 1992)As the terms “clinician” and “clinical” are stronglyassociated with medical treatment, and these guidelinesare about improving the quality of treatment in nonclinical settings, they are called “treatment guidelines”rather than “clinical guidelines”.In these guidelines, “residential treatment” is theintervention period from assessment through intake tothe residential program and finally reintegration backinto the community through continuing care. The threephases of intervention which these guidelines coverare commonly known as assessment, treatment andreintegration. These guidelines do not address theresidential stay in a detoxification or withdrawal program.1.3What is a drug and alcoholresidential treatment service?In this document, “residential treatment service” is ageneral term for 24-hour, staffed, residential treatmentprograms that offer intensive, structured interventionsafter withdrawal from drugs of dependence,including alcohol.Residential treatment is based on the principle that aresidential setting free of non-prescribed drugs andalcohol provides an appropriate environment in which toaddress the underlying causes of dependence. Residentialtreatment services aim to effect lasting change and toassist with reintegration back into the general communityafter treatment.Distinctions do need to be made between residentialtreatment intended to produce therapeutic change andresidential care intended as a welfare intervention.Residential care may be a necessary precursor toresidential treatment for some potential residents whoselevel of dependence, social isolation and dysfunctionhave been barriers to entering treatment in the past.Some residential facilities provide welfare functions suchas beds and a drug and alcohol-free living environmentbut do not provide treatment for drug and alcoholproblems. A stay in this sort of residential care will usuallyprovide respite from drug and alcohol use, but will notgive residents the skills to remain drug/alcohol free oncethey have left the facility.PAGE NSW Health Drug and alcohol treatment guidelines for residential settings
Residential programs that do intervene to change anindividual’s drug or alcohol use have in the past beencolloquially referred to as “rehab”. “Rehabilitation”is a term that accurately reflects the objectives oftreatment, ie:The main distinction that has emerged among residentialtreatment programs is between therapeutic communitiesand other residential programs.n Therapeutic communities emphasise a holisticapproach to treatment and address the psychosocialand other issues behind substance abuse. The“community” is thought of as both the context andmethod of the treatment model, where both staff andother residents assist the resident to deal with his orher drug dependence.n Other residential programs deliver regular treatmentto residents, such as counselling, skills training andrelapse prevention, to address the psychosocial causesof drug dependence. Types of residential programsinclude:to educate and help (a person affected by accidentor disease) to take up normal activities again.To re-establish (a person, character, name, etc)in a position of respect. To return formally toan earlier position, rank, rights etc(Macquarie Dictionary)Differences of opinion over the aetiology of drug andalcohol dependence mean that “rehabilitation” is notalways the accepted term for all residential treatment.In this document, the term “residential treatment” is used.1.4Residential treatment modalities– Short term residential treatment, often providedin conjunction with a medically supervisedwithdrawal programVarious modalities or treatment approaches for residentialtreatment are available in New South Wales, reflectingthe range of philosophies and interventions availableand the range of special populations served bydifferent programs. – Longer term residential treatment over 12–52weeksResidential programs generally include living skillstraining, parenting skills, case management andcounselling using cognitive behaviour therapy ormotivational interviewing. Most programs use groupwork as part of a structured program. – Opioid substitution treatment tapering toabstinence.– Low intensity residential treatment and extendedcare, in which clients live semi-independently withsupport(NSW Health Drug and Alcohol Program StrategicDirections 2005–2010).NSW Health Drug and alcohol treatment guidelines for residential settings PAGE
SECTION 2A brief history of residential treatment in NSWIntroduction2.1Residential treatment programs in NSW have a longhistory and were, until the early 1980s, characterisedby disease concepts, “Twelve Step” approaches andtreatment models imported from overseas. Treatmentresponses to illicit drug use have evolved since the 1970swith the introduction of methadone and the first longterm residential treatment programs. The long-termprograms were established primarily for heroin users,some of whom were bonded by the courts to programs.In the last two decades, shorter term residentialtreatment programs have arisen to suit the needs ofpeople with less severe alcohol and drug problems, andwith a focus on cognitive/behavioural and relapseprevention interventions. In NSW about one third of theresidential beds available fall into this category, with aprogram duration of about one month.2.2In NSW there are 34 health funded residential treatmentservices providing more than 900 beds. All but two areprovided by non-government organisations (NGOs) andare members of the Network of Alcohol and DrugAgencies (NADA).NGO residential treatment programs and their locationsare listed on the NADA website www.nada.org.auThe provider NGOs exhibit differences that can bedescribed in part by their origin, in part by theiraffiliations and in part by their practice:nFor both short and longer-term treatment programs,it is the residential setting that is crucial to thetreatment process.There are three types of residential treatment serviceproviders in NSW:services: These agencies aremostly independent organisations that have arisenthrough community effort and successfully soughtfunding at some time after they were initiated.The most common examples are the