Your rights and options in treatment and care of drug addicts

Transcription

1 Your rights and options in treatment and care of drug addicts 1

2 INTRODUCTION Do you think you are addicted? Then read this! This booklet is for you want to stop using drugs or other dependence-forming medication. The way out of addiction varies, and opportunities for care are different in different parts of Sweden. But no matter where in Sweden you live, you have the right to treatment for your use of drugs or medicines. You may have to fight for other rights such as maintenance therapy with Subutex and methadone, and help with accommodation. It can feel tough, when you are on your way towards a life free from addiction, and you run into ways in which the system sometimes does not work. It is easy to start thinking that some rights seem to exist only on paper. But there are often ways around even problems that seem impossible. The Social Welfare Act states that: The Social Welfare Committee shall actively ensure that the individual addict receives the help and care that he or she needs to escape from addiction. And you must be given the chance to participate in deciding what help you need, both from the social services and medical care. It is the duty of society and your right. This booklet also has information about other possibilities to get help from public healthcare. Voluntary organisations, associations and self-help groups have helped many to return to a life free from drugs. We also give tips and advice about how you can do things if Swedish is not your mother tongue. The booklet has been translated into Somali, Arabic, English and Russian. In short, it is about your rights and options in Swedish treatment and care of drug addicts. You who work with addiction treatment or in reach-out casework can also benefit from reading this booklet. The booklet is not intended for you who are aged under 20, since other laws and regulations apply to young people with addiction problems. 2

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4 Contents Introduction... 5 What is dependence?... 7 What is good care? Seeking care through the social services What help can I get from medical care? Your rights as a patient Dependence on medication Double diagnosis Healthcare Guarantee The role of voluntary organisations Work Good to know about housing Economy these are your rights Confidentiality and children at risk Secrecy law in brief Care guidelines

5 Introduction You re not alone Substance abuse and addiction is a growing public health problem. It is a problem with many sides. About one million Swedes regularly receive sedatives, painkillers or sleep-inducing medicine from their doctor. Of them, at least 250,000 have become dependent and need help to quit. In many cases, they have had problems and are receiving medicine from their doctor to deal with anxiety, sleeping problems or pain. 30,000 are heavily dependent on narcotics, that is, they inject or use narcotics daily. The range of new drugs is growing. Together with lower prices, this means that narcotics abuse has spread to new groups in all social classes. Becoming a drug addict immediately leads to two problems. You are not only an addict or dependent. In the eyes of the law you are also a criminal. Hidden addiction is thought to be considerable. But help is available. The sooner you decide to change your habits, the less the risk that you will end up in serious addiction. But even serious dependence problems can be treated. Once you have decided to do something about your situation, you have already taken a big step. We have chosen not to deal with alcohol problems as a separate issue in this booklet. This is because there is already plenty of information available elsewhere. But you can still benefit from reading this if you think that alcohol is part of your problem. Mixing different drugs, where alcohol is one of them, is very common. Addiction to or abuse of several drugs is a serious threat to your health, which often requires both medical care and other care to escape. 5

6 Whatever your reason for quitting, you have the right to receive help. And even though the law does not accept the use of narcotics, you must receive the help you need when you need it. This applies wherever you live and whatever drug you use. Deciding to seek help Being dependent or addicted may feel shameful. You are afraid of the reactions of others. Of what employers and the public officials may say and do. You begin to worry about how your family and friends will feel and react. The law too deals with different kinds and addiction and dependence. It is illegal to use narcotics. But to take large quantities of pharmaceutical narcotics is legal as long as you obtain them from your doctor. It can be for example medicine for insomnia, anxiety or pain, but which has made you dependent. If you are in pain or have severe insomnia it can make it feel extra difficult to decide to quit taking these medicines especially if you are afraid that there is no other care available. All this means that many people wait far too long to seek help. Out of worry about the physical consequences, or from fear of revealing their problems. Many do not decide to seek help until they have lost control over parts of their life, and it has become difficult to manage daily life and work. Your economy may be ruined, you may be in trouble with the police and other authorities. You may have problems in your relationship with someone close to you. It can be a question of someone needing you giving you an ultimatum: Quit or I leave! 6

