Unodc-Community-Based Treatment Guidance (011-048)

CONTENTS
LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................................. I

LIST OF BOXES AND FIGURES ..................................................................................................................... II
DEFINITION OF TERMS ............................................................................................................................. III
1. NATURE OF SUBSTANCE USE AND DEPENDENCE .............................................................................. 1
2. CONTEXT OF TREATMENT ................................................................................................................ 7
2.1 POLICY FRAMEWORK TO COMBAT ILLICIT DRUG USE ........................................................................................ 7
2.2 NATIONAL HEALTH SYSTEMS ....................................................................................................................... 9
2.2.1 Community level services ........................................................................................................... 11
2.2.2 Primary Care .............................................................................................................................. 11
2.2.3 Drug abuse treatment and rehabilitation centers (residential and non-residential),
hospitals/medical centers, and specialty hospitals .................................................................. 12
3. COMMUNITY-BASED TREATMENT APPROACH ................................................................................ 13
3.1 PHILOSOPHY OF THE COMMUNITY-BASED APPROACH .................................................................................... 13
3.2 SERVICE DELIVERY MODEL......................................................................................................................... 15
3.3 COMPONENTS OF A COMMUNITY-BASED APPROACH ..................................................................................... 18
3.3.1 Community (including outreach) ............................................................................................... 20
3.3.2 Community health centers ......................................................................................................... 21
3.3.3 Drug abuse treatment and rehabilitation centers (residential and non-residential),
hospitals/medical centers, specialty hospitals ......................................................................... 22
3.3.4 Non-governmental organizations (NGOs) and social support services ..................................... 24
3.3.5 Law Enforcement ...................................................................................................................... 24
4. GUIDELINES FOR INTERVENTIONS .................................................................................................. 29
4.1 SCREENING ............................................................................................................................................ 29
4.2 ASSESSMENT AND TREATMENT PLANNING ................................................................................................... 30
4.2.1 History taking............................................................................................................................. 32
4.2.2 Physical examination and investigations................................................................................... 34
4.2.3 Treatment options ..................................................................................................................... 35
4.3 CASE MANAGEMENT ............................................................................................................................... 35
4.3.1 Treatment (care) plans .............................................................................................................. 36
4.3.2 Reviewing treatment progress .................................................................................................. 37
4.4 COUNSELING .......................................................................................................................................... 38
4.4.1 Responding to Stage of Change ................................................................................................. 39
4.4.2 Types of counseling.................................................................................................................... 41
4.4.3 Setting for counseling ................................................................................................................ 47
4.4.4 Duration and general structure of counseling sessions ............................................................. 47
4.4.5 Attributes of an effective counselor........................................................................................... 49
4.4.6 Basic counseling skills ................................................................................................................ 51
4.4.7 Things to avoid in drug dependence counseling ........................................................................ 59
4.5 MEDICAL AND PHARMACOTHERAPY ........................................................................................................... 61
4.5.1 First aid for people affected by drug use and dependence ........................................................ 61
4.5.2 Responding to overdose, ............................................................................................................ 62
4.5.3 Detoxification............................................................................................................................. 64
4.5.5 Medications to support relapse prevention ............................................................................... 68
4.6 TREATMENT OF PSYCHIATRIC COMORBIDITIES .............................................................................................. 68
4.6.1 Depression ................................................................................................................................. 69
4.6.2 Anxiety ....................................................................................................................................... 70
4.6.3 Psychotic disorders .................................................................................................................... 71
4.7 SUSTAINED RECOVERY MANAGEMENT ........................................................................................................ 71
4.8 OTHER INTERVENTIONS ........................................................................................................................ 79
Medication-assisted (maintenance) treatment .................................................................................. 79
5. TOOLS FOR SCREENING, TREATMENT AND EVALUATION ................................................................ 89
5.1 DRUG ABUSE SCREENING TEST 10 (DAST-10) ........................................................................................ 89
5.2 CAGE – SCREENING FOR ALCOHOL USE PROBLEMS ................................................................................... 90
5.3 ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST).......................................... 90
5.4 DIAGNOSTIC GUIDELINES FOR DRUG DEPENDENCE..................................................................................... 91
5.5 SEVERITY OF DEPENDENCE SCALE (SDS) ................................................................................................. 92
5.6 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT) ......................................................................... 93
5.7 KESSLER-10 PSYCHOLOGICAL DISTRESS SCALE (K-10) ............................................................................... 94
5.8 ADDICTION SEVERITY INDEX (ASI) ......................................................................................................... 96
5.9 CLINICAL OPIATE WITHDRAWAL SCALE (COWS) .................................................................................... 109
5.10 LEVEL OF AGITATION SCALE ................................................................................................................ 110
5.11 EXAMPLE SERVICE AGREEMENT AND CONSENT FORM .............................................................................. 111
5.12 CASE NOTES FORM FOR INDIVIDUAL COUNSELING SESSION ....................................................................... 112
5.13 CLIENT CHANGE PLAN ........................................................................................................................ 114
5.14 RECOVERY CHECKLIST ......................................................................................................................... 115
5.15 RELAPSE ANALYSIS CHART ................................................................................................................... 116
5.16 TREATMENT EVALUATION FORM ........................................................................................................... 117
5.17 CONTINUING TREATMENT PLAN ........................................................................................................... 119
5.18 FUNCTIONAL ANALYSIS OR HIGH-RISK SITUATION RECORD ........................................................................ 120
5.19 EXTERNAL TRIGGER QUESTIONNAIRE..................................................................................................... 121
5.20 INTERNAL TRIGGER QUESTIONNAIRE ..................................................................................................... 122
5.21 EXTERNAL TRIGGER CHART .................................................................................................................. 123
5.22 INTERNAL TRIGGER CHART .................................................................................................................. 124
5.23 QUESTIONNAIRE FOR THE ASSESSMENT OF STANDARDS OF CARE ............................................................... 125
5.24 FEATURES OF A METHADONE PRESCRIPTION........................................................................................... 126
5.25 FEATURES OF METHADONE CLIENT TRANSFER DOCUMENTATION ............................................................... 127
5.26 METHADONE DISPENSING RECORD FOR PATIENT ..................................................................................... 128
ANNEX 1 – ADAPTING THE REGIONAL GUIDANCE DOCUMENT FOR THE PHILIPPINES AND THE WAY
FORWARD ............................................................................................................................................ 129
Guidance for Community-Based Treatment and Care Services for People Affected by Drug Use and Dependence in the Philippines
LIST OF ABBREVIATIONS AND ACRONYMS
ADAC Anti-Drug Abuse Council

AIDS Acquired Immunodeficiency Syndrome, in which the immune
system is weakened and unable to combat infectious diseases
ASI Addiction Severity Index
ASSIST Alcohol, Smoking, and Substance Involvement Screening Test
AUDIT Alcohol Use Disorders Identification Test
CBT Cognitive-behavioral therapy
CBTx Community-based treatment
CHO City Health Officer
CM Contingency management
CRA or CRAFT Community reinforcement approach or community reinforcement
approach with family therapy
DAST Drug Abuse Screening Test
DATRC Drug Abuse Treatment and Rehabilitation Center
DDAPTP Dangerous Drugs Abuse Prevention and Treatment Program
DDB Dangerous Drugs Board
DepEd Department of Education
DILG Department of Interior and Local Government
DOH Department of Health
DSM-5 Diagnostic and Statistical Manual of Mental Disorders – 5
DSWD Department of Social Welfare and Development
HIV Human immunodeficiency virus, the infectious agent that causes
ICD-10 AIDS
International Classification of Diseases, Tenth Revision
IDADIN Integrated Drug Abuse Data and Information Network
IDU Injecting drug user or use
LGU Local government unit
K-10 Kessler-10 Psychological Distress Scale
MHO Municipal health officer
MSM Males who have sex with males
NADPA National Anti-Drug Plan of Action
NGO Non-governmental organization
PDEA Philippine Drug Enforcement Agency
PNP Philippine National Police
PWID People who inject drugs
PWUD People Who Use Drugs
RA Republic Act
RO Regional office
SBNT Social behavior network therapy
SDS Severity of Dependence Scale
UNODC United Nations Office on Drugs and Crime
WHO World Health Organization
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LIST OF BOXES AND FIGURES
Box 1: Principles for a substance abuse treatment system
Box 2: Republic Act 9165 or The Comprehensive Dangerous Drugs Act of 2002
Box 3: Treatment and rehabilitation in the NADPA 2015-2020
Box 4: Functions of the DOH related to drug abuse
Box 5: ABCDs of drug abuse treatment and rehabilitation services
Figure 1: Thorley’s model of drug use
Figure 2: Service organizations pyramid for substance use disorder treatment and care
Figure 3: Model of community-based treatment
Figure 4: Model of community-based treatment and care for people who are affected by
drug use and dependence
Figure 5: Assessment guide for community organization outreach teams or social

workers
Figure 6: Assessment guide for health centers
Figure 7: Assessment for drug abuse treatment and rehabilitation center,

hospitals/medical centers, specialty hospitals
Figure 8: Stages of change
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DEFINITION OF TERMS
Abstinence Refraining from using drugs

