Prevention in Focus

Fall 2015 

New Best Practice Recommendations Part 2: Service referrals for substance use treatment, mental health services, and housing services

By Carol Strike and Tara Marie Watson

Many people who use drugs have unmet needs for substance use treatment, mental health, and housing services.1,2 Harm reduction programs are well positioned to reach these people and help them identify and access available client-centred services in the community. This article introduces new evidence-informed recommendations for referrals from needle and syringe programs (NSPs) and other harm reduction programs to substance use treatment and mental health and housing services.

What do we mean by “referrals?”

“Referrals” can mean different things or take different forms. A referral can range from a brief discussion between program staff and clients, during which service information is exchanged (for example, clients are given a list of resources or telephone numbers), to a more formal process involving healthcare providers and follow-up procedures.

By offering a variety of service referrals, harm reduction programs can connect clients to other types of services. This article will focus on referral partnerships between NSPs and substance use treatment, mental health, and housing services – services that can further assist clients achieve greater life stability and positive health outcomes.

Referrals to substance use treatment

Given the populations that harm reduction programs target, it is unsurprising that many programs provide referrals to substance use treatment programs.3 Referrals can be made to many different forms of substance use treatment. These include inpatient and outpatient programs, detoxification and withdrawal management, drug substitution therapies, psychotherapy, and group counselling.

Clients of an NSP may benefit from referral to a range of substance use treatment types that cover various substances, including alcohol-related treatment and tobacco cessation. It is important that staff at harm reduction programs find out about, and are familiar with, the various types of substance use treatment services available in their community. It is worth noting that urban settings will likely have more service options available than low-density or rural communities. That said, getting into substance use treatment programs in any setting might be challenging or limited because of waiting lists and/or specific program criteria.

The development of formal relationships with substance use treatment programs may be one important strategy to enhance the referral process.

Harm reduction programs should also find out about the needs of their clients and develop client-centred referral services to meet those needs. This includes an understanding of what services clients can realistically access and/or afford. Referral recommendations should take into account the preference and comfort level of each client.

Offering referrals to substance use treatment programs means that harm reduction programs can be a bridge to client enrollment in treatment and thus another avenue to reducing drug-related harm. Evidence shows that the availability of comprehensive drug treatment services, especially methadone maintenance treatment, helps reduce transmission of blood-borne infections through reductions in drug use and risk behaviours such as needle sharing.4,5,6,7,8

Referrals to mental health services

Many people who use drugs, including those who inject drugs and/or smoke drugs like crack cocaine, also have mental health conditions such as depression.9,10,11,12,13 People who inject drugs and also have mental health issues may exhibit worse mental health symptoms, fewer social supports and resources, and high-risk behaviours for HIV and hepatitis C infection, among other issues.14,15 This makes access to mental health services important.

Referrals are one important way to increase access for clients of harm reduction programs to appropriate mental health services. It is important that harm reduction programs find out about and are familiar with the various types of mental health services available in their community. However, harm reduction programs should look for mental health services with experience working with people who use drugs. Such experience may help reduce the stigma and discrimination often encountered and perceived by people who use drugs and/or who have concurrent mental health needs.16,17

The development of formal relationships with these mental health services may be another critical strategy to enhance NSPs’ referral systems and to fully support their clients. 

Referrals to housing services

Housing status can change over short and long periods of time. Housing status can also vary from stable to insecure or unstable housing to absolute homelessness. Housing supports are vital to people who use drugs and are homeless or unstably housed. People in this situation are at increased risk of death, suicide, HIV and hepatitis C infection, re-initiation into injection drug use, sexual risk behaviours, physical injuries, hospital and emergency visits, and mental health issues.18,19,20,21,22,23,24,25,26,27

These issues make access to housing services very important for people who use drugs to lessen these harms. There are many different types of housing services available and harm reduction programs should be familiar with the various types of housing services available in their community.

The literature highlights one interesting approach to housing that is available in different parts of Canada. It is considered by many to be a best practice for use with people who use drugs.28,29 Housing First is a recovery- and rights-oriented approach designed to provide people with housing first and then follow up with other services (such as substance use treatment, mental health services, education, and employment services) as needed. Across Canada, Housing First has been applied using different models of support. Housing First works from a harm reduction framework. In this model, to obtain and keep housing, people who use drugs do not have to show that they are abstinent, that they are interested in abstinence, or compliant with substance use treatment.28

Recommendations regarding service referrals

New evidence-based recommendations for referrals to substance use treatment, mental health and housing services have been developed by a multi-stakeholder team, the Working Group on Best Practice for Harm Reduction Programs in Canada. These recommendations make up part of Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 2.

Substance use treatment, mental health and housing services are clearly components of broader health-related strategies, including HIV and hepatitis C prevention and treatment, for people who use drugs.

