Guidelines for Community-Based Treatment and Support Services for Persons Who Use Drugs in Primary Health Care Settings

August 29, 2017

DOH ADMINISTRATIVE ORDER NO. 2017-0018

 

I. BACKGROUND AND RATIONALE

In response to the unprecedented influx of drug users who surrendered to authorities under the government's Barangay Anti-Drug Clearing Program, DOH established a task force that developed an algorithm on dealing with surrenderers (Client Flow for Wellness and recovery from Substance-Related issues), which was subsequently approved by the Dangerous Drugs Board (DDB). Under this framework, the venues for care and service provision to Persons Who Use Drugs (PWUDs) are stratified according to the severity of their condition. Using the figures reported by the United Nations Office for Drugs and Crime (UNODC) in the World Drug Report 2016, it is estimated that only about 1-2% of drug dependents will require initial care in a residential drug treatment facility; 4-6% will need structured outpatient services; while the remaining 90-95% can be managed with community-based treatment and care services, hence this guideline was formulated. HTcADC

This policy was informed by the recommendations in the document Guidance for Community-Based Treatment and Care Services for People Affected by Drug Use and Dependence in the Philippines and based on the Principles and Policies Governing Community-based Treatment and Care Services (Annex A). This was enhanced through a consensus development workshop participated by various stakeholders representing national government agencies, local government units, public and private health care facilities and providers, and civil society organizations.

II. OBJECTIVES

A. To prescribe guidelines for the effective implementation of community-based treatment and support services for PWUD in all primary health care settings that covers the following:

1. prevention and promotion

2. treatment and rehabilitation

3. after care and reintegration

4. monitoring and evaluation

B. To prescribe guidelines that are premised on the principles and values of appropriateness, accessibility, affordability, acceptability, effectiveness, efficiency, equity, and quality.

C. To provide reference guidelines to Local Government Units (LGUs) in the enactment of ordinances, resolutions, or other policy issuances in implementing community-based treatment and support services under their jurisdiction.

D. To adopt the global evidenced-based guidelines and principles as may be applicable in community settings.

III. SCOPE OF APPLICATION

A. This Order shall initially prescribe the minimum components of a community-based treatment and support program covering the critical phases of drug treatment, management and rehabilitation of PWUD in communities in all primary health care settings.

B. This shall also apply to all individuals, institutions and organizations involved in the provision of community-based treatment and support services, including the intended beneficiaries or PWUD being managed or assisted in the community. CAIHTE

IV. DEFINITION OF TERMS

A. Abstinence — refraining from of use of an addictive drug.

B. Aftercare — services that help recovering drug dependents to adapt to everyday community life after completing earlier phases of treatment and rehabilitation through planned follow-up treatment intervention.

C. Community-Based Treatment — holistic model of treatment in the community which provides a continuum of care from outreach through integration including maintenance pharmacotherapy, and coordination of services and assistance from a number of health, and non-health specialists to meet the PWUD needs.

D. Person Who Uses Drugs (PWUD) — individual who has used, abused, or is dependent on a dangerous drug.

E. Random Drug Testing — conduct of a drug test, using approved methodologies, the timing of which is not announced, or is unknown to a PWUD.

F. Random System Audits — is quality management system tool intended to mitigate further commission of lapses in the implementation of policies, procedures, standards, and guidelines in relation to safety, quality, and competencies of facilities and personnel. This is conducted at random and choice of area for audit shall be decided by monitoring and evaluation team prior to the audit.

G. Relapse — the recurrence of drug use after apparent recovery.

H. Rehabilitation — a dynamic process or intervention emphasizing on aftercare and follow-up treatment, directed towards attaining change in physical, psychological, social, and spiritual life of the PWUD.

V. GENERAL GUIDELINES

This Order aligns with the Philippine Health Agenda (PHA) 2017-2022 to guarantee services for both well and the sick in addressing triple burden of disease including substance use disorder.

A. Community Based Drug Rehabilitation Program shall be implemented in all communities in line with the 12 Legacies for Health by 2022.

B. All primary health care facilities in communities shall endeavor to provide community-based treatment and support services for PWUD as an essential part of a continuum of care for PWUDs.

C. All primary care health facilities providing community-based treatment and support services shall be part of a network (e.g., Anti Drug Abuse Councils or ADAC) with resource mapping to ensure that PWUDs receive holistic and integrated care. aScITE

D. All primary care health facilities providing community-based treatment and support services, specifically, the health worker in charge, shall follow the algorithm of "Client Flow for Wellness and Recovery from Substance Related Issues" provisions of DDB Regulation No. 4, series of 2016 (Annex B).