Agonist A substance that acts on receptor sites to produce certain
responses, for example both heroin and methadone are agonists
for opioid receptors.
Alcoholics Mutual help or self-help group; twelve step method
Anonymous
Analgesic A substance that reduces pain and may or may not have
psychoactive properties. Opioids are analgesics.
Antagonist A substance that counteracts the effects of another agent.
Pharmacologically, an antagonist interacts with a receptor to
inhibit the action of agents (agonists) that produce specific
physiological or behavioral effects mediated by that receptor. For
example, naloxone and naltrexone are both antagonists for opioid
receptors.
Antidepressant One of a group of psychoactive agents prescribed for the
treatment of depressive disorders; also used for certain other
conditions such as panic disorder. There are three main classes:
tricyclic antidepressants (which are principally inhibitors of
noradrenaline uptake); serotonin receptor agonists and uptake
blockers; and the less commonly prescribed monoamine oxidase
inhibitors.
Antisocial personality Previously known as ‘psychopathy ’ or ‘sociopathy’, this disorder is
disorder characterized by a pattern of complete disregard for others. Deceit
and manipulation are central features.
Anxiety disorders Characterized by problematic anxiety that is so persistent, or so
frequent and intense that it prevents the person from living in a
way they would like. Panic attacks are common symptoms of
anxiety disorders.
Anxiolytics Anti-anxiety drug. Benzodiazepines are examples of anxiolytics.
Benzodiazepine A group of structurally related drugs used mainly as sedatives/
hypnotics, muscle relaxants, and anti-epileptics. Benzodiazepines
were introduced as safer alternatives to barbiturates. They do not
suppress REM sleep to the same extent as barbiturates, but have
a significant potential for physical and psychological dependence
and misuse.
Bipolar disorders Also known as bipolar affective disorders or manic depression,
these disorders are characterized by recurrent episodes of mania
(or hypomania) and major depression. In between episodes the
person is usually completely well.
Borderline Personality Marked by persistent patterns of instability in relationships, mood,
Disorder and self-image. Borderline Personality Disorder is also
characterized by marked impulsivity, particularly in relation to
behaviors that are self-damaging.
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CAGE Screening questionnaire for alcoholism, the name of which is an

acronym of its four questions: (1) Have you ever felt you needed
to Cut down on your drinking? (2) Have people Annoyed you by
criticizing your drinking? (3) Have you ever felt Guilty about
drinking? (4) Have you ever felt you needed a drink first thing in
the morning (Eye-opener) to steady your nerves or to get rid of a
hangover?
Cannabis (sativa) General term for the products of the plant Cannabis sativa. See
also marijuana and hash.
Cocaine An alkaloid obtained from coca leaves. Cocaine is a powerful
central nervous system stimulant used to produce euphoria or
wakefulness.
Craving A strong desire or urge to use drugs, most apparent during
withdrawal and may persist long after cessation of drug use.
Symptoms are both psychological and physiological. Cravings
may be triggered by a number of cues, e.g. seeing a dealer,
walking past a place where drug use occurred in the past.
Delusions False beliefs that usually involve a misinterpretation of perceptions
or experiences. For example, sufferers may feel that someone is
out to get them, that they have special powers, or that passages
from the newspaper have special meaning for them.
Demand reduction A general term used to describe policies or programs directed at
reducing the consumer demand for psychoactive drugs. It is
applied primarily to illicit drugs, particularly with reference to
educational, treatment, and rehabilitation strategies, as opposed
to law enforcement strategies that aim to interdict the production
and distribution of drugs (supply reduction).
Depressant Any agent that suppresses, inhibits, or decreases some aspects of
central nervous system (CNS) activity. The main classes of CNS
depressants are the sedatives/hypnotics, opioids, and
neuroleptics. Examples of depressant drugs are alcohol,
barbiturates, anaesthetics, benzodiazepines, opiates and their
synthetic analogues.
Depressive disorders Involve only the experiencing of major depressive episodes.
Depressive disorders are distinct from feeling unhappy or sad
(which is commonly referred to as ‘depression’) in that they involve
more severe and persistent symptoms.
Diacetylmorphine, Alternative generic names for heroin.
diamorphine
Diazepam A common benzodiazepine
Diversion program A program of treatment or re-education for individuals referred
from criminal courts (criminal diversion) in lieu of prosecution or
incarceration, which is usually held in abeyance pending
successful completion of the diversion program.
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Drop-in centers Drop-in centers are places that drug users can feel safe to visit,
where their various health and other needs could be met. Drop-in
centers are less stigmatizing and more attractive to people who
are affected by drug use and disorder. They provide a range of
services such as peer support, needle and syringe programs,
referral and other health, nutritional, social and recreational
activities. A small health team, comprising doctors, nurses; health
workers, peer educators or outreach workers can effectively
address drug-related health problems in drop-in centers.
Dual diagnosis A general term referring to comorbidity or the co-occurrence in the

same individual of a psychoactive substance use disorder and
another psychiatric disorder. Also known as comorbidity.
Gateway drug An illicit or licit drug, use of which is regarded as opening the way
to the use of another drug, usually one viewed as more
problematic.
Halfway house Often, a place of residence that acts as an intermediate stage
between an inpatient or residential therapeutic program and fully
independent living in the community. Halfway houses are used for
drug users trying to maintain abstinence, people with mental
health disorders and those leaving prison.
Hallucinations False perceptions such as seeing, hearing, smelling, sensing or
tasting things that others cannot.
Hallucinogen A chemical agent that induces alterations in perception, thinking,
and feeling. Examples include LSD (Lysergic acid diethylamide),
mescaline, and phencyclidine (PCP).
Harm reduction Policies or programs that focus directly on reducing the harm
resulting from the use of alcohol or drugs, for example clean
needle programs.
Hash Extracted resin of cannabis sativa, also known as hashish or hash
oil.
Hypomania Like mania, but less severe.
Incidence The rate at which conditions or illnesses occur, often expressed in
terms of the number of cases per 10,000 people per year.
Inhalants A group of psychoactive substances, which are central nervous
system depressants, rapidly changing from a liquid or semi-solid
state to vapor when exposed to air. The most commonly used
inhalants include petrol, lacquers and varnishes containing
benzene, and adhesives, spray paint, glue and paint thinners
containing toluene. Also called solvents or volatile substances,
their appeal is linked to being inexpensive, readily available, easily
concealed, and rapid intoxication with accompanying rapid
resolution of intoxication.
Lapse Sometimes called a slip, a lapse is an isolated occasion of drug
use after a period of abstinence.
Maintenance A stage of behavior change in which a dependent drug user tries
to remain abstinent or tries to maintain the behavioral change they
have achieved.
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Maintenance therapy Prescription of medication on a long-term basis to support

behavioral change. Opioid agonists (methadone, buprenorphine)
and antagonists (naltrexone) can both be used in maintenance
therapy.
Marijuana Lower potency dried flowering heads and leaves of the cannabis
(marihuana) sativa plant.
MDMA Contracted from 3,4-methylenedioxy-methamphetamine, a
psychoactive drug of the substituted
methylenedioxyphenethylamine and substituted amphetamine
classes of drugs that are consumed primarily for euphoric and
empathogenic effects.
Medication-Assisted Combination of pharmacological intervention with counseling and