7 What is dependence? The reasons behind dependence are highly individual. Your life situation and your conditions early on in life are environmental factors which can contribute. There may also be hereditary factors. We know today for example that stress hormones increase the sensitivity of the body s reward system. A stressful life situation can mean a greater risk of developing drug dependence. It can also vary how long it takes to develop and how difficult it is to get away from. We know that it is easier to become dependent on certain drugs than others. This applies to substances such as alcohol, tobacco and narcotics. Of course, this applies whether you get them legally, in the state-run Systembolaget or via your doctor s prescription. Something common to everyone who has developed dependence is that the brain s reward system has changed. To put it briefly, the brain has been kidnapped. It has become used to the drug and has developed a drug memory. To many, therefore, the only way out of dependence is to completely stop using the drug that has caused dependence. Harmful and harmless drugs It is a common opinion that hard drugs such as heroin are much more dangerous than soft drugs like cannabis. If you have experience of different drugs, it can feel strange to talk about all narcotics as being equally dangerous. But that is the point: Stress increases the risk of dependence related problems. Too much - or too little work, crisis reactions and grieving are situations where it is easy to want to sedate oneself to escape from feelings. And even more risky to do it 7

8 it is impossible to know beforehand which drug you are highly sensitive to. It is the drug you are hooked on that was the most dangerous one for you. In Sweden in therefore, we do not distinguish between soft and hard drugs. We want to avoid looking at for example cannabis or khat as harmless drugs. How do I know if I am dependent? In the care sector, of course, we speak of different stages of drug dependence. You can look at it as a flight of stairs where the lowest step is easy to get down from. The top step dependence - can be very difficult to climb down from without help. Harmful drug abuse Short periods of use without consequences. This normally does not require that you seek care, but means that you are in the risk zone and may develop dependence. *) Addiction Excessive use that leads to consequences. You have not yet become dependent. At least one of the following items applies to you and your situation in the past year: 1. Repeated use of the drug, leading to failure to carry out duties in your job, at school or in the home. 2. Repeated use of the drug in risky situations, such as driving or in the workplace. *) since it is illegal to use narcotics which you have not received through your doctor, all use of such narcotics is considered drug abuse. 8

9 3. 4. Repeated contact with the judicial system due to addiction. Continuing use in spite of recurring problems. Dependence If you answered yes to at least three of these seven questions, you have developed dependence. 1. Increasing dose required to get high. 2. Withdrawal symptoms when use stops. 3. Consumption of greater amount or consumption for a longer time than intended. 4. Long-standing wish to reduce consumption, or fewer attempts to do so. 5. Considerable part of life devoted to acquiring, consuming drugs and recovering from their use. 6. Important social, professional activities or leisure time activities are neglected. 7. Continued use in spite of physical or mental damage. This is based on the international DSM-IV system, which is one of two manuals used in medical care and other specialised treatment and care of drug addicts. The other manual is called ICD 10 and is very similar. Contrary to what many people believe, dependence is a more serious condition than addiction. Things have gone further. Dependence, if untreated, sooner or later has consequences in all areas of the victim s life physically, mentally and socially. The stair you are on should decide what care you are offered, either at hospital addiction clinics or if you seek help from the social services. To make matters simpler in this booklet, from now on, as often as possible we will use the word use of drugs or medicines instead of addiction or dependence. This is also because you have a right to help even if you have not yet reached the addiction or dependence stage. 9

10 Addict diagnosis or term of abuse? In Sweden, use of and/or handling of narcotics is illegal. All use is considered abuse. This applies also if you use controlled medicines in an illicit way, for example by going to different doctors or by buying tablets illegally. You could say that it is an undesirable side-effect of how legislation is designed that you are considered a criminal more than a person in need of help. In medical care, addiction and dependence are different diagnoses In treatment and care of drug addicts, substance addiction is a diagnosis that can be made alongside the diagnosis dependence. You can also be diagnosed as a substance abuser without having developed an addiction. So you are not automatically classed as an addict in the case system even if substance abuse can be one of your problems. The nature of our intervention depends on how big your problems are Ask to be informed of what alternatives there are in your county council and local council. You can always call and ask for advice anonymously, or ask a relative or friend to help you. You can also turn to a voluntary organisation for advice and support. Finding the right way Especially at the beginning of coming off drugs you may need to receive help from several sources. It can be a question of contact both with treatment and care of drug addicts and with self-help groups or some other client organisation. As you succeed in staying off drugs, the need for the community s input becomes less. Eventually, and hopefully, you can manage completely without community support. In that phase, a self-help group or client organisation that you feel at home in will be important. The group that you have got to know can play a big role both in your social life and in your freedom from drugs (read more about voluntary organisations on p.57). 10