E. All primary care health facilities shall adhere to monitoring and evaluation requirements from DDAPTP (DOH Regional Offices reporting to Central Office) or ADAC as may be appropriate relative to quality implementation of the community-based treatment and support services for PWUD and shall require PWUD or their duly recognized representative to comply with client satisfaction survey requirements for program improvements.

F. All primary care health facilities providing community-based treatment and support services shall institute policies that adhere to human rights and dignity of PWUD.

G. All health service providers and support workers shall (1) adhere to the highest possible professional and ethical standards in the performance of their functions, and (2) show sensitivity to culture, ethnicity, religion, age, gender and sexuality in dealing or relating, treating and managing PWUD.

VI. SPECIFIC GUIDELINES

A. Respect for Human Rights and Dignity in Primary Care Facilities for Community-Based Treatment and Support Services for PWUD

Community health service providers and support workers shall:

1. Provide services in a non-stigmatizing and respectful manner to PWUD

2. Obtain informed consent from PWUD or a legal representative prior to initiating any service

3. Guarantee PWUD the option to withdraw from the program subject to the guidelines of the Local Government Unit (LGU) for admission and discharge

4. Develop individual care plan jointly with the PWUD

5. Protect the rights to privacy and confidentiality of the PWUD, Collection and disclosure of personal data shall be in accordance with the Data Privacy Act of 2012

B. Promotion and Prevention Program in Community-Based Treatment and Support Services for PWUD

1. ADAC shall lead in the formulation of the plan of action for community-based treatment and support services on the promotion and prevention of drug abuse in communities in coordination with other members of the network in LGU.

2. The DDAPTP LGU Coordinator shall supervise the community health team tasked with the promotion and prevention program for community-based treatment and support services in primary care facilities and other service providers as may be identified. DETACa

3. Focus of operational strategies and interventions of the program are the following, but not limited to: (a) educating communities on ill effects of drug use and abuse, (2) encouraging PWUD to voluntarily undergo the appropriate tests, (3) mobilizing different sectors or actors to collaborate, support and build capacities to treat and manage PWUD (4) establishing good media relationship for possible media mileage.

4. The campaign slogan "Sa DROGA Talo Ka, ACHIEVE ang PAGBABAGO!" shall be adapted by the primary care facility in advocating for the promotion and prevention of drug abuse in communities.

All messaging materials shall be approved by the DOH Health Promotion and Communication Service with DOH DDAPTP, for concurrence by the DDB.

Information, Education and Communication (IEC) materials shall be monitored by the ADAC Communication Team.

5. The program shall use the 4 Steps in Operationalizing the Core Messages, which are:

a. Raising knowledge and awareness: Alamin ang wasto, Makiisa sa Pagbabago

b. Creating perception: Kaisa mo ako

c. Directing attitude: Kasama mo ako

d. Ensuring behavioral change: Ikaw at ako, tungo sa pag achieve ng pagbabago

6. The preferred language for communicating the messages shall be any of the following: English, Filipino, or Local Dialect.

7. Only licensed counselor, psychologist or psychiatrist shall provide counseling services to PWUD. Other service providers such as psychometritian and rehabilitation practitioners shall provide counseling services only under supervision by licensed counselor, psychologist or psychiatrist.

B.1 Program for Low Risk for Drug Abuse and Dependence

1. PWUD assessed as low risk for drug abuse and dependence shall be provided with at least one (1) service from each of the following service categories:

a. Individual and Family Programs — e.g., orientation and briefing, seminars, brief intervention, family counseling, individual counseling

b. Community Care Interventions — e.g., skills training, livelihood opportunities, job placement

c. Health Psycho-education — e.g., drug awareness lecture

d. Psychological/Social/Spiritual Support Services — e.g., recollection, retreat

The minimum duration for this program is one (1) month.

2. PWUD shall receive additional support through network collaboration if deemed appropriate or essential. These interventions shall include, but not limited to, the following: livelihood projects, recreational activities, Alternative Learning Systems (ALS), and employment.

3. PWUD can be subjected to voluntary Random Drug Test Administration for the planned duration of his/her program. If found positive, PWUD shall be referred to a physician for further assessment and appropriate intervention. HEITAD

4. PWUD shall be provided with an Individual Treatment Card/Book. All services received by the PWUD and results of the drug test/s shall be recorded in the treatment card/book.

5. PWUD shall be issued a "Certificate of Community Program Completion" upon successful completion of the program. This shall be signed by the head of the primary health care facility or service provider who directly supervised PWUD treatment. Additional signatories shall include the Health Officer, DDAPTP Program Coordinator, or Local Chief Executive.