The Working Group recommends that NSPs and other harm reduction programs do the following to increase access to substance use treatment programs and mental health and housing services among these populations:

  • Educate clients about substance use treatment (for example, detoxification, drug substitution programs and psychotherapy), mental health and housing services options
  • Refer clients to substance use treatment programs and mental health and housing services in the community
  • Establish and maintain relationships with a variety of agencies providing substance use treatment, mental health and housing services
  • Evaluate and publish any referral initiatives undertaken

Research on readiness to change and treatment readiness30,31,32 suggests that overemphasizing substance use treatment may alienate some clients and discourage them from accessing services. In addition, some research shows low rates of substance use treatment enrollment among NSP clients given referrals,6 as well as challenges with treatment retention.33 It is important to understand that when NSP clients express interest in substance use treatment, this does not necessarily mean they are fully ready to enter or stay in treatment. This could be due to personal but also social-structural barriers related to, for example, costs and transportation. Therefore, the Working Group also makes a recommendation specific to substance use treatment referrals and that is to educate program staff on how to properly assess and respond to client motivation and readiness for substance use treatment.

Need for more evidence

More research and evaluations are needed that are specific to NSP and other harm reduction program referrals to these services, particularly in relation to mental health and housing services. There are numerous gaps in what we know about the frequency of such service referrals and outcomes.

Another consideration that deserves more attention concerns co-location of services. Some NSPs and other harm reduction programs may want to consider the option of providing on-site services beyond drug use equipment distribution and other basic educational and health-related services already provided. “Low-threshold” substance use treatment like methadone maintenance treatment might work well at NSPs.7,34

An obvious advantage of having multiple services in one place is the convenience for clients. However, lack of resources or funding is likely a major barrier to on-site service integration for NSPs and other harm reduction programs, especially those that are already strained and those located in low-density areas. Finally, program clients should have their voices heard and be asked whether more referrals and/or services on site would meet their needs and increase service uptake.

Conclusion

The recommendations we outline and a full description of the evidence behind them can be found in the soon to be published Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 2. We summarize only several sections of Part 2 here and invite readers to check out other new recommendations in the document pertaining to: service model design; equipment distribution for injecting steroids and hormones, piercing and tattooing, smoking heroin, and smoking crystal methamphetamine; testing and vaccination; injection-related complications; referrals to HIV and hepatitis C treatment; relationships with law enforcement; and education and other services for the prison context. Overall, Part 2 promotes consistent policy and practice at programs that provide service to people who use drugs throughout the country.

In 2013, we launched the Part 1 document35 which covers topics such as: distribution of needles, other injection-related equipment, and safer crack cocaine smoking equipment; disposal and handling of used drug use equipment; safer drug use education; and overdose prevention.

Acknowledgements

The authors would like to thank the Canadian Institutes of Health Research for project funding.

The Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People who Use Drugs and are at Risk of HIV, HCV and Other Harms: Part 2 is the product of the Working Group on Best Practice for Harm Reduction Programs in Canada that, in addition to Strike and Watson, includes: Gohil H, Miskovic M, Robinson S, Arkell C, Challacombe L, Buxton J, Demel G, Gutierrez N, Heywood D, Hopkins S, Lampkin H, Lebounga Vouma J, Leonard L, Lockie L, Millson P, Morissette C, Nielsen D, Petersen D, Tzemis D, Young S, and Zurba N.

Resources

Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms Part 1

Further examples and resources related to mental health and addiction services in Canada

See the Centre for Addiction and Mental Health (CAMH) website for information and numerous resources.

Gap Analysis of Public Mental Health and Addictions Programs (GAP-MAP) Final Report from Alberta

Trauma-Informed Practice Guide developed on behalf of the BC Provincial Mental Health and Substance Use Planning Council

Further examples and resources about housing-related services, plans, and needs in Canada

At Home/Chez Soi information and resources

Calgary Homeless Foundation

Strong Communities: An Action Plan. Manitoba Housing & Community Development

Housing and Harm Reduction: A Policy Framework for Greater Victoria. Pauly B, Reist D, Schactman C, Belle-Isle L. University of Victoria, Centre for Addictions Research of BC; 2011.

See case studies from across Canada in Housing First in Canada: Supporting Communities to End Homelessness. Gaetz S, Scott F, Gulliver T, 2013.

References 

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About the author(s)

Carol Strike, PhD, is an associate professor at the University of Toronto's Dalla Lana School of Public Health, with 15 years of experience in harm reduction, addiction treatment and health services research.

Tara Marie Watson completed her PhD at the Centre for Criminology and Sociolegal Studies, University of Toronto. She has long-standing research interests and experience in drug policy, harm reduction and corrections.