11 Alternatives to group support Talking in a group is not something for everyone. Many find it difficult or impossible to talk openly with other people about their addiction or dependence. One alternative can be to choose a family doctor whom you trust, or other care personnel with time to listen for example a medical care counsellor, therapist or drugs counsellor in your local council. A health centre can also help you with medical checks, blood tests for example, if you feel that it help you stay off drugs. There is a choice of many other sorts of private therapy of course. But that can be expensive. Getting off drugs first You do not need to make a decision straight away. Coming off drugs is often a period when you take one step at a time until you find the kind of support that works best for you. When you have read this booklet you will have an idea of some of the alternatives that there are. Straight or crooked, any road you find to feeling well without drugs or medicines is a good road! What is society s responsibility? Municipalities are responsible through the social services for overall long-term rehabilitation. This is set out in the Social Services Act. The Social Services Act is an outline law. This means that it must be interpreted and it provides scope for individual judgments. Therefore it is not an absolute law governing rights you can appeal against social services decisions in court. Medical care is responsible for the treatment of withdrawal symptoms (detox) and psychiatry. It also provides maintenance therapy with methadone or Subutex. Medical care operates according to the Health and Medical Services Act, HSL, and the regulations of the National Board of Health and Welfare (Socialstyrelsen). If you do not receive the care you want in time, for example, then you cannot appeal in court. But medical care still has far-reaching obligations to admit you. And once you are a patient, you have many rights. They must not refuse you admission in an emergency Both laws emphasise that it is important that care is given on a voluntary basis - as far as possible. Treatment of offenders is also responsible for the treatment and care of drug addicts, for example in drug free sections. Even if you are serving a sentence, you are covered by the principles and rights described in this booklet. 11

12 What is good care? Good care is based on science. You should not need to receive addiction treatment unless we know it works. The basics of good treatment are the same for many types of dependence. When you seek help, it can be a good idea to have a checklist of what good care really means. * ) Let us start with the rule above all other rules: you take part in the planning. You have a right to this, both in contact with medical care and with the social services. Checklist 1. You have the right to be assessed individually according to your needs and conditions. This requires that the municipalities are able to offer different alternatives. Medical care and the social services must inform you if there are several different types of treatment, and give you a choice. 2. You take part in planning of treatment and rehabilitation. One step towards getting the most out of an intervention from the social services or long-term rehabilitation in medical care is that you take part in planning and choosing care if there are several alternatives. A good care provider listens and tries to go along with your wishes. *)There are special guidelines for the treatment and care of drug addicts. This booklet is partly based on those guidelines. You can read more about the guidelines and county council care programmes at the end of the booklet. 12

13 BRIEF FACTS Psychosocial treatment Good treatment is psychosocial treatment. By psychosocial is meant that you receive help in dealing with your choices in life, your relationship with the drug, and tools to change your life situation. The treatment can be designed in different ways. Here are some common examples: CBT (Cognitive Behavioural Therapy) This is a wide field. The method is based on you getting help to change your behaviour. Here you work intensively to change thought and behavioural patterns connected to the addiction. Psychodynamic therapy The aim is the same as with CBT, to solve your drug problems. But here the focus is on the factors that contribute to or lie behind the addiction. The therapy is about becoming aware of why the drug has taken over and one condition for solving the problem is first to understand it. A therapist helps you see unconscious patterns and break them. 12-step treatment It is based on the activities of Alcoholics Anonymous and the 12 steps that they identify. Treatment based on the 12-step method involves visits to NA - Anonyma Narkomaner (counterpart of DAA or Drug Addicts Anonymous) or AA meetings. The idea is for you to continue with the meetings after the treatment has ended. This is one of the most widespread treatment methods and it has held many all over the world. The big advantage with AA and NA is that there are groups in practically every community in country. The basis of the treatment is that you are not totally against any kind of God concept. 13