B.2 Program for Mild Severity of Drug Use and Dependence

1. PWUD assessed as mild severity for drug abuse and dependence upon assessment shall be provided with at least one (1) service from each of the following service categories:

a. Case Management with individual treatment plan

b. Psycho-education/Advocacy — may include topics on diseases related substance abuse and dependence, triggering factors, legal consequences of substance use, family values

c. Brief Intervention

d. Education/Employment Support — e.g., alternative learning system, livelihood, vocational skills, food processing, bread and pastry making, job placement/employment

e. Relapse Reduction

f. Motivational Intervention

The minimum duration for this program is four (4) months.

2. PWUD shall receive additional support through network collaboration on a voluntary basis. These shall include, but not limited to, the following: tree planting, street/drainage cleaning, garbage collection and/or segregation, assisting in medical missions, or recreational activities.

3. Random Drug Test Administration can be performed any time within the duration of the program. PWUDs shall be oriented of the process and informed of the test results and the appropriate, possible or alternative treatment available, including support services. PWUD shall be referred to a capable physician for further assessment and appropriate intervention, if found positive.

4. PWUD shall be provided with an Individual Treatment Card/Book. All services received by the PWUD and results of the drug test/s shall be recorded in the treatment card/book. aDSIHc

5. PWUD shall be issued a "Certificate of Community Program Completion" upon successful completion of the program. This shall be signed by the primary care facility staff or Chief or service provider who directly supervised PWUD treatment. Additional signatories shall include the Municipal or City Health Officer, DDAPTP Program Coordinator, or Local Chief Executive.

C. Community Support, Aftercare and Reintegration (CSAR) Program

1. CASR shall focus on relapse reduction and reintegration into the community. PWUDs who have successfully completed general interventions, treatment and rehabilitation programs shall be referred to take this program.

2. The program consists of the following core services/interventions:

a. Medical/Dental Services

b. Psychological Services

c. Social Services

The minimum duration for this program is six (6) months and may be extended depending upon assessment of the community health team.

3. ADAC shall lead the Community Health Team in this program in close collaboration with other network members such as, DSWD, LGU, PNP, and NGOs.

4. PWUD shall receive additional interventions, such as but not limited to the following: family support group sessions (family visioning and crafting of mission by the PWUD and their families), family psycho-education to address stigma within the family, parent feedback, organization of parent-helping-parent, weekly family process groups, and weekly dialogue/seminar/lecture of parents and significant other.

5. Random Drug Test Administration can be performed any time within the duration of the program for signs of relapse. This shall complement the history taking and physical examination results performed by primary health care facilities (public and private). If found positive, PWUDs shall be referred to a capable physician for further assessment and appropriate intervention.

6. PWUD shall be provided with an Individual Treatment Card/Book. All services received by the PWUD and results of the drug test/s shall be recorded in the treatment card/book. ATICcS

D. Monitoring and Evaluation

1. Regional DDAPTP Coordinator shall designate a Local DDAPTP Coordinator to carry out the responsibility of monitoring and evaluation of Community-Based Treatment and Care Services.

2. Regional DDAPTP Coordinator shall schedule quarterly meetings with all primary health care facilities providing community-based treatment and support services under its area of jurisdiction. The specific agenda for the quarterly meeting shall include status of implementation of the program, identification of gaps and challenges, and interventions.

3. ADAC shall undertake Multi-level monitoring using a standard tool and shall provide feedback to DDAPTP local coordinator pertinent to health and health-related concerns for appropriate action by DOH.

4. Random Systems Audit shall be conducted to all primary health care facilities (public and private) by a DDAPTP designated professional quality provider at least once a year. Notice of audit shall be sent to the primary health care facility selected one (1) month prior to the scheduled audit.

a. Coverage of the audit shall include implementation of procedures, standards, guidelines, policies, safety, facilities, and competencies of personnel.

b. Result of audit shall be submitted to the DDAPTP Regional Office for appropriate action.

5. PWUD or their duly recognized representative shall be required to submit complete client survey forms at the end of the program.

a. Feedback forms shall be equal to 10 percent of the total number of PWUD clients who completed the program. ETHIDa

b. All completed survey forms shall be analyzed and reported to DDATP, for presentation during the annual system audit.

6. DDAPTP Regional Coordinators shall gather for an annual evaluation meeting of the program implementation of primary health care facilities for drug abuse and treatment and support services in communities. The evaluation results or outputs shall be forwarded for appropriate action by all concerned offices or entities.

E. Roles and Responsibilities

DOH DDAPTP shall be responsible for the oversight functions of this Order. The respective ADAC with the designated local DDAPTP coordinator shall coordinate closely with the designated DDAPTP regional coordinator.

Annex C provides the specific functions and responsibilities of key actors.

VII. REPEALING CLAUSE

All issuances which are inconsistent with this Order are hereby repealed.