Treatment (MAT) behavioral therapies. This provides the patient with a
comprehensive approach in the treatment of substance misuse
disorders.
Methadone A synthetic opiate drug used in maintenance therapy for those
dependent on opioids. It has a long half-life, and can be given
orally once daily with supervision.
Mood disorders The predominant feature of mood disorders is a disturbance of
mood where emotions are experienced to the extreme. They
involve having “episodes” of dysfunction, which may be major
depressive episodes, manic episodes, a mixture of both manic
and depressive, or hypomanic.
Naloxone A short-acting opioid receptor-blocking agent that is primarily
used for the reversal of opioid overdose.
Narcotic A chemical agent that induces stupor, coma, or insensibility to
pain. The term usually refers to opiates or opioids, which are
called narcotic analgesics. It is often used imprecisely to mean
illicit drugs, irrespective of their pharmacology.
ANeedle-sharing The use of syringes or other injecting instruments by more than
one person, particularly as a method of administration of drugs.
This confers the risk of transmission of viruses (such as human
immunodeficiency virus and hepatitis B) and bacteria (e.g.
Staphylococcus aureus).
Neuro-adaptation The process whereby the brain adapts to the presence of a drug.
Neuroleptic One of a class of drugs used for the treatment of acute and
chronic psychoses. Also known as major tranquillizers and
antipsychotics.
Nicotine The major psychoactive substance in tobacco, nicotine has both
stimulant and relaxing effects.
Opiate One of a group of alkaloids, including morphine and heroin,
derived from the opium poppy (Papaver somniferum) with the
ability to induce analgesia, euphoria, and, in higher doses, stupor,
coma, and respiratory depression.
Opioids All drugs with morphine-like activity, both natural opiates and
synthetic drugs such as methadone.
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Personality disorders Characterized by destructive patterns of thinking, feeling,

behaving and relating to other people across a wide range of
social and personal situations. These maladaptive traits are
stable and long lasting. Antisocial personality disorder and
borderline personality disorder are the most prevalent and tend to
impact most upon treatment of drug abuse.
Poly-drug use The simultaneous or sequential non-medical use of more than
one drug.
Prevalence A measure of the extent of a particular condition or illness usually
expressed in terms of the number of cases per 10,000 people in a
given population.
Psychoactive drug or A substance that, when ingested, affects mental processes. Not
substance all psychoactive drugs produce dependence.
Psychotic disorders People experiencing a psychotic episode lose touch with reality.
Their ability to make sense of both the world around them and
their internal world of feelings, thoughts and perceptions is
severely altered. The most prominent psychotic symptoms are
delusions and hallucinations.
Relapse A return to uncontrolled drug use, or use at levels similar to those
prior to a period of abstinence.
Sedative/hypnotic Any of a group of central nervous system depressants with the
capacity of relieving anxiety and inducing calmness and sleep.
Benzodiazepines and alcohol are examples.
Self-help/Support A group in which participants support each other in recovering or
group maintaining recovery from alcohol or other drug dependence or
problems, or from the effects of another’s dependence, without
professional therapy or guidance. Prominent groups in the alcohol
and other drug field include Alcoholics Anonymous, Narcotics
Anonymous, and Al-Anon (for members of alcoholics’ families),
which are among a wide range of twelve-step groups based on a
non-denominational, spiritual approach. “Self-help group” is a
more common term, but “mutual-help group” more exactly
expresses the emphasis on mutual aid and support.
Shabu Local term for methamphetamine hydrochloride, an
amphetamine-type stimulant (ATS).
Stimulant Any agent that activates, enhances, or increases central nervous
system activity. Examples are amphetamines, cocaine and
caffeine.
Substitution treatment See Medication-Assisted Treatment
Supply reduction A general term used to refer to policies or programs aiming to
interdict the production and distribution of drugs, particularly law
enforcement strategies for reducing the supply of illicit drugs.
Tolerance A state in which continued use of a drug results in a decreased
response to the drug. Increased doses are needed to achieve the
same level of effect previously produced by a lower dose.
Tranquilizer A calming agent, a general term for several classes of drugs used
in the management of various mental disorders.
Twelve-step group A mutual-help group organized around the 12-step program of
Alcoholics Anonymous or Narcotics Anonymous.
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1. Nature of substance use and dependence
People who use illicit drugs and other substances

are a heterogeneous population who may
experience multiple and complex difficulties.
A model presented by Thorley1 shows that

problems may arise from some patterns of drug
use and not just because someone is dependent
on a drug. A common misconception is to think
that if someone has a drug problem then they
must be dependent. Thorley’s model explains that
problems arise from intoxication, regular or
excessive use and dependency.
Figure 1: Thorley's Model of Drug Use
Thorley’s model (Figure 1) has three parts:

 problems from getting drunk or stoned (intoxication);
 problems from using alcohol or drugs regularly (regular or excessive use);
 problems with not being able to stop using alcohol or drugs (dependence).
The circles are drawn so they overlap, indicating that people can have problems in one or
more areas.
Intoxication
Problems from getting intoxicated usually arise from the short-term effects of a drug. The
problems that people most often see are, by their nature, the most disturbing and visible
and are most likely to be social in nature (see table 1 below).
Table 1. Short-term effects from the use of illicit drugs and other substances
Medical Social Legal Economic
Hangover Arguments Being intoxicated Loss of income
Feeling sick or Fighting Criminal damage Unnecessary
vomiting Neglecting children Driving under the expenses
Stomach pains and Violence at home influence of alcohol
problems Sexual assault or drugs
Head injuries from falls Child abuse Assaulting people
Other accidents and Accidental killing
injuries Drug possession
Drowning offenses
Accidental overdose
1
Thorley, A. (1980), “Medical responses to problem drinking”. Medicine, 3rd Series, 35:1816-1833.
1
Regular or excessive use
Problems from regular or excessive use come from continual use over a period of time.
This practice may not allow the person’s body to recover completely from the last time they
used, so each time their health may get a little worse. Money problems may develop
because of regular spending on the drug. Table 2 presents some problems of regular or
excessive use.
Table 2. Long-term effects from the use of illicit drugs and other substances
Medical Social Legal Economic
Brain and nerve Family problems Drug possession Loss of employment
damage Marriage problems offenses Hospitalization
Mental health Work problems Driving under the Loss of property
problems Neglected children influence of alcohol or Sex work
Heart disease, No food in the house drugs
diabetes and cancer Education problems Not paying bills
Infectious diseases Drug dealing
Sleep and dental
problems
Dependency
Drug dependence develops after a period of regular use, with the time period varying
according to the quantity, frequency and route of administration, as well as factors of
individual vulnerability and the context in which the drug use occurs.
Many young people who have experimented with drug use do not become frequent users,
and many who become frequent users do not become dependent.
Multiple factors, including the availability of drugs, family and peer influences and the
environmental context, contribute to the initial decision to try drugs. Once use has occurred,
further factors contribute to the likelihood of developing dependence, including:
 environmental factors (cues, conditioning, external stressors);
 drug-induced factors (molecular neurobiological changes resulting in altered behaviors);
 genetic factors through traits such as response to drug use, personality, concurrent
psychiatric disorders.2
Based on the Dangerous Drugs Board (DDB) Integrated Drug Abuse Data and Information
Network, or the 2014 IDADIN Report (Facility-based), seven substances have been
identified as being used/abused in the Philippines. Shabu is the highest (91.23%), followed
by marijuana (35.77%), inhalants (e.g. contact cement and adhesives) (1.68%),
benzodiazepines (1.64%), cocaine (1.16%), nalbuphine hydrochloride (0.77%), and MDMA
or ecstasy (0.75%).
2
Kreek, M.J. et al. (2005). Pharmacogenetics and human molecular genetics of opiate and cocaine addictions and their
treatments. Pharmacological reviews, 57(1): 1-26.
2
The way in which dependence develops is much the same for all drugs. Daily, or almost
daily, use over a long period of time leads to physical and psychological changes.
Physically, the body adapts or ‘gets used to’ having a drug on a regular basis. Eventually,
the drug is needed to function ‘normally’ and more is needed to get the same effect. When
this happens, stopping or cutting down is very difficult because a person will start ‘hanging
out’ or withdrawing. The drug may then be taken to ease or stop withdrawal effects
occurring.
Psychologically, a person’s thoughts and emotions come to revolve around the drug. A
person will ‘crave’ the drug (have strong urges to use), and feel compelled to use even
though they know (or believe) it is causing them difficulties – perhaps financial or legal
worries, relationship problems, work difficulties, physical health and psychological problems
such as depression and anxiety.
Smoking, sniffing, snorting or ingesting methamphetamine (shabu) is a significant form of