therapeuticcommunities. These services largely emerged in responseto the growth in illicit drug use since the 1970s.2 Private for-profit providers, mainly private hospitalsn Associations incorporated under the AssociationsIncorporation Act 1984n Co-operatives under the Co-operation Act 1992n ajor charities: Some major charitable organisationsMprovide alcohol or drug treatment services as part ofa larger social welfare commitment. They often havestrong religious affiliations and are well known to thecommunity. They are large organisations which caninfluence Government and tend to maintain highpublic profiles. Grant funding supplements the maincharitable income source for these agencies.n Community-based1 Government administered agencies provided byArea Health Services3 Incorporated not-for-profit agencies, includingcharities, benevolent institutions under the tax actand organisations incorporated under the followingprovisions:Range and type of serviceprovisioninitiated NGOs: These services are amore recent phenomenon where Government hasdetermined a need for a specific type of service andhas sought to have it provided by a non-governmentorganisation. These services have emerged in the last10 to 15 years.n Government Companies under corporations law.PAGE NSW Health Drug and alcohol treatment guidelines for residential settings
Most residential treatment services are in or near theSydney metropolitan area. Historically, regions which didnot have adequate withdrawal and ambulatory servicesusually did not provide residential treatment services, asthere was no “feeder” system. This is gradually changingas new rural withdrawal units are built or NGOs establishtheir own withdrawal units.There are relatively few dedicated services for women,women and children, families, or people from nonEnglish speaking backgrounds.2.3Residential services provided byArea Health ServicesTwo Area Health Services provide adult residentialtreatment services (25 beds in total). The services weredesigned to provide brief intensive support and to focuson the transition phase of supported accommodation,outreach counselling and social support. Successfuloutcomes for these programs are predicated on intensivefollow-up after discharge from the residential setting.Some of the larger residential treatment programs doprovide services for people from non-English speakingbackgrounds and Aboriginal and Torres Strait Islanderpeople, and a small number of services provide separatewomen’s programs that can also accommodate children.There are also eight dedicated Aboriginal and TorresStraight Islander residential treatment services in NSW(Brady 2002).NSW Health Drug and alcohol treatment guidelines for residential settings PAGE
SECTION 3Effectiveness of residential treatment3.1Evidence of effectivenessDespite the popularity of various residential treatmentprograms, most of the literature about this type oftreatment focuses on the therapeutic community model.There is little available on the effectiveness of residentialtreatment modalities other than the therapeuticcommunity (Ernst & Young 1996).The 12-month and 24-month findings of the AustralianTreatment Outcome Study suggest that residentialtreatment services do see people who are “harder cases”– that is, people with longer-standing drug problemsand/or a history of failed treatment, lack of socialsupport, psychological comorbidity (Ross et al 2004).The 24-month follow-up study found that 71 per centof study participants were abstinent in the month beforetheir follow-up interview and that changes in other druguse from baseline were most evident in the residentialtreatment group (Darke et al 2006).Residential treatment is thought to be the mostappropriate treatment for alcohol dependence when theperson is a chronic drinker with a long history of drinkingand a high level of dependence. Similarly, for other drugdependencies residential programs are usually indicatedfor dysfunctional, long-term drug users who suffersignificant harms from use and whose social networksare supportive of continued drug use (Dale & Marsh2000). People in residential treatment have a significantlyhigher number of previous treatment episodes, a lowerage of first intoxication, have used and injected moreclasses of drugs, experienced more overdoses and havesignificantly higher levels of previous suicide attemptsand psychopathology than clients in methadonemaintenance or withdrawal programs. Despite theseclient characteristics, residential treatment services werefound to have good levels of short and long termretention in treatment (Ross et al 2004). After 12 months,residential treatment produced significantly higher levelsof abstinence than either methadone maintenance orwithdrawal programs, while non-treatment had a0 per cent rate of abstinence. These findings indicatethat residential treatment is an effective option, especiallyfor those people with more severe drug use andpsychological issues (Ross et al 2004).Although residential treatment has success with “hardercases”, this group should not be considered the soletreatment population for residential services ortherapeutic communities. People with less entrenchedhistories and less dysfunctional lifestyle also benefit fromresidential treatment.Principles for effective treatment3.2The US National Institute on Drug Abuse has developedgeneral principles for effective treatment of people witha drug dependency (NIDA 1999). These principles arerelevant to residential and other forms of treatment:1 No single treatment is appropriate for allindividuals.n Matching treatment settings, interventions, andservices to each individual's particular problemsand needs is critical to his or her ultimate successin returning to productive functioning in thefamily, workplace and society.2 Treatment needs to be readily available.PAGE NSW Health Drug and alcohol treatment guidelines for residential settingsn Because individuals who are dependent on drugsmay be uncertain about entering treatment,taking advantage of opportunities when they areready for treatment is crucial. Potential treatmentapplicants can be lost if treatment is notimmediately available or is not readily accessible.