14 Good help is naturally whatever works for you individually. There are alternative kinds of aid that are not mentioned here and which have helped many people, for example client organisations that run accommodation and co-operatives which work to their own tried and tested traditions without specially trained care personnel. (You can read more about this later in the booklet.) But in treatment and care of drug addicts, the treatment is based on theoretically sound methods totally focused on giving you help to get out of your addiction. Such treatment must fulfil certain conditions. 3. We use scientific interview methods. We interview you about your problems according to methods that give a good picture of what you actually need help with. We usually have forms which you can complete together with specially trained care personnel, forms such as ASI or DOK (read more on p.21). In medical care, we use internationally approved diagnostic models. 4. Good treatment must be structured. This means focusing on the addiction/ dependence. General conversations that do not focus on what you need help with are seldom effective. Residential care of the old school detox homes where the only intervention offered is to rest up and put on weight represent the opposite to structured treatment. Check the aims of the institution before you accept a place in residential care. There are many different private and municipal alternatives in Sweden, and the treatment philosophy can vary a lot. 5. Treatment must be based on a tested treatment method. It can mean anything from individual psychotherapy to CBT and 12-stage treatment or different forms of psychosocial treatment, which means that you are given the tools to change your attitude to drugs and your living habits. Prevention of slipping back is an important part. 6. The care personnel must have the skills for the method they are working with. 7. We consider how your surroundings function. Do you have support from your family or close friends? Can they help, and do you want them to participate in your rehabilitation? If you cannot expect support from your surroundings, it is usually better for you to travel to somewhere else during treatment, rather than being treated as an out-patient in your home community. 14

15 8. Selection of the treatment intervention must be based on your entire life situation. This also applies to your physical and mental state of health. When you seek help from the social services, then with your permission they can contact medical care. (If they consider that you are in such a bad way that you need compulsory care they can still contact the hospital.) Medical care can also, if you give permission, contact the social services (see the section on Confidentiality, p.65 and the exceptions if a child is in danger). This can be a question of you needing help with accommodation, maintenance or treatment. 9. Dependence calls for longer rehabilitation than addiction problems. You need proper aftercare, probably for at least one year after completing your first treatment - primary treatment. Aftercare must be adapted to the kind of care you have received as primary treatment. Aftercare must have a clear target of freedom from drugs. Good aftercare also includes help in cases of slipping back. 10. Those responsible for your treatment must cooperate. Medical care, social services, psychiatry, employment and housing services, social insurance or correctional treatment? It makes no difference. For intervention to be as effective as possible, all those involved must work together. Request network meetings! This is something well known in both medical care and social services, and the experts consider that collaboration and synchronisation are factors crucial to success. Between meetings, it is good if you have a contact person to turn to, who in turn contacts your other care providers. 11. If you need an interpreter in your contacts with care providers it is important that you are given an interpreter you can trust. The law gives you the right to an interpreter. Take a chair but how do you avoid falling between chairs? Many need help from authorities as well as self-help groups or other client organisations to get away from dependence in the long term. And sometimes it is vital to get help from the community for several problems at the same time! Read more about this in the chapter Double diagnosis on page 55 - there is advice about what you can ask for and demand in order to prevent ending up between the different areas of responsibility of different authorities. 15

16 Of course, you cannot count on every single one of these points being fulfilled. But this provides a good background to what you should ask for when planning your care together with your treatment provider, regardless of whether this is addiction treatment in medical institutions or with the social services. You won t find the same help everywhere The availability of community care and help is different depending on where you live in Sweden. In some parts, there are more specialities in medical care, in other parts, the municipal care sector is both specialised and more accessible. Under the county councils, this can mean that care is organised in one way in one county and another way in the neighbouring county. In sparsely populated areas it can be far to the detox centres and unreasonably sparse between clinics that issue methadone or Subutex. But basically, the county councils are supposed to offer the care that is needed in the county including treatment and care of drug addicts. If necessary, they can help you get care from another county council. This applies to all planned care and is part of the Swedish Healthcare Guarantee. It is not governed by law, but can nevertheless be referred to. Read more about it on p.56. There can be an even greater difference between municipalities. All municipalities are required to comply with the Social Services Act and offer rehabilitation to those who have succeeded in escaping from drug abuse or dependence (the basic rule for dependence on pharmaceutical substances is that it is the responsibility of medical care to help). But for economic reasons, small municipalities often have limited resources. Many municipalities still lack treatment locally. Swedish municipalities also have a right to decide themselves how to use the resources. This means that in practice it is impossible to guarantee that everyone will receive the same and equal help no matter where they live. This applies not least to housing support and trial flats which are in short supply in many places....but there is always an alternative! If your home municipality lacks specialised treatment and care of drug addicts, most county councils can nevertheless offer such care if for no other reason than the existence of the Healthcare Guarantee. Your county council can also admit you for psychiatric care or emergency medicine when you need withdrawal treatment. There is also a big selection of residential care in the whole country where your municipality can pay for care. There are voluntary organisations and client organisations in both large and small communities from north to south. You can read more about them in the chapter The different voluntary organisations Major towns offer a wide range of both municipal care and county council care. This has contributed to many people with drug abuse problems eventually ending up in a major city. This can have happened during their addiction or because it has 16