drug use in the Philippines. Amphetamine-type stimulants (particularly methamphetamine)
are used to enhance the ability to work, as well as in recreational or social situations. Work
requiring stamina, long hours and hard work is closely linked to methamphetamine use for
some people. Such work provides higher income, but the user enters a vicious cycle of
using methamphetamine in order to be able to do the work, but then has to work more to
get enough money to buy drugs and so on. Alcohol consumption may also be linked to
methamphetamine use, and used to help relax, sleep and eat, but also as a substitute when
methamphetamine is not available.
Marijuana, the second most commonly used drug in the Philippines is mostly smoked or
ingested. There are several psychoactive preparations of the marijuana (hemp) plant,
Cannabis sativa. They include marijuana leaf (in street jargon: grass, pot, dope, weed, or
reefers), bhang, ganja, or hashish (derived from the resin of the flowering heads of the
plant), and hashish oil. Cannabis contains at least 60 cannabinoids, several of which are
biologically active. Cannabis intoxication produces a feeling of euphoria, lightness of the
limbs and, often, social withdrawal. Its effects can include impairment of driving or other
complex, skilled activities. Other signs of intoxication may include excessive anxiety,
suspiciousness or paranoid ideas in some and euphoria or apathy in others, impaired
judgment, conjunctival injection (redness in the eyes), increased appetite, dry mouth, and
tachycardia. Cannabis is sometimes consumed with alcohol, a combination that is additive
in psychomotor effects. Acute anxiety and panic states and acute delusional states have
been reported with cannabis intoxication; they usually remit within several days.
Cannabinoids are sometimes used therapeutically for glaucoma and to counteract nausea
in cancer chemotherapy. Cannabinoid use disorders are included in the psychoactive
substance use disorders in ICD-I0 (classified in Fl2).3
‘Dependence’ is widely accepted as describing a characteristic set of cognitive, behavioral

and physiological symptoms (see 5.4 – Diagnostic guidelines for dependence). As indicated
by these criteria, drug dependence is not necessarily heavy drug use, but a complex health
condition that has social, psychological and biological dimensions, including changes in the
3 WHO Lexicon of alcohol and drug terms http://www.who.int/substance_abuse/terminology/who_lexicon/en/
accessed 20150619.
3
brain – not a weakness of character or will.
The key elements of dependence are a loss of control over use, and continued use despite
awareness of problems caused or exacerbated by the using behavior. It is these aspects
that make dependence particularly damaging to the individual, family, and the community.
The high risk of harm to individual users, their families and the community make this
population the target for treatment services.
Because of its nature as a chronic health disorder with frequent relapses, drug dependence
requires long-term treatment and care. People who inject drugs comprise a substantial
group of people at risk for human immunodeficiency virus (HIV), tuberculosis (TB) and other
blood-borne diseases and opportunistic infections. Drug dependence treatment and care
should, therefore, include a continuum of care for people infected with HIV. It should include
services that will reduce the harm associated with drug use, approaches to prevent the
further spread of HIV and the means to treat other co-occurring disorders.
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Box 1: Principles for a substance abuse treatment system
The nine principles of drug dependence treatment, as outlined by a UNODC-WHO

2008 discussion paper, provide guidance for gradually implementing quality treatment
to those in need:
Principle 1: Availability and accessibility of dependence treatment

Treatment services need to be available, accessible, affordable and evidence-based
to deliver quality care for all people in need of support.
Principle 2: Screening, assessment, diagnosis, and treatment-planning

Comprehensive assessments, diagnosis and treatment planning are the basis for
individualized treatments that address the specific needs of each patient, and that will
also help to engage them into treatment.
Principle 3: Evidence-informed dependence treatment

Evidence-based good practice and scientific knowledge on dependence should guide
interventions.
Principle 4: Dependence treatment, human rights, and patient dignity

Treatment interventions should comply with human rights obligations, be voluntary
and provide the highest attainable standards of health and well-being.
Principle 5: Targeting special subgroups

Several groups within the larger population of those affected by dependence require
special attention, including adolescents, women (including pregnant women),
individuals with co-morbid disorders (either mental or physical), sex-workers, ethnic
minorities and homeless people.
Principle 6: Dependence treatment and the criminal justice system

Dependence should be seen as a health care condition, and dependent individuals
should be treated in the health care system rather than the criminal justice system
with community-based treatment offered as an alternative to incarceration where
possible.
Principle 7: Community involvement, participation, and patient orientation

Community-based treatment responses to drug and alcohol abuse and dependence
can promote community change and active involvement of local stakeholders and
support for community funding models.
Principle 8: Clinical governance of dependence treatment services

It is important that treatment services have clearly defined policies, treatment
protocols, programs, procedures, a definition of professional roles and responsibilities,
supervision, and financial resources.
Principle 9: Treatment systems: policy development, strategic planning and

coordination of servicesA systematic high-level policy approach to substance use
disorders and individuals in need of treatment, as well as a logical, step-by-step
sequence that links policy to needs assessment, treatment planning, implementation,
and to monitoring and evaluation is most beneficial.
5
6
2. Context of treatment
2.1 Policy framework to combat illicit drug use
Treating drug dependence as a medical condition does not imply that illicit drug use is
condoned. Rather, the existence of illicit drug use is acknowledged. In the context of good
public health, the objective is to take appropriate measures to limit the harm to people who
are affected by drug use and dependence through community-based treatment, resulting in
reintegration back to society, thus affecting their families and the rest of the community
positively.
Box 2: Republic Act 9165 or The Comprehensive Dangerous

Drugs Act of 2002
The Comprehensive Dangerous Drugs Act of 2002 or Republic
Act No. 9165 is a consolidation of Senate Bill No. 1858 and
House Bill No. 4433. It was enacted and passed by the Senate
and House of Representatives of the Philippines on 30 May 2002,
and 29 May 2002, respectively. President Gloria Macapagal-
Arroyo signed it into law on 23 January 2002. This Act repealed
the Republic Act No. 6425, otherwise known as the Dangerous
Drugs Act of 1972, as amended, and providing funds for its implementation. Under this
Act, the Dangerous Drugs Board (DDB) remains as the policy-making and strategy-
formulating body in the planning and formulation of policies and programs on drug
prevention and control. The enactment of RA 9165 reorganized the Philippine drug
enforcement system with the new Dangerous Drugs Board (DDB) that serves as a policy
and strategy formulating body. The DOH, as the lead agency in health, is continuously
and actively participating in the country’s fight against drug abuse in partnership with the
Dangerous Drugs Board, PDEA, Dep Ed, DSWD, other government agencies, LGUs,
non-governmental organizations, and other stakeholders.
The Philippine National Anti-Drug Strategy 2002 has recently been updated, and the
Philippine National Anti-Drug Plan of Action (NADPA) 2015-2020 published.4 In the
foreword, its purpose is defined as “to redefine the tasks of all National Government
Agencies, Government-Owned and Controlled Corporations, Local Government Units
(LGU), Non-Government Organizations, Community-Based Organizations, Private
Organizations and other organizations involved in the anti-drug campaign.”
The NADPA expresses national concerns and charts the response to drug use and abuse
and efforts to prevent and control these problems. Its objectives include the following:
a. to stop the production, processing, trafficking, financing and retailing of dangerous
drugs, precursors, and other essential chemicals;
b. to formulate policies in accordance with the new dangerous drugs law;
c. to develop and implement preventive education programs for various target groups;
d. to adopt and utilize effective treatment and rehabilitation and after-care programs;
e. to continue the conduct of research on vital aspects of the drug abuse problem;
4
National Anti-Drug Plan of Action 2015-2020, p1.
7
f. to promote public awareness on the evils of dangerous drugs;

g. to reduce the production of marijuana and eventually eliminate its cultivation;
h. to forge and foster cooperation with regional and international agencies and
counterparts and participate in drug-related international efforts.
The NADPA contains five strategic concepts,5 the second of which, the Demand Reduction
Strategy, addresses preventive education, research, and treatment and Rehabilitation.
Box 3: Treatment and rehabilitation in the NADPA 2015-2020
To enhance easy access to treatment and rehabilitation of drug dependents:

