Severe Substance Dependence Treatment Act 2010

Severe Substance Dependence Treatment Act 2010 Dr Martyn Lloyd-Jones Department of Addiction Medicine St Vincent’s Hospital Melbourne Drug and Health Alliance 28th April 2011

from this to this

Background • Alcoholics and drug-dependent Persons Act 1986 • Felt to be less than ideal and (hence) little utilised (about 10 cases in 2009) • Allowed for 7 days treatment (which could be extended by another 7 days if felt necessary by the senior doctor providing treatment) • No provision for ongoing care and no funding

NSW • SWAHS • Trial- 12 months • Population of 1.2 million • Budget of $3.1 million • Locked ward at Nepean Hospital • 42 certificates issued • 46 declined

The Act • “provides for the detention and treatment of persons with severe substance dependence where this is necessary as a matter of urgency to save a person’s life or prevent serious damage to a person’s health” • Last resort treatment option • Designed for those who do not have the capacity to make choices about their substance use

Persons subject to a detention and treatment order can be detained in a treatment centre and treated involuntarily for up to 14 days • “Detention and treatment is aimed at providing a critical intervention that will help bring the person back from the brink” • …and a chance to recover their capacity…think more clearly about their situation and the opportunity to engage in voluntary treatment”

“The Act is not targeted at people who are capable of making choices about their substance use, including refusing treatment” Nor does it replace the Mental Health Act

Criteria • The person has a severe substance dependence • and • because of the severe substance dependence immediate treatment is necessary as a matter of urgency to save the person’s life or prevent serious damage to the person’s health • and • the treatment can only be provided to the person through the admission and treatment of the person in a treatment centre • and • there is no less restrictive means reasonably available to ensure the person receives the treatment

“severe substance dependence” • the person has a tolerance to the substance • and • the person shows withdrawal symptoms when the person stops using, or reduces the level of use of, the substance • and • the person is incapable of making decisions about his or her substance use and personal health, welfare and safety due primarily to the person’s dependence on the substance

Process • Any person over 18 can apply to the Magistrate’s Court for the person to be placed on a detention and treatment order (except the medical practitioner making the recommendation for the order) • Before taking the matter to Court the person must be examined by a prescribedmedical practitioner to determine if the criteria for the detention and treatment apply to the person • In making their assessment the PMP must consult with the senior clinician of the declared treatment service before making a recommendation

Process • The applicant must provide a copy of the application to the person who is the subject of the application within 24 hours • The Court must list the application for hearing within 72 hours of the application being lodged • The person who is the subject of the application has the right to attend Court and obtain legal representation • The applicant must satisfy the Court that each of the criteria for detention and treatment apply to the person whom is the subject of the application

Process • The Magistrate decides the application based on the evidence • If the Court makes a detention and treatment order, the applicant must make the necessary arrangements (in consultation with the alcohol and drug treatment centre) for the person to be taken and admitted to the treatment centre

What happens after admission? • Provided with help to withdraw from substance(s) they have been using • Within 24 hrs of admission must be examined by senior clinician of unit and decision made whether criteria for detention and treatment continue to apply • Person must be given a written statement about their rights and entitlements under the Act, including the right to seek legal advice and obtain a second medical opinion, and if required help to revoke the order on their behalf • While being treated a person may nominate someone to help protect their interests, be consulted about treatment and discharge options

The senior clinician must inform the Public Advocate and the nominated person and the person’s guardian (if the person has one) of the person’s admission • The Public Advocate must visit the person as soon as practicable to provide advice and assistance • The person subject to a detention and treatment order may apply at any time to the Magistrate’s Court to have the order revoked

If at any time the criteria no longer apply to the person the detained person must be released from the order • A treatment and discharge plan must be developed in conjunction with the person • Following the discharge from the detention and treatment order the person will be encouraged to continue treatment in a voluntary capacity. The person will be offered ongoing case management support for up to 6 months post the detention and treatment order

“prescribed medical practitioner” • a class of medical practitioner who has expertise in severe substance dependence • and who are prescribed in the regulations

What is the role of the PMP? In making a recommendation the PMP must: • Personally examine the person • Determine whether all the criteria are met • Consult with the senior clinician of the treatment centre (who must be an addiction medicine specialist)

In consulting with the senior clinician of the treatment centre the PMP must: provide information about the nature of the person’s severe substance dependence, the nature of the urgent risk to the person’s life or health and any previous efforts to treat the person’s substance dependence discuss if there are less restrictive options available to ensure the person receives treatment confirm that the treatment centre has facilities or services to treat the person

If the PMP is relying on facts additional to his or her own observations, these facts must be distinguished from their observation sin the recommendation • The PMP must, to the extent that it is reasonable, explain the purpose of the examination to the person and record what steps were taken to give that explanation in the clinical notes • If a person refuses to be examined by a PMP, any person may apply to the Magistrate’s Court for a special warrant to examine the person for the purposes of making a recommendation

What happens once the application is filed? • Onus of proof on applicant to show that criteria are met • The Court must: • Be satisfied on the balance of probabilities that all of the criteria for D&T apply • Having regard to all other relevant matters that, consider the D&T of a person at a treatment centre is necessary • Have obtained a certificate of available services from the senior clinician at the treatment centre • A certificate of available services outlines the facilities at the treatment centre • In making a D&T order the Court authorises the person to be held in a D&T centre for up to 14 days • Arrangements will then be made by the applicant for the person to be taken to the treatment centre

What treatment can be provided on an involuntary basis? Treatment under the SSDT Act means anything done in the course of the exercise of professional skills to provide medically assisted withdrawal from a severe substance dependence or to lessen the ill effects of the pain and suffering of the withdrawal

What happens once the person is discharged from the D&T order? • Senior clinician prepares a treatment plan at admission and a discharge plan outlining follow-up treatment and support that is to be provided to that person • Case management support will be provided at discharge for up to 6 months • Voluntary treatment is preferred to a DTO and it is hoped that people will elect to continue with voluntary treatment once they are discharged from the DTO

Case scenarios 1 • 34 year old female • Alcohol dependent • History of impulsive overdoses • History of cutting • Anorexia nervosa and bulimia • Weight 42kg (BMI=16.4) • Low phosphate, low albumin, potassium 1.5 • Does not want to stop drinking • CAT team attended and wish to make recommendation under SSDT Act

Case scenarios 2 • 54 yo male • “he’s a drinker” • Seen in ED, tremulous, fetor, confused • Spider telangiectasiae, jaundice, muscle wasting, foetor hepaticus, palmar erythema • Wanting to leave • SW wishes to apply to magistrate for treatment order

Case scenarios 3 • 23 yo female • Known amphetamine user • Reported to police as seen running down street naked and wandering into the path of oncoming traffic • Brought into ED • Unkempt, screaming and requiring physical restraint

Summary • Medical complications/co-existing conditions need treating on their merits in appropriate setting • SSDT Act Does not replace Section 13 of Mental Health Act 1986 • Psychotic disorders best treated in acute psychiatric setting, if necessary under appropriate section of MHA • Treatment of the substance dependence must be likely to be of benefit

suitability this not this

Copy of legislation available at www.legislation.vic.gov.au Acknowledgements: Prof Jon Currie SVH, Amanda Norman SVH, Patricia Lutz SWAHS

Severe Substance Dependence Treatment Act 2010