17 turned out to be difficult to get help in the municipality from which they came. The social services in major towns often want your home municipality to take its responsibility and give you rehabilitation in your home community instead of you being forced to move. If your home municipality has set up a care plan for you, it may not then neglect its responsibility for you. ( ) But you have the right to move anyway. (See brief facts on p. 29). 17

18 Seeking care through the social services Drug addiction, once it has gone a long way, is a life-threatening condition. But there is treatment that works even if you have a serious addiction or dependence. To decide to quit is often a long process. Living with the drug has become the normal situation and many bridges have been burned along the way. What finally makes you ask for help can be anything from a slowly emerging decision to quit, to a crisis: you are unable to cope with the pressure of always needing more, or perhaps your body cannot take it. What eventually makes you ask for help, you alone can tell. Try to keep the decision alive in you, because you are facing what is often an uphill struggle. When seeking care through the social services, the first step can be to ensure that you get withdrawal treatment so that you become detoxed. Withdrawal is not always of a kind that means you need to be admitted to a hospital ward and some drugs, such as amphetamine and hash in normal cases do not require detox treatment. But if you are on high doses, or for some other reason there are medical risks, then you need hospital care. You can read more about withdrawal treatment in the next chapter. Many hospitals that work with care of drug addicts require that you have made a plan together with the social services before they admit you for withdrawal treatment. They preferred that detox is planned and that you arrive with a care plan from the social services. This is because it is believed that the result is better if you have a plan for what will happen after detox. It can feel like you are being turned away and your motives are in question now that you have finally decided to seek help. But when it has gone so far that you feel that you need hospital care in order to come off you often have other things that you also need help with. If you already have somewhere to live and can pay your way, then self-help groups and client organisations can help. Some people are lucky enough to have an employer they can count on. You can read more about employers responsibilities further on in this booklet. If these possibilities are not available then it is the social services who have the ultimate responsibility, economically too. The bottom line is that they are the only ones who are obliged to help you back to a life free from drugs. No matter how committed a family is, it can be difficult for them to do enough for you to get back to a life without drugs and stay there. 18

19 What social service shall I contact? Your home municipality has the responsibility for your rehabilitation. Your home municipality is the municipality way you get what is called your main nightly rest, i.e. where you yourself consider that you live and belong. It is here you should register in the public records unless you already have it is both an obligation and a right to be registered where you actually live. This is what you can apply for Help from the social services is called support, even when it is a question of care and treatment. Support must meet needs which you cannot get help with in any other away, which is stated in the Social Services Act, Ch 4 Sect 1. There is both out-patient care and round-the-clock care. The social services are to inform you of the help that is available in your particular municipality. The municipality is to buy services from other care providers, for example private residential care, if their open activities do not include an alternative that works for you. Ask for a presentation of what agreements your home municipality has and what help alternatives there are. Out-patient care means that you can remain living at home. It can be individual treatment conversations or group treatment during the day. Group treatment can include training, employment and therapy. Round-the-clock care and accommodation where there are treatment personnel or other help, for example: Round-the-clock care at a residential care centre. For example 12-step treatment, often for five weeks with an option to extend. Short-term accommodation. Temporary accommodation while waiting for more long-term housing. Have you ended up in the Drugs of Dependence Unit in a crisis? Many hospitals that work with care of drug addicts require that you have made a plan with the social services before they admit you for withdrawal treatment. But if you are in sufficiently bad condition, then of course medical care cannot turn you away. From here you can contact the social services so that you can begin to set up a care plan while you are in hospital. 19

20 Residential care home. if you need somewhere to live where you receive support and help from personnel. If you are in very bad physical or mental state you can apply for this form. Placement in a foster home for adults. Here you live with a family during rehabilitation, often long-term. How is a plan set up? You and your social worker together produce an overall plan: The care plan is long-term. It will form the basis for what the social services are to do for you. The plan is significant economically and legally. It says what care you are going to receive and for how long or how a decision about it will be made. The care plan usually contains details of earlier treatment and about your situation now. It shall contain information about what needs you have and how they are to be met, for example through placement in care. If there is a need for a care chain, with several different interventions involved, it shall say how it is intended to work. Cooperation with other care providers, for example concerning supporting controlled medication is also covered here, and whether your family is to participate in any way in your rehabilitation. and a more detailed plan for day-to-day goals The treatment plan is based on the everyday situation. It is possible to change the plan during the treatment time, and take into consideration your individual needs if something changes. Together with your treatment provider you go through it to see if it needs to be rethought. A check like this should be done often: once a week or once a fortnight. This is where the concrete goals are set out - what do you want to achieve and how you will see to it that the plan works. There can be one or several goals, either long-term or short-term. In the treatment plan there is also a description of the methods to achieve the goal or goals. The law gives you the right to influence The Social Services Act states (Ch 5 Sect 9): The Social Welfare Committee shall actively ensure that the individual addict receives the help and care which he or she needs in order to escape from addiction. In consultation with the individual the committee shall plan the help and care, and carefully monitor that the plan is followed. (The Social Welfare Committee is the committee in the municipality that decides on issues within the social services. In certain cases it is another committee that has responsibility, but the law still applies in the same way.) 20