1. continue providing financial support for the construction, maintenance and
operation of treatment and rehabilitation centers;
2. capacitate and accredit more physicians on diagnosis and management of drug
dependents;
3. set-up mechanisms to facilitate entry/admissions to drug rehabilitation centers;
4. implement a one-stop-shop treatment facility to encourage drug dependents to
undergo treatment and rehabilitation;
5. formulate policies in support of the inclusion of recovering drug dependents in the
coverage of the conditional cash transfer program.
It is relevant to note that enhancement of the economic and social well-being of

communities, particularly those in areas where cultivation of marijuana or opium poppies is
possible or has occurred, is an important element in reducing the supply of illicit drugs. As
the illicit drug trade does not respect borders, it is also important for countries in the region
to cooperate on measures to control the supply of drugs.
The Guide for Community-Based Assessment, Treatment and Care Services for Drug
Users in the Philippines is an important step in the implementation of Strategy Two in the
NADPA. It will support the goal of the treatment and rehabilitation component of this
strategy (i.e. to enhance easy access to treatment and rehabilitation of drug dependents).
The responsibilities of the DOH, as enumerated in the NADPA, are as follows:
a. oversee the regulation and implementation of tertiary prevention programs (treatment
and rehabilitation);
b. supplement demand reduction efforts;
c. enhance the capacities of human resources involved in treatment and rehabilitation
through the provision of advanced training and competency development;
d. enhance access to controlled medications by providing additional mechanisms to
medical practitioners;
e. participate/coordinate with PDEA in the prevention/control of the diversion/misuse of
medicines and legitimate production/importation of plant sources by drug
traffickers/clandestine laboratories/users;
f. initiate and/or oversee relevant researches and address emerging concerns (HIV-
5
NADPA p. 25, A. The drug supply reduction strategy; B. The drug demand reduction strategy; C. The alternative development
strategy; D. The civic awareness and response strategy; and, E. The regional and international cooperation strategy.
8
PWID, new psychoactive substances, etc.) on drugs/substance use and abuse;

g. conduct studies and continuously monitor the effects of dangerous drugs on people’s
health;
h. assist in the collection of drug-related data through the effective management and
enhancement of the Integrated Drug Testing Operations Management Information
System and other drug-related hospital data;
i. mobilize and empower barangay health workers in the prevention and control of drug
abuse;
j. perform other tasks as appropriate.
2.2 National health systems
The Department of Health (DOH) holds the overall technical authority on health in the
Philippines, as it is the national health policy-maker and regulatory institution.
The DOH has three major roles in the health sector: (1) leadership in health; (2) enabler
and capacity builder; and (3) administrator of specific services. Its mandate is to develop
national plans, technical standards, and guidelines on health. Aside from being the
regulator of all health services and products, the DOH is the provider of special tertiary
health care services and technical assistance to health providers and stakeholders.
RA 9165 or The Comprehensive Dangerous Drugs Act of 2002 highlighted the

responsibility of the DOH in developing policies and standards for the licensing and
accreditation of drug testing laboratories, and drug treatment and rehabilitation facilities.
The DOH was also given a mandate to train and accredit substance abuse physicians and
rehabilitation practitioners. The administration of all government-managed drug treatment
and rehabilitation centers was transferred to the DOH. The DDB retained overall policy and
oversight functions while the Philippine Drug Enforcement Agency (PDEA) remained
responsible for enforcing all legal provisions related to dangerous drugs.6
Box 4: Functions of the DOH Related to Drug Abuse
1. Formulate national policies and standards for health related to drug abuse.
2. Prevent and control drug abuse and its health-related effects.
3. Develop surveillance and health information systems related to drug abuse.
4. Maintain and operate DOH drug abuse treatment and rehabilitation centers
(outpatient/residential), detoxification units and drug testing laboratories with
modern and advanced capabilities to support local services.
5. Promote health and well-being through public information and to provide the
public with timely and relevant information on the risks and hazardous effects
of drug abuse.
6. Develop and implement strategies to achieve appropriate expenditure
patterns in health related to drug abuse as recommended by international
agencies/partners.
7. Development of and coordination with regional/local facilities or offices for
health promotion, drug abuse prevention and control, standards, regulations,
6
National Objectives for Health, Philippines 2005-2010, p. 272.
9
and technical assistance.

8. Promote and maintain international linkages for technical collaboration.
9. Ensure the quality of training and human resources development at all levels
of care for drug abuse.
10. Oversee and ensure equity and accessibility to health services for drug users.
11. Conduct research related to drug abuse prevention and control.
12. Ensure the provision of sufficient resources and logistics to attain excellence
in evidence-based interventions for drug abuse and its health-related effects.
SOURCE: National Objectives for Health, Philippines (2011-2015).
The Dangerous Drugs Abuse Prevention and Treatment Program (DDAPTP) take the lead
in the planning and implementation of the mandates of the DOH by virtue of RA9165 and
executive orders:
 Executive Order 102 series of 1999: Redirected the functions and operations of the
DOH and specified its mandate to provide assistance to LGUs, people’s
organizations and other members of civil society in effectively implementing
programs, projects and services related to drug abuse.
 Executive Order 273 Series of 2004 mandated the transfer of operations of the
government drug treatment and rehabilitation centers and program nationwide to the
DOH.
The general structure of national health systems is a hierarchy with increasing

specialization. As the degree of skill and specialization of services increases with each
level, the service delivery model is one of stepped care. A key issue is determining when it
is appropriate or necessary to refer a person to the next level of care.
Health interventions need to reach people at either their homes, schools, and workplaces,
or by encouraging them to visit health facilities. Programs based in communities can reduce
the costs and barriers that impede people’s access to services. On the other hand, general
primary care can act as an interface between community health programs and individual
clinical care, whether ambulatory or inpatient. Hospitals are needed to reinforce community
and primary care services when specialized equipment or skills are required for particular
interventions.
Table 3. Summary of roles and responsibilities of DOH offices/units

Central office Regional offices TRCs, hospitals and Attached agencies
medical centers
 Formulates policies,  Responsible for  Provide hospital-  Provide assistance
standards and field operations of based care to DOH functions
guidelines the Department in  Provide  Perform specific
 Issues regulations its administrative specialized or mandates related
 Takes charge of region general services to health
planning,  Provide catchment  Conduct research
organizing, area with efficient on clinical priorities
monitoring and and effective and act as training
evaluation health services hospitals for
 Implement laws, medical
10
 Oversees the regulations, specialization

overall policies and
implementation of programs
various programs,  Coordinate with
projects, and regional offices of
activities the other
Departments,
offices and
agencies, as well
as with local
government
The implementation of the Republic Act (RA) 7160 or Local Government Code of 19917
resulted in the devolution of health services to LGUs, which included, among other matters,
the provision, management and maintenance of health services at different levels of LGUs.
Health functions are largely devolved to provinces and municipalities. RA 7160 outlines the
roles of different levels in health care, including barangay (village), municipality and
province.
In the public sector, the DOH delivers tertiary services, rehabilitative services, and
specialized healthcare while the LGUs deliver health promotion, disease prevention,
primary, secondary, and long-term care. Primary health services are delivered in barangay
(village) health stations, health centers and hospitals.
2.2.1 Community level services
Community-based services provide families with information and resources. They can also
mobilize additional resources, such as volunteers’ time, local knowledge, and community
confidence and trust.
Community-level programs may include a range of interventions but focus on services

related to safe motherhood, nutrition, and simple prevention and treatment options.
Community-based health clinics provide basic services, supported by outreach workers,
often with no specific training or qualifications. The DOH, as the prime national health
agency, has the authority to provide coherence and direction in enhancing the operational
effectiveness of local health systems towards improved health status in local communities.
2.2.2 Primary Care
The basic notion of primary care is a range of health care services that act as an interface
between families and community programs on the one hand and hospitals and national
health policies on the other. A well-functioning general primary care system is integral to the
success of a health system because it provides the bulk of services close to the population.
It also acts as the bridge between local care and care at the next levels, such as hospitals.
In the Philippines, primary health care includes outpatient, dental and laboratory services
and disease programs that address tuberculosis, malaria and dengue.
7
Republic Act 7160 or the Local Government Code of 1991 provides the overarching framework of local governance in the Philippines.
Its key principles include local autonomy, decentralization, accountability and participative governance.
11
2.2.3 Drug abuse treatment and rehabilitation centers (residential and non-
residential), hospitals/medical centers, and specialty hospitals
Health facilities in the Philippines include government hospitals, private hospitals, primary
health care facilities and drug abuse treatment and rehabilitation centers. Hospitals are
classified as either public or private, according to ownership.
Drug Abuse Treatment and Rehabilitation Centers (DATRCs), hospitals, medical centers
and specialty hospitals provide services that are more sophisticated, technically
demanding, and specialized than those available at a primary care facility. The range of
services that these institutions offer includes outpatient, inpatient and hospital care,
laboratory and special procedures, acute and emergency treatment, care, counseling, and
rehabilitation. They may also provide health information, training, and administrative and
logistical support to primary and community health care programs.
12
3. Community-based treatment approach
3.1 Philosophy of the community-based approach
The core goal of the community-based treatment model is to ensure a holistic approach to
the treatment and care of drug users; the intensity of essential care varies according to the
nature and complexity of the problems experienced by the individual. As such, the
approach is broadly based on the World Health Organization’s pyramid of mental health
services (figure 2).
Figure 2. Service organization pyramid for substance use disorder treatment and care
The key principles of community-based treatment are:

