1. PILOT INVOLUNTARY TREATMENT PROGRAM Kevin Hedge Sydney West Area Health Service Centre for Addiction Medicine Nepean Hospital

2. Background NSW Inebriates Act 1912 provides for involuntary psychiatric admissions for 12 months for inebriates High levels of practitioner and consumer dissatisfaction with Inebriates Act Review of Inebriates Act tabled in 2004 NSW Government Response to the Report on the Inebriates Act 1912 recommended a new system of short term involuntary care

3. Background Development of Bill and service model supported by NSW Taskforce, chaired and led by MHDAO, NSW Health including membership by eminent practitioners and broad cross agency representatives Pilot will be supported by cross Government MOU providing comprehensive interventions Pilot to be subject of independent, external evaluation

4. NSW DRUG AND ALCOHOL TREATMENT BILL Objects of the Bill: To provide for involuntary treatment for persons with severe substance dependence, and Facilitate comprehensive assessment in relation to dependency Facilitate stabilisation through medical treatment including medically assisted withdrawal To give those persons the opportunity of engaging in voluntary treatment

5. NSW DRUG AND ALCOHOL TREATMENT BILL Dependency Certificate: Authorised medical practitioners can issue a certificate detaining a patient in care for management of withdrawal for 14 days Can be extended for additional 14 days Certificate can be issued for 3 months in patients with ARBD

6. NSW DRUG AND ALCOHOL TREATMENT BILL Legislative criteria: The person has a severe substance dependence, and Care, treatment or control of the person is necessary to protect the person from serious harm, and The person is likely to benefit from treatment for his or her substance dependence but has refused treatment, and No other appropriate and less restrictive means for dealing with the person are reasonably available

7. NSW DRUG AND ALCOHOL TREATMENT BILL Key features: 2 year pilot restricted to residents of SWAHS (Auburn to Lithgow). Prescribed by Regulation Referrals by responsible person Legislation pertains only to inpatient admission (no CTO equivalent) Provisions for restraint and seclusion Provision for involuntary medical care Judicial review and official visitors

8. NSW DRUG AND ALCOHOL TREATMENT BILL Safeguards in legislation: Involuntary detention and treatment is a last resort Interests of the patient is paramount Patients to receive best possible care in least restrictive environment Interference with rights, dignity and self respect of patients to be kept to minimum necessary

9. SERVICE MODEL Overriding purpose of involuntary care to: Protect patient from immediate harm through provision of medical care/safety Stabilise and assess the patient Restore health and decision-making capacity Provide opportunity to engage the patient in voluntary treatment Establish improved care arrangements including guardianship where appropriate

10. PROPOSED SERVICE MODEL Key elements of suitability for Dependency Certificate: Severe dependence Patient has significantly reduced capacity to make decisions about their well-being due to compulsion to engage in drug use in the face of: Serious harm to self and others Extreme misadventure, self neglect and physical and psychological morbidity

11. PROPOSED SERVICE MODEL Key elements of suitability for Dependency Certificate – Care and control is required to protect the person The affected person has lost control over their own ability to address or ameliorate harms arising from their substance use and Loss of control is consequence of their substance dependence and the associated compulsion to continue consumption and Serious harms have escalated in gravity.

12. PROPOSED SERVICE MODEL Key elements of suitability for Dependency Certificate – refusal to enter treatment voluntarily Consultation with the affected person regarding the harms that are arising from their substance use and A range of clinically meaningful voluntary options for addressing current harms have been canvassed with the person and The person has refused voluntary participation in a program of care that would ameliorate harm The person’s refusal of assistance is assessed as a consequence of their intense compulsion to continue consuming the harmful substance.

13. PROPOSED SERVICE MODEL Key elements of suitability for Dependency Certificate – No less restrictive means of care is available All other clinically meaningful and timely options to address harm have been considered or attempted without success and Involuntary clinical care at this time is the only option available to address harm in a meaningful way and Involuntary care will be a timely and effective response to ongoing harm

14. PROPOSED SERVICE MODEL Key elements of suitability for Dependency Certificate – established treatment plan Identification of important clinical issues including withdrawal risks and physical and psychiatric comorbidity Plan for assessment and management of functional capacity Discharge plan for rehabilitation, aftercare, assisted living arrangements etc

15. PROPOSED SERVICE MODEL Purpose of involuntary care: Clinically safe, evidence-based management of severe withdrawal Referral to specialist medical care according to need Provision of supportive interventions Establishment of voluntary or Guardianship post discharge support arrangements

16. PROPOSED SERVICE MODEL Clinical outcomes: Safe completion of withdrawal Neuroadaptation reversal and reduced intensity of craving Improved general health Reduced risk of relapse through relapse prevention strategies and aftercare arrangements Improved living arrangements

17. PROPOSED SERVICE MODEL Identified risks: Physical, neurological and psychological complications arising from withdrawal Risks associated with rapid reinstatement following withdrawal including overdose Oppositional, aggressive and violent behaviour Worsened hopelessness if interventions are unsuccessful Unmet community expectations of extended admissions

18. PROPOSED SERVICE MODEL 3 phase care model under Dependency Certificate: Phase 1 – Assessment and induction Phase 2 – Acute medical management of withdrawal Phase 3 – Assessment, care planning and brokerage Currently developing aftercare components Recognition of high risk clinical population

19. PROPOSED SERVICE MODEL Specific considerations: Conformity to UN principles for involuntary care for people with a mental illness Involuntary care is a last resort Order to be least restrictive in terms of type and duration Appropriate safeguards to be in place – official visitors and magistrate review Contraindications – aggression/violence and pts assessed as requiring involuntary care under MH Act Care of pts with ARBD