21 Ask questions! The social services are to inform you of what help is available. It can be good to find out how things look in your particular municipality before you seek help. The better prepared you are, the more you are able to suggest what you think is best for you. What agreements does the municipality have with for example private residential care? How is cooperation with medical care? Are there different forms of out-patient care? You can have a relative with you as support, or a friend or contact person from a special-interest organisation, if you feel that there is a lot to remember. The basis for good planning is a good investigation It can be done in this way: In many social services, the personnel work with interviews and forms to find out how your problems look. They want to know about your substance abuse, what you use, how much and how often. The material can also contain many different questions about your background and how your life looks at the moment. This is done to gain an overall picture of you, but it is also part of the methods used in treatment and care of drug addicts to be systematic when meeting new visitors. The questionnaire is either called ASI or DOK: both have the same purpose. It can be a difficult situation to answer a lot of questions which at first glance seem to have nothing to do with your use of drugs. But the fact that the social worker uses these interview methods does not mean that the social worker is unnecessarily nosing around. Neither is there an attempt to make a diagnosis, it is simply to get an idea of how best to help using the resources that exist in the municipality s treatment and care of drug addicts. (If you need other help, for example psychiatric, they can instead write a referral for medical care.) What we look at when deciding what to do For you to receive the treatment that corresponds to your needs, there is a need to weigh up everything that has cropped up in the interviews. The idea is to try to match the interventions with your needs and conditions. It can be a question of: Age if it is an advantage for you to undergo a treatment together with others your age. Interventions and residential care work in different ways. But nobody can deny you help just because you are not young any more. For how long and how much you have abused drugs. Whether you have received help before and whether it was effective. 21

22 Medical care and the social services may use different forms and interview methods. It may be hard work to answer questions that do not always seem connected to drug problems. But it is designed to find out all the needs you might have. The same questions are put to everybody who seeks help. Whether you had other problems for example with your mental health or housing situation. How ready you are to receive care and how well aware you are of your problems. Finally an individual assessment is made. We sum up your total situation. If you have received help before, it is of great interest to us how you managed your planning and how you took part in it. It is an assessment where the opinion of the social worker is ultimately very important, even if the decision is formally taken by a committee or chief social welfare officer. Even though you have taken part in the planning, the decision on what kind of help you need may be a different one from what you wanted. You can then ask for reconsideration of the decision before you take it further and appeal against it. To be able to appeal, you must first have the decision in writing. (Read more about appealing on p.27.) Worth remembering: it is not unusual for those who have succeeded in staying off drugs for a long period to have been through several rounds of treatment. What details has the investigator the right to ask for? If you are seeking help because of dependence it is mostly your use of drugs that is of interest so that the responsible officer can assess what intervention you will need. You must also state whether you have children or custody of children. If you have a steady job, the responsible officer may want to know who your employer is in the event that your employer will be paying for any treatment you may have (read more in the section on employers responsibility, p.59.) Your case officer may not contact your employer against your wishes, but on the other hand it is often an advantage to be able to have cooperation on these problems with your employer. 22

23 The ASI form which many social services work with contains a number of highly personal questions. If the social services cannot offer you help, for example in dealing with the aftermath of sexual assault, and you think it is difficult to answer, you have the right to refuse to answer. But it is good if you try to stay as close to the truth is possible so that it is possible to match you with the right sort of treatment. Do not forget that you yourself if you want can contact medical care if there is good help there which the municipality itself cannot provide. If you cannot give an overall picture of your problems, then perhaps you will receive less help than you are entitled to. Who decides whether out-patient care or in-patient care is best? There are no easy answers as to what sort of treatment suits you best. Some prefer to get help as out-patients to be able to live at home and have access to their ordinary network. Others find it better to break with their habitual environment and prefer to come The need of special treatment as a woman If you are a woman, it is possible that you prefer to undergo treatment where only women participate. It may sound self-evident that this should be available, but unfortunately it is not very common. If you are pregnant or have small children, it can be extra important. The municipality is always required to take children s perspective into account. You can demand that they make an effort to find an alternative, even if they do not usually work with gender segregated treatment in your municipality. Naturally, this also applies if you have problems of your own to deal with which can be difficult to handle in mixed groups, such as beatings or prostitution. 23