 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;
 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;
 acceptance that relapse is part of the treatment process and will not stop an individual
from re-accessing treatment services.
13
Benefits of community-based interventions
There are many benefits of community-based interventions, both for people who are
affected by drug use and dependence, as well as the community itself. Essential elements
of the community-based approach are the forging of close linkages and collaboration
between service providers in the community and the health sector, and social welfare
support for rehabilitation and reintegration. The process usually starts and is sustained by
the community in which the drug user and their family lives and is implemented with the
assistance of all community organizations, with a substantial contribution from the non-
government sector:
 Active patient involvement aims to promote ownership and responsibility, changes in

individual behavior and improvement in the quality and utilization of health services.
 Community and service users play an important role in helping shape an approach
that ensures appropriate accountability and responsibilities of all those involved in
the delivery of services. There is increasing recognition that the process of service
development needs to be accountable to and shaped by a wide range of community
interests.
 Community-oriented interventions can increase community support for people with

drug problems and promote supportive public opinions and health policy. Community
information and empowerment can also help reduce discrimination and social
marginalization. Reducing the stigma of drug use is a factor that is likely to
substantially improve accessibility to treatment and reintegration into society.
 Mainstreaming drug dependence treatment in health and social care interventions

not only enables the treatment of a larger number of patients, but it also promotes a
paradigm change within society to acknowledge drug dependence as a multi-
factorial disorder.
 Treatment provided in the community is less invasive than other treatments such as
residential or inpatient treatment, and less disruptive to the family, working and social
life, thereby fostering independence of the client or patient. It has the added
advantage of facilitating the use of a range of treatment and rehabilitation services
that are more accessible and affordable. Crucially, the community-based approach,
by not sending drug users away and out of sight, helps the community to understand
the complexities of drug problems and thereby helps reduce stigma and
discrimination against drug users.
It is expected that the implementation of community-based drug treatment will enable

people with drug-related problems to have improved access to a range of quality services
from education, information and drug counseling, to assistance in stopping or reducing drug
use. This approach aims to help avoid the harmful health and social consequences of drug
use, especially HIV, hepatitis and sexually transmitted infections. People who are affected
by drug use and dependence will be offered help to improve the overall quality of their life
and well-being through social support for rehabilitation and reintegration into the
14
community.
3.2 Service delivery model
The model provides for comprehensive care for people who are affected by drug use and
dependence. Examples of these services include community support, primary health
services, and expert medical and psychiatric diagnoses and services in district and referral
hospitals or specialized clinics. Clients are referred to whichever community services are
appropriate, based on a screening of drug and alcohol problems. This approach ensures
community participation and linkages to ongoing drug-use prevention and other services,
which aim to reduce the harm associated with drug use in the community.
People who are affected by drug use and dependence may enter the treatment system at
any point. For example they may:
 first seek help from community health staff or social workers;
 go directly to a health center or medical clinic;
 go to the Anti-Drug Abuse Council (ADAC);
 go to a municipal/city health office;
 go directly to a hospital/DATRC;
 be referred from one service to another.
There should be linkages between drug dependence treatment services and hospital
services, such as those from the emergency medical services, infectious diseases and
internal medicine departments, and specialized social services such as housing, vocational,
mental health training and employment. Integrating psychiatric and drug dependence
treatment increases retention of patients with comorbid psychiatric disorders.
Figure 3: Model of community-based treatment

15
Implementing partner non-governmental organizations (NGOs) can play a significant role in

the provision of services for patients with drug dependence in coordination with the public
health system. They can be particularly helpful in the process of reaching out, scaling-up
treatment, and providing support in the community and facilitation of rehabilitation and
reintegration.
Where feasible, services should be offered as “one-stop-shop”. Alternatively, linkages with

existing services should be established, and referral ensured through case management.
Services, however, should be designed to serve the needs of specific population
subgroups, such as women (including pregnant women), children and adolescents, PWID,
MSM, transgender, and sex workers.
Engagement with law enforcement authorities at national, local and community levels
through agreements with community services can help ensure an enabling environment
and fosters a facilitative/supportive role for law enforcement agencies in the delivery of a
continuum of care to drug users.
Three major components of community-based treatment model
There are three major components to the model (Figure 3):

• Community organizations, including NGOs, help identify drug users and conduct basic
screenings of drug problems and refer users to primary health services when required.
Community organizations also focus on preventive education, health promotion and the
delivery of basic support, reintegration and rehabilitation services.
• Primary health services are provided in health centers and specialist health services are
provided in hospitals.
• Social welfare agencies and NGOs offer education, vocational and skills training,
income generation opportunities, micro-credits, etc.
16
Figure 4: Model of community-based treatment and care for people who are affected by drug use and
dependence
The role of the community is at the core of the model. The journeys of the people affected
by drug use through the system of treatment and rehabilitation begin and end in the
community. Although there is no one single “best” way of entering the treatment system,
drug users are often identified in the community by a variety of stakeholders including
family members, NGO peer and outreach workers, law enforcement personnel and others.
The provision of drug and HIV information, a preliminary screening of drug and alcohol
problems and risk behaviors usually is undertaken in the community. Upon identification
drug users may be either helped in the village or community or, if willing, may be referred to
a drug treatment health clinic or hospital.
The model reflects the complexity of identification, diagnosis and treatment interventions for
people who are affected by drug use and dependence in the community. It is clear that
there is no single identifiable entry point into the treatment and intervention system. Drug
users may, if they so wish, go directly to the health center or hospital or specialized clinic,
or request assistance from government agencies or NGOs. Consequently, the model may
be best described as a circular form around the individual client/patient rather than linearly
(figure 4).
17
The combination of services provides a continuum of care from informal community care
and community outreach services to drug withdrawal, counseling, aftercare, rehabilitation,
and reintegration. The model provides the basis for close collaboration between NGOs,
health, and social support services at the village or community level and provides a focal
point for regular liaison between local law enforcement agencies and the community. Such
a mechanism includes the raising of awareness among law enforcement officials of their
role in facilitating access to health and social services for people with drug-related problems
as an alternative to punitive sanctions.
3.3 Components of a community-based approach
The key components and roles and responsibilities of key actors in a community-based
approach are presented in table 4. In addition, flow diagrams providing referral guides for
each of the components are included in this section as an additional explanation of the
roles of each component of the community-based approach.
Table 4. Roles and responsibilities of key actors in community-based approach

Components Responsibilities Key Actors Tasks
Community  Awareness  Community  Identification of drug users
raising members  Preliminary screening and
 Public education  Community- basic needs assessment
 Health promotion based  Basic counseling and support
workers  Referral of people who are
 NGO peer believed to have a substance
outreach abuse problem to health
workers centers
 Other
individuals
and
organizations
operating in
the
community
 ADACs
Community  Provision of basic  Health center  Provision of basic health
health centers health care staff education and brief counseling
including  Community on risks of drug-related
assessment and volunteers problems
management of  Representativ  Provision of support to drug
minor injuries es from local users who are not drug-
and diseases authorities 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
DATRCs or DOH-accredited
physicians
Treatment and  Treatment of  Health  Assessment and diagnosis of
rehabilitation complicated care/medical substance use and
centers, cases staff dependence
18
Components Responsibilities Key Actors Tasks

hospitals/  Provision of  Volunteers  Diagnosis and treatment of
medical centers medical, surgical, drug use disorders and
diagnostic and potential comorbidities
emergency  Medicated detoxification (if
services required)
 Counseling and  Psychosocial counseling
Rehabilitation  Mental health examination
 Treatment of medical problems
Non-  Ensure a  NGO staff  Education about the effects of
governmental continuum of  Volunteers drugs including HIV prevention
organizations care education to the community
 Provide ongoing  Training of drug use disorders
support to clients to law enforcement
and family  Collaboration with other
 Focal points for stakeholders and organizations
client in the community
management and  Psychosocial counseling
coordination of  Help support groups
care
Law  Consider options  PDEA, PNP  Collaboration with community
enforcement other than arrest and other law members and organizations in
 Direct referral to enforcement the identification and
residential agencies preliminary screening of drug
centers for drug users
users  Discussion with drug users and
 Assist drug users families of options for treatment
in receiving help
in the community
19
3.3.1 Community (including outreach)