3 Effective treatment attends to multiple needs ofthe individual, not just his or her drug use.n To be effective, treatment must address theindividual’s drug use and any associated medical,psychological, social, vocational, and legal problems.7 Medications are an important element oftreatment for many people in treatment,especially when combined with counsellingand other behavioural therapies.n4 An individual's treatment and services planmust be assessed continually and modified asnecessary to ensure that the plan meets theperson's changing needs.n An individual may require varying combinationsof services and treatment components during thecourse of treatment and recovery. In addition tocounselling or psychotherapy, an individual attimes may require medication, other medicalservices, family therapy, parenting instruction,vocational rehabilitation, and social and legalservices. It is critical that the treatment approachbe appropriate to the individual's age, gender,ethnicity and culture.5 Remaining in treatment for an adequate periodof time is critical for treatment effectiveness.n The appropriate duration for an individualdepends on his or her problems and needs.Research indicates that for most people, thethreshold of significant improvement is reached atabout three months in treatment. After thisthreshold is reached, additional treatment canproduce further progress toward recovery. Becausepeople often leave treatment prematurely,programs should include strategies to engage andkeep people in treatment.6 Counselling (individuals and/or group) and otherbehavioural therapies are critical componentsof effective treatment for people with drugdependence.n Methadone, and buprenorphine are very effectivein helping individuals dependent on heroin orother opioid drugs stabilise their lives and reducetheir illicit drug use. Naltrexone is also an effectivemedication for some opioid-dependent peopleand some people with co-occurring alcoholdependence. For tobacco-dependent individuals,a nicotine replacement product (such as patchesor gum) or an oral medication (such as bupropion)can be an effective component of treatment.For people with mental disorders, bothbehavioural treatments and medicationscan be critically important.8 Dependent or drug-abusing individuals withcoexisting mental disorders should have bothdisorders treated in an integrated way.n Because dependence disorders and mentaldisorders often occur in the same individual,people presenting for either condition shouldbe assessed and treated for the co-occurrenceof the other type of disorder.9 Medical detoxification is only one stage oftreatment and by itself does little to changelong-term drug use.n Medical detoxification safely manages the acutephysical symptoms of withdrawal associated withstopping drug use. While detoxification alone israrely sufficient to help those dependent on drugsachieve long-term abstinence, for some individualsit is a strongly indicated precursor to effectivetreatment of drug dependence. In therapy, people address issues of motivation,build skills to resist drug use, replace drug-usingactivities with constructive and rewarding nondrug-using activities, and improve problem-solvingabilities. Behavioural therapy also facilitatesinterpersonal relationships and the individual'sability to function in the family and community.NSW Health Drug and alcohol treatment guidelines for residential settings PAGE
10 Treatment does not need to be voluntaryto be effective.n Strong motivation can facilitate the treatmentprocess. Sanctions or enticements in the family,employment setting, or criminal justice system canincrease significantly both treatment entry andretention rates and the success of drug treatmentinterventions. This does not imply “boot camps”,detention or forced labour camps for youngpeople, but the use of external pressure toencourage young people to enter and completeappropriate treatment.11 Possible drug use during treatment must bemonitored continuously.n Lapses to drug use can occur during treatment.The objective monitoring of an individual’s drugand alcohol use during treatment, such as throughurinalysis or other tests, can help the individualwithstand urges to use drugs. Such monitoringalso can provide early evidence of drug use so thatthe individual’s treatment plan can be adjusted.Feedback to people who test positive for illicitdrug use is an important element of monitoring.Programs offering residential treatment for people withdrug or alcohol problems should include:n acomprehensive initial assessment of the potentialresident (see section 4.1)n atreatment matching procedure which addresses thepresenting problem and the needs of the individual(see section 4.2)n clearlyn aclearly articulated treatment approachevaluation component built into the program(see section 9.4)n relapse Counselling can help those receiving it avoid highrisk behaviour. Counselling also can help peoplewho are already infected manage their illness.13 Recovery from drug dependence can be a longterm process and frequently requires multipleepisodes of treatment.nidentified and published aims and objectivesn an12 Treatment programs should provide assessmentfor HIV/AIDS, Hepatitis B and C, tuberculosis andother infectious diseases, and counselling to helpmodify or change behaviours that place thosebeing treated or others at risk of infection.nMinimum standards for residentialtreatment programs3.3 As with other chronic illnesses, relapses to druguse can occur during or after successful treatmentepisodes. Substance dependent individuals mayrequire prolonged treatment and multiple episodesof treatment to achieve long-term abstinence andfully restored functioning. Participation in self-helpsupport programs during and following treatmentoften is helpful in maintaining abstinence.PAGE 10 NSW Health Drug and alcohol treatment guidelines for residential settingsprevention strategies and continuing carestrategies for the period after residential treatment(see section 8.1).