24 to residential care. If you are homeless it can be almost impossible to undergo outpatient treatment. Talk it over with your social worker and ask for other help, if the help you are receiving does not work the way you want. This is what was written about out-patient care and round-the-clock care in a state investigation (the Parliamentary Standing Committee on Health and Welfare 2005:82). Out-patient care has proven to give results just as good as in-patient care where less serious drug abuse is concerned both the costs and the possibility of a return to normal social speak in favour of out-patient care. But in cases concerning more serious addiction (heavier drug dependence and several parallel problems) then care that begins on an in-patient basis often gives better results. No treatment model suits everyone 12-step treatment has been the most common treatment form in recent years. It has helped many people and been used for a long time and it in large parts of the world. Perhaps your dependence social worker will advise you to take 12-step treatment though many who seek help would like to try residential care where the 12 steps are used. But no treatment form suits everyone. If you are of a different opinion then your social worker speak in favour of the care form you would prefer. Find out how it works and describe why you think it suits you better. The right to take part in selecting care naturally applies regardless of which form of care you are referred to and do not want. You can also refer to the national guidelines of Socialstyrelsen (The National Board of Health and Welfares) on treatment and care of drug addicts You can read more about the guidelines at the end of the booklet. They state that there are several ef- 24 Out-patient care is becoming more common. In the past it was customary for the municipality to offer a place in residential care for a short or long period. It was considered good to change the environment and circle of acquaintances to devote oneself completely to the treatment. Today on the other hand out-patient care is more common. The municipalities start their own activities where you can undergo daytime treatment in your home municipality. It is often group activities in accordance with the 12-step programme or other group therapy. But there are also individual conversations with the municipality s own therapists.

25 fective forms of treatment. When you receive care that suits you, then obviously in the long run it becomes less costly for the municipality. Aftercare Many round-the-clock treatments, which involve you going away for (say) five weeks, are followed by aftercare in your municipality when you return home. It can be the same method, and sometimes the same group as in residential care. Such aftercare is often privately run and the municipality or employer buys the service. The municipality may also provide its own aftercare, in group form or through individual conversation. Good aftercare is long. Count on a year! If you have an agreement with the social services or employer that means you must show that you are off drugs, a urine sample may be part of the plan for aftercare. If you slide back, you must be offered relapse treatment, to then be able to return to your aftercare group. NA, AA or other client organisations often have a big and important role to play in aftercare. For many, the self-help group or client organisation is an important support even when aftercare is completed. Many stay in this community much longer than a year, sometimes all their lives. Read more about client organisations p.57. Who pays for treatment? If you have no assets of your own, the social services pay. you have a sickness allowance or pension, it is determined whether or not you can contribute to the costs yourself. This applies if you go away for treatment or for example live in assisted accommodation. If you are on square one with the insurance office i.e. you have no right to compensation then the social services pay. It does not cost any thing to have treatment for care in the social services. If you are in residential care or in a foster home for adults you may be charged something for accommodation and food. If you have an income, you may be required to pay all or part of the cost, otherwise the social services will pay the cost. The charge is in principle the same as if you are receiving care in hospital. 25