The major tasks for all community
organizations are ‘awareness-
raising’, public education and
health promotion, highlighting the
complexity of drug use behaviors
and consequences. The following
are other tasks of the community:
 Community-based workers
help identify drug users,
conduct preliminary screening
interviews and a basic needs
assessment of the user and
their family and together devise
an ‘action plan’. The initial
interview and plan determine
whether the people who are
affected by drug use and
disorder can be helped (in the
first instance, in their
8
barangays ) or whether they
need to be referred for more
expert advice to local health or
drug treatment clinics or a
hospital.
 Community members and
NGO-trained peer outreach Figure 5: Assessment Guide for Community Organization
workers assist by offering basic Outreach Teams or Social Workers
counseling and support to

people who are affected by drug use and their families if uncomplicated home-based
withdrawal is indicated. They also support people who are affected by drug use and
their families in their recovery, reintegration and rehabilitation during and following
treatment at the clinic or hospital. Treatment options include modification strategies,
which minimize the harm associated with drug use. Key individuals and organizations
operating in the community can be mobilized to identify, engage, inform and assist drug
users and their families to deal with drug problems. The role of community organizations
is key to the process. There are many resources in most communities, including civil
and religious groups, health services, and political establishments.
 Support groups are mechanisms to increase community ownership and involvement in
health issues in the community barangay. Volunteers include parents, students,
teachers and youth and are offered training by NGOs. Health support groups work to
mobilize community participation in the health care system.
It is assumed that community members, including community health workers, outreach and
8
A barangay is the smallest administrative division in the Philippines and is the native Filipino term for a village, district, or ward.
20
peer workers, family members, police, and ADAC members, will refer people who are
believed to have a substance use problem to health centers. Some will come of their own
accord once they hear that help is available.
3.3.2 Community health centers

Health centers are the closest
public health facility to the
population. They provide basic
health care, including the
assessment and treatment of
minor injuries and diseases such
as malaria, diarrhea, sexually
transmitted diseases, TB, and
leprosy.
The close geographical proximity

of community health centers
removes an important access
barrier for people who are affected
by drug use and dependence.
Health centers offer a good
opportunity for brief counseling,
which is appropriate for people
who do not have severe problems.
People who are affected by drug
use and dependence and their
families can benefit from the help
of trained health staff. If treatment
can be offered in the health center, Figure 6: Assessment guide for health centers
patients will not have to leave their
community or barangay nor be sent far from home for treatment.
Health centers refer cases to hospitals or specialized clinics if necessary. Community

health centers provide screening for substance use problems and associated health
conditions and provide basic primary health services.
Drug users presenting with complex problems of psychiatric comorbidity, poly-drug use or
serious medical problems are referred to hospitals. The health center offers basic health
education and brief counseling on risks of drug-related problems, working in tandem with
community organizations, outreach workers, and families. It is expected that community
health staff will be able to offer help and support to a large number of drug users who are
not drug dependent but who require services to prevent an escalation and worsening of
drug-related problems and ameliorate the adverse consequences of existing drug use.
Health centers liaise with NGOs in the community, and refer patients back to community
organizations who provide follow-up aftercare and facilitate access to rehabilitation and
reintegration services when needed.
21
The following are further roles and responsibilities of health centers:

 screening for substance misuse using standardized instruments (see section 5 – tools
for screening, treatment and evaluation);
 providing primary health, physical and psychiatric examination;
 providing treatment of basic health problems and symptomatic treatment for health
consequences of substance use;
 providing access to voluntary counseling and testing, medications for HIV, tuberculosis
and sexually transmitted infections;
 providing brief counseling;
 referring patients to community, DATRC or DOH-accredited physicians9 as
appropriate.
It is feasible to establish on-site primary health care services for people who are affected by
drug use and dependence within a drug treatment clinic, especially if an outpatient program
of medication-assisted treatment exists. Such services may be attractive to drug treatment
clients, and it is highly likely that they will voluntarily use them.
3.3.3 Drug abuse treatment and rehabilitation centers (residential and non-
residential), hospitals/medical centers, specialty hospitals
Hospitals provide complementary services including treatment of complicated cases, and
medical, surgical and obstetrical emergency cases, surgery, maternal and child health, X-
ray, ultrasound and laboratory services, and rehabilitation services. Hospitals are not equal
in their service provision, with some offering less extensive services. Only some can
diagnose and treat drug use disorders and potential comorbidities.
Drug treatment clinics, on the other hand, focus on drug treatment rather than general
public health services. However, drug treatment clinics may also operate at the community
level.
Hospitals provide a higher level of medical care than that of health centers. Patients
referred to hospitals undergo a comprehensive assessment and diagnosis of substance use
and dependence, a mental health examination leading to diagnosis and treatment – if
indicated – of psychiatric comorbidities (including psychosis, depression and suicidal
ideation, anxiety disorders, etc.). In addition to drug use problems, hospital medical staff
treat all medical problems including coinfection with HIV or hepatitis C, tuberculosis or
sexually transmitted infections. Hospitals also provide medicated detoxification if required,
either on an inpatient or outpatient basis. Psychosocial counseling is the core approach for
those dependent on amphetamine-type stimulants while counseling with pharmacotherapy
is the key service for those dependent on opioids.
Treatment planning with the patient forms the basis for further interventions and
rehabilitation. The hospitals liaise with treatment and care partners at all levels. They refer
patients back to community services as soon as practicable and work together with
community-based organizations and patients to develop realistic rehabilitation and
reintegration plans. The hospital follows up patients to determine the efficacy of their
9 DOH-accredited physicians are those physicians authorized to conduct drug dependency examinations in the Philippines.
22
interventions.
The key responsibilities of drug

abuse treatment and rehabilitation
centers, hospitals or specialized
clinics are:
 assessment and diagnosis of
drug and alcohol problems
using appropriate instruments
(see section 5);
 assessment of physical health
(with special attention to drug
use comorbidity);
 medicated withdrawal;
 psychosocial counseling;
 treatment planning and
consultation with case
managers in the community;
 referral to social welfare
services;
 referral back to the community;
 referral to mutual support
groups.
One essential element of the

community-based approach is the
forging of close linkages and
collaboration between different
service providers in the community
and the health sector and with Figure 7: Assessment for drug abuse treatment and
rehabilitation center, hospitals/medical centers, specialty
ancillary health and welfare support hospitals
and rehabilitation programs.
Aspects to be considered in a treatment plan (in the context of hospital or specialist clinic),
and agreed with the patient and family if appropriate, include:
 Determine the major problems confronting the patient.
 Focus treatment on the most pressing issues (not necessarily drug problems).
 Determine whether the patient needs pharmacologically assisted withdrawal. If yes,
should it be in the hospital or at home?
 How will supervision of withdrawal be undertaken?
 Is the patient suitable for medication-assisted treatment (if dependent on opioids)?
 What happens after withdrawal? Counseling? Relapse prevention? Referral to
rehabilitation?
 Counseling approaches will depend on the availability of counselors (behavioral
approaches, motivational interviewing, relapse prevention).
 Agree on the review and monitoring of the treatment plan.
23
3.3.4 Non-governmental organizations (NGOs) and social support services
NGOs have a key responsibility to ensure a continuum of care and to provide ongoing
support to clients and their families and are the focal points for client management and
coordination of care in a community-based approach. Social welfare and NGOs provide a
large number of services in the community. In the community-based treatment approach,
they provide screening and case management for clients. NGOs also provide drug and HIV
prevention education in the community, including services to minimize the harm done by
using drugs.
Key activities of social welfare and NGOs include to:

 provide education to the community about the effects of drugs, especially the links
between drug use and HIV infection, sexual health and condom use, and facilitate
referral to voluntary counseling and testing;
 provide sensitivity training on drug use disorders to law enforcement, community
leaders, local authorities, teachers, parents, traffic police, and religious leaders;
 collaborate with stakeholders in the community (including law enforcement) in
conducting preliminary screening for drug and alcohol use for people for whom there is
community concern;
 collaborate with other organizations working with people who are affected by drug use
or dependence and HIV and with organizations providing rehabilitation training;
 assist in referral to medical treatment in health centers, hospitals or clinics as
appropriate;
 provide information and services that will reduce the harm from drug use, particularly on
sexual risks, condom use and clean injecting practices, through outreach, peer
education, drop-in centers, and support groups;
 provide psychosocial counseling to people affected by drug use and dependence and
their families;
 provide rehabilitation services such as life skills and vocational training;
 support mutual help and support groups for people affected by drug use and
dependence;
 provide home visits and home-based care when required and help support non-
pharmacological withdrawal and relapse prevention when indicated.
3.3.5 Law Enforcement
Police participate in the community-based approach by collaborating with other community-