VIII. EFFECTIVITY

This Order shall take effect immediately after publication in a newspaper of general circulation or in the DOH website.

(SGD.) PAULYN ROSELL-UBIAL, MD, PH, CESO IISecretary of Health

ANNEX A

Principles and Policies Governing Community-based Treatment and Care Services

The following principles, enunciated in the Guidance for Community-Based Treatment and Care Services for People Affected by Drug Use and Dependence in the Philippines, shall govern community-based approaches to rehabilitation:

• continuum of care from outreach, basic support and reducing the harm from drug use to social reintegration, with no "wrong door" for entry into the system; TIADCc

• delivery of services in the community — as close as possible to where drug users live;

• minimal disruption of social links and employment;

• integrated into existing health and social services;

• involve and build on community resources, including families;

• participation of people who are affected by drug use and dependence, families and the wider community in service planning and delivery;

• comprehensive approach, taking into account different needs (health, family, education, employment and housing);

• close collaboration between civil society, law enforcement, and the health sector;

• provision of evidence-based interventions;

• informed and voluntary participation in treatment;

• respect for human rights and dignity, including confidentiality; and

• acceptance that relapse is part of the treatment process and will not stop an individual from re-accessing treatment services.

Furthermore, the implementation of these guidelines shall be in compliance with existing international agreements and treaties, statutes, regulations, and other policy issuances, such as, but not limited to, the following:

• Transforming our world: the 2030 Agenda for Sustainable Development

• ASEAN Work Plan on Securing Communities against Illicit Drugs 2016-2025

• Philippine Development Plan 2017-2022

• Republic Act No. 9165, otherwise known as the Comprehensive Dangerous Drugs Act of 2002, and its Implementing Rules and Regulations

• Executive Order No. 4, Providing for the Establishment and Support of Drug Abuse Treatment and Rehabilitation Centers Throughout the Philippines

• Executive Order No. 15, Creation of an Inter-Agency Committee on Anti-Illegal Drugs (ICAD) and Anti-Illegal Drug Task Force to Suppress the Drug Problem in the Country

• Pertinent regulations and resolutions of the DDB, including Board Resolution No. 3, series of 2016 (Re: Guidelines on Handling Voluntary Surrender of Drug Personalities) and Board Resolution No. 75, series of 2015

• Pertinent issuances of the DOH regulating the standards in the provision of treatment and care services for drug use and drug dependence. cSEDTC

ANNEX B

ANNEX C

Roles and Responsibilities of Key Actors in Community-Based Approach

 

Components	Responsibilities	Key Actors	Tasks
Community	• Awareness raising • Public education • Health promotion	• Community members • Community based workers • NGO peer outreach workers • Other individuals and organizations operating in the community • ADACs	• Identification of drug users • Preliminary screening and basic needs assessment • Basic counseling and support • Referral of people who are believed to have a substance abuse problem to community health centers
Community-based Health Services (Primary Health Care)   with or without   Community-based Recovery Facilities such as:   Recovery Clinics (Substance Use Disorder Outpatient Clinics) and Recovery Homes step up care from a recovery clinic or primary care facility or step down care from a higher level of treatment.	• Provision of basic health care including assessment and management of minor injuries and diseases	• Health center staff • Community volunteers • Representative/s from local authorities	• Provision of basic health education and brief counseling on risks of drug-related problems • Provision of support to drug users who are not drug dependent • Liaising with NGOs in the community and referral of patients back to community organizations for follow-up and aftercare • Referral of drug users to DOH-accredited physicians, community based recovery facilities, DATRCs
Treatment and Rehabilitation Centers	• Treatment of severe and or complicated cases	• Health care/medical staff • Rehabilitation practitioners • Administration services	• Assessment, diagnosis, rehabilitation, treatment and care of substance use and dependence
Hospitals/medical centers	• Provision of medical, surgical, diagnostic and emergency services • Counseling and provision of outpatient substance use disorder clinical services	• Health care/medical staff • Volunteers	• Diagnosis and treatment of drug use disorders and potential comorbidities • Medicated detoxification (if required) • Psychosocial counseling • Mental health examination • Treatment of medical problems
Non-governmental organizations	• Ensure a continuum of care • Provide ongoing support to clients and family • Focal points for client management and coordination of care	• NGO staff • Volunteers	• Education about the effects of drugs including HIV prevention education to the community • Training of drug use disorders to law enforcement • Collaboration with other stakeholders and organizations in the community • Psychosocial counseling • Help support groups
Law Enforcement	• Referral of drug users to health care providers • Assist drug users in receiving help in the community	• PDEA, PNP and other law enforcement agencies	• Collaboration with ADAC, health sector and organizations in the identification and preliminary screening of drug users • Discussion with drug users and families of options for treatment