SECTION 4Who should receive residential treatment?4.1Assessing the needs of peopleseeking treatmentn positiven strengthsAll people seeking entry into a drug and alcohol residentialtreatment program need to be properly assessed for theirtreatment needs. An adequate, unbiased assessmentshould cover a number of domains, including:n demographics:gender, ethnicity, income, mobility,accommodation, children, key friends, and so onn druguse, including perceived reasons for use, howand when initiated, substances used, mode ofadministration and any changes over time, periods ofnon-use, frequency of use, last use, quantity used,cost of drugs, where and with whom they use drugsn effectsof use requiring attention: immediate (egcomplicated withdrawal with possible fitting), or lessacute (eg respiratory conditions)n previoustreatment received and experiences of thisprevious treatmentn familylifen mentalhealthn historyof abuse (physical, emotional and sexual)n educationlevel and needs for remediationn vocationaltraining level and needsn employmentn incomen interpersonalfunctioningn criminalDifferent services are likely to use different modes ofassessment. Some services may conduct phone-basedassessments, while others will use face-to-face interviewsat induction centres. Irrespective of the means ofconducting the interview, an initial assessment should beused to assess the degree of risk to the client and othersas well as the potential suitability of the client for theparticular residential service.n Theinitial assessment should be focused on decidingwhether the service can meet the client’s needsdiscussion with the client’s medical practitioner(with t
(Macquarie Dictionary) Differences of opinion over the aetiology of drug and alcohol dependence mean that "rehabilitation" is not always the accepted term for all residential treatment. In this document, the term "residential treatment" is used. 1.4 Residential treatment modalities Various modalities or treatment approaches for residential
The Drug and Alcohol Office (DAO) is the business name of the Western Australian Alcohol and Drug Authority, which is an independent statutory authority. Its functions are set out in the Alcohol and Drug Authority Act 1974. Enquiries Enquiries regarding this publication should be directed to: Community Programs Team Drug and Alcohol Office
CCAPP Academy Alcohol and Drug Treatment Studies Graduation from Alcohol and Drug Treatment Studies Alcohol and Drug Studies is taught in three hour and six hour classes held over 56 weeks for a total of 336 hours. At the com- pletion of which the student receives a Graduation Diploma. Cost The cost of the 336-hour course is 3,000.00. Staff .
The Human Resources Department provides DOT-approved drug-free workplace training programs to inform employees and supervisors regarding substance abuse and addiction, the effects of drug/alcohol use upon the individual, the drug/alcohol testing process, and available resources for drug/alcohol counseling and Rehabilitation.
The metabolism of alcohol is primarily dependent on the activity of ADH, and the average adult blood alcohol concentration decreases 15 - 20 mg/dL/hour. A drink of alcohol is defined as 14 grams of alcohol. Fourteen grams of alcohol are contained in 12 ounces of beer (5% alcohol content), 5 ounce
Services Administration (SAMHSA) -- Use the Locator to find alcohol and drug abuse treatment or mental health treatment facilities and programs around the country Substance Abuse Treatment Services Locator Search more than 11,000 alcohol and drug abuse/addiction treatment facilities and programs Mental Health Treatment Services Locator
Adult drug and alcohol treatment business definitions V13.03 6 1. Introduction The National Drug Treatment Monitoring System (NDTMS) data helps drug and alcohol treatment demonstrate the outcomes it achieves for the people it treats, and in doing so aids accountability for the money invested in it. NDTMS is a national standard and is
the alcohol and other drug rule is found in violation, a letter is sent to the parents of student explaining the university alcohol and other drug rules, promoting prevention and education programs and inviting parents to partner with the University in the prevention of alcohol and other drug use and abuse.
ences (CRAS) has implemented a drug abuse and alcohol prevention program and policies to prevent the unlawful possession, use, or distribution of illicit drugs and alcohol by students and employees. CRAS is committed to providing a drug free environment. Any type of drug use, including alcohol, is dangerous and potentially life threatening.