based organizations in the identification and preliminary screening of drug users, and
through discussions with drug users (and their families if appropriate) about options for
treatment.
There are fundamental differences between drug dependence treatments and law
enforcement procedures. In the treatment context, drug dependence is considered a
complex health problem combining social, mental and physical aspects. In the context of
law enforcement, illicit drug use is regarded as criminal behavior.
24
A positive paradigm of community-based care can occur when police recognize the value of
a treatment that will change with greater understanding of the nature of drug dependence.
Once drug dependence is recognized as a chronic health disorder having negative health
and social impacts with many contributing factors, the required response will also be
understood as a long-term health intervention.
A multi-sectoral approach involving law enforcement, health, and social sectors will produce
the most effective response in terms of reducing drug use in the community. Promoting
treatment for drug dependence as an alternative to punishment will provide support for an
effective approach with a continuum of care. The strengthening of partnership at all levels,
particularly between government and agencies that directly or indirectly target people who
are affected by drug use and dependence, is critical.
As the agency in the community charged with upholding the law of the land and ensuring
public safety, the police have a critical role in supporting a community-based approach by
participating in the program and contributing to associated strategic planning and activities.
It is important to engage the police at national, provincial, district and community level and
alerting them to the advantages of the community-based treatment approach.
PDEA, PNP and other law enforcement units contribute to the effectiveness of a
community-based approach by considering options other than arrest or direct referral to
residential centers for drug users, and assist the drug user in receiving help in the
community.
Box 4: ABCDs of drug abuse and rehabilitation services
Accessible, affordable, equitable, and quality health services.

Basis for treatment – screening, assessment, diagnosis and treatment planning.
Coordination of services, policy development and strategic planning – systematic, high-
level, policy approach and a logical, step-by-step sequence that links policy to needs
assessment, treatment planning, implementation, monitoring and evaluation.
Dignity of patients, human rights, and “voluntary” admission are primarily considered to
provide the highest attainable standards of health and well-being.
Evidenced-based good practice and scientific knowledge on drug abuse guide all
interventions.
Focus special attention on sub-groups – adolescents, women (including pregnant
women), sex workers, ethnic minorities, homeless people, LGBT and PWIDs.
Good clinical governance – clearly defined policies, treatment protocols, programs,
procedures, definition of professional roles and responsibilities, supervision and
financial resources.
Health care system management rather than the criminal justice system.
25
Involvement and active participation of the affected individual, family, community and
other stakeholders.
Dealing with community concerns about drug use
The primary role of police is to enforce the law. However, there may be alternatives to the
criminal justice system that can assist people affected by drug use and dependence to
access help. Such alternatives can help reduce drug problems and serious health
consequences, as well as drug-related crime. Thus, the community-based approach is also
more likely to promote integration and employment.
Few people who use drugs, once dependent, will stop using because they are concerned
about the police and law enforcement. This is because ‘dependence’ means a compulsion
to continue to use, as well as experiencing unpleasant symptoms once drug use is
discontinued. Hence, there is a need to assist drug users in identifying realistic options
since punishment and coercion do not work. Police can act as a useful resource for schools
in drug education programs and take part in community education about drugs and HIV
risks. Police can provide a supportive environment for health center drug services, hospitals
and specialized clinics, drop-in centers, and needle and syringe programs by not targeting
the vicinity of these programs to arrest users.
In any situation, police have to consider their actions and responses and what impact those
actions may have on the whole community. Ideally, the police and health and community-
based non-government workers cooperate to reduce the harms caused by drug use. Police
can assist by avoiding activities that further marginalize drug users, and avoiding creating a
climate of fear that leads to problematic and chaotic drug use. This way, the police can
promote and support agencies that deal with people affected by drug use and dependence
on an ongoing basis. The police can take every opportunity to promote activities that reduce
the harm associated with drug use, and explain the reasons for taking such an approach –
one that will provide a much more helpful and positive message for the community and
shows good leadership.
It is important that police are fully aware of community-based approaches to drug use
problems because their role in helping to reduce drug-related harm in the community is
critical. A community-based approach allows for careful screening and assessment of the
nature and severity of drug problems and allows the police to use a range of strategies to
deal with people affected by drug use and dependence – approaches that are more
effective than punishment, compulsory centers, or residential centers for drug users. These
alternative approaches have the potential to free up a lot of police time normally used to
deal with minor drug offenders – time that can be used to tackle more harmful crimes in the
community, such as drug trafficking, robberies and assaults.
Police can provide leadership and guidance in the development of programs that aim to
reduce drug-related harm to individuals and communities and can use their discretion in
dealings with drug users. When a person who is affected by drug use and dependence is
apprehended, police should consider:
26
 How should the good of the community be assured?

 Does the offense committed by the person who is affected by drug use and
dependence constitute a danger to the rest of the community?
 Are there alternatives to arrest and to take the person to court or send them to a
residential center for drug users?
 Police are well placed to encourage entry into drug treatment programs because:
– police have a presence 24 hours a day, seven days a week;
– police have frequent contact with all members of the community including
people who are affected by drug use and dependence;
– police often have contact with users at times of crisis when motivation for
treatment is high, such as after an overdose, public dispute or family violence,
driving under the influence of alcohol, etc.
It is recommended that police consider referring people suspected of using drugs or

excessive alcohol to NGO staff, peer educators and outreach workers, self-help groups or,
whenever possible, to a designated community case manager and/or health center for
screening and assessment.
Police should avoid making arrests at the scene of a drug overdose, as such action can
deter people from calling for medical help without delay because of the fear of prosecution.
27

Unodc-Community-Based Treatment Guidance (011-048)

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CONTENTS

LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................................. I

LIST OF ABBREVIATIONS AND ACRONYMS

ADAC Anti-Drug Abuse Council

LIST OF BOXES AND FIGURES

Box 1: Principles for a substance abuse treatment system

Box 3: Treatment and rehabilitation in the NADPA 2015-2020

Box 4: Functions of the DOH related to drug abuse

Box 5: ABCDs of drug abuse treatment and rehabilitation services

Figure 1: Thorley’s model of drug use

Figure 3: Model of community-based treatment

Figure 5: Assessment guide for community organization outreach teams or social

Figure 6: Assessment guide for health centers

Figure 7: Assessment for drug abuse treatment and rehabilitation center,

Figure 8: Stages of change

Abstinence Refraining from using drugs

CAGE Screening questionnaire for alcoholism, the name of which is an

Dual diagnosis A general term referring to comorbidity or the co-occurrence in the

Maintenance therapy Prescription of medication on a long-term basis to support

Medication-Assisted Combination of pharmacological intervention with counseling and

Personality disorders Characterized by destructive patterns of thinking, feeling,

1. Nature of substance use and dependence

People who use illicit drugs and other substances

A model presented by Thorley1 shows that

Thorley’s model (Figure 1) has three parts:

Regular or excessive use

Smoking, sniffing, snorting or ingesting methamphetamine (shabu) is a significant form of

‘Dependence’ is widely accepted as describing a characteristic set of cognitive, behavioral

brain – not a weakness of character or will.

Box 1: Principles for a substance abuse treatment system

The nine principles of drug dependence treatment, as outlined by a UNODC-WHO

Principle 1: Availability and accessibility of dependence treatment

Principle 2: Screening, assessment, diagnosis, and treatment-planning

Principle 3: Evidence-informed dependence treatment

Principle 4: Dependence treatment, human rights, and patient dignity

Principle 5: Targeting special subgroups

Principle 6: Dependence treatment and the criminal justice system

Principle 7: Community involvement, participation, and patient orientation

Principle 8: Clinical governance of dependence treatment services

Principle 9: Treatment systems: policy development, strategic planning and

2.1 Policy framework to combat illicit drug use

Box 2: Republic Act 9165 or The Comprehensive Dangerous

f. to promote public awareness on the evils of dangerous drugs;

Box 3: Treatment and rehabilitation in the NADPA 2015-2020

To enhance easy access to treatment and rehabilitation of drug dependents:

It is relevant to note that enhancement of the economic and social well-being of

PWID, new psychoactive substances, etc.) on drugs/substance use and abuse;

2.2 National health systems

RA 9165 or The Comprehensive Dangerous Drugs Act of 2002 highlighted the

Box 4: Functions of the DOH Related to Drug Abuse

and technical assistance.

SOURCE: National Objectives for Health, Philippines (2011-2015).

The general structure of national health systems is a hierarchy with increasing

Table 3. Summary of roles and responsibilities of DOH offices/units

 Oversees the regulations, specialization

2.2.1 Community level services

Community-level programs may include a range of interventions but focus on services

2.2.2 Primary Care

3. Community-based treatment approach