26 you are in steady employment or other long-term position, then the social services usually want your employer to pay all or part of your treatment. There is no law requiring the employer to pay for this care, but many do it anyway. If employers do not want to, then the social services negotiate with them. If this fails, then the social services take all responsibility for payment. Read more in the sections Employer s responsibility, p.59 and Secrecy law, p.70. There we go over your rights. (This sometimes means that it takes time to start treatment. It is often preferred that you accept out-patient care provided by the municipality, if this is available. Out-patient treatment can be offered quickly. But it needs to be judged from case to case. If your employer doesn t want to contribute, this should not disqualify you from round-the-clock treatment if this is what you need. The municipality can afford it! In many cases, the municipality wishes to try out-patient care first. It costs less than residential care, and can be as good or better. But basically, an assessment of your needs must be the deciding factor and not the municipal finances. The municipality has the possibility to exceed the budget. It is not unusual for municipalities to save money by setting up municipal out-patient units. It becomes a question of priorities for your municipality to ensure that its citizens have the opportunity of round-the-clock care. It should not be your headache if you get to the end of the financial year and need a certain form of treatment the Social Services Act applies all year, of course. It is the responsibility of local councillors ahead in the next financial year to ensure that the budget fits the needs of the citizens in the municipality. Get in touch with a client organisation if you run into problems and need advice or help to appeal. When can they refuse your application for voluntary care? You shall not be punished for earlier failures. It is after all a question of you getting help quit substance abuse. But if you have been through treatment many times, and this has not worked, then finally the social services have to produce a report on compulsory care, under the Care of Abusers (Special Provisions) Act (LVM) (read more on p.39). As far as possible, the decision shall be for voluntary care, but it can eventually seem impossible to continue. When things have really gone too far, they are obliged to investigate whether compulsory care is needed. The terms of the Care of Abusers (Special Provisions) Act comes into play if 26

27 Not happy with the decision? This is how you appeal If you do not agree with the decision, you can appeal against it to the County Administrative Court in your county. An appeal must be put in writing. It can be done in a very simple way, and you do not need to fill in a form. The main thing is that you state what decision you are appealing against and why you disagree. The social services are obliged to inform you how to appeal at the same time as they reject an application. They must also help with an appeal if you ask for help. This is what to do: send the appeal to the social services. They must receive your appeal no later than three weeks after you received the decision. First, the social services decide whether to overturn their decision. If the decision is not changed, then the social services send it together with your appeal to the County Administrative Court. If the County Administrative Court does not change the decision, you can take the case further in the Court of Appeal. The decision of the Court of Appeal can also be appealed against to the Supreme Administrative Court, which is the highest court of appeal. the need for care cannot be met in compliance with the Social Services Act or in any other way due to your addiction, your physical or mental health is seriously threatened you are running a serious risk of ruining your life, or there is reason to fear that you will seriously injure yourself or someone close to you. (In some cases, the Care of Abusers Act 1988:870 applies) Who decides in the municipality? The proposals for intervention are based on the assessment by the individual social worker, or by the social worker in consultation with his or her superior, as well as your needs. The proposals are based on the Social Services Act and the municipality s own guidelines (which must comply with the Social Services Act). Decisions must be approved by the Social Welfare Committee or another subcommittee in the municipality (or town district) with responsibilities for substance abuse matters. Sometimes the right to make decisions is delegated to the different unit heads at the social welfare office. The County Administrative Court can overturn decisions which are wrong. That is, if you appeal. 27

28 What does the social worker write in your file? You have the right to access the documentation of your case. The social worker is obliged to keep and update documentation. This means it is obligatory for them to write down what has been decided and why. Through good documentation of decisions and the plans you set up, you can keep track of your case. Your file becomes a tool used in your planning and in following up how things develop. The file my also be used by other personnel in the social services if this is necessary. The details can also be used as research documentation. Researchers who gain access to the details are not allowed to pass them on and must ensure that all your personal details are removed before the research results are presented. You always have the right to see what has been written about you and can request copies of your own. Is treatment available in another language than Swedish? You have a right to an interpreter when contacting medical care. But treatment offered by municipalities in other languages is very unusual (there are one or two treatment alternatives in Finnish). However, there are treatment cooperatives in other countries run by client organisations where the social services can buy places. One example is Dianova, which has activities in 14 countries. Another way can be as far as possible to use the treatment and care of drug addicts offered by medical care. If you think it feels wrong to have an interpreter present - take along a relative or an acquaintance who speaks Swedish and can support you during your rehabilitation. Read more in Your rights as a patient p.42. Immigrant associations that have been operating for a fairly long time in Sweden can often provide useful information about how to go about things in the county where you live. Whatever happens, you always have a right to meet your basic needs: somewhere to sleep and something to eat, even if in the worst case this can mean food coupons and hostel accommodation. A roof over your head guarantee, is a popular expression for what the Social Services Act actually demands that all municipalities help their disadvantaged citizens with. This is the basic level you are entitled to according to the Social Services Act. 28

29 This is what law says The social services in your municipality must actively ensure that you receive the help you need to escape from substance abuse. This is written in the Social Services Act (Ch 5 Sect 9). Here it also says that the administrator officer shall consult you before it is decided what intervention is needed. The Social Services Act furthermore states that what you yourself think is important must be weighed in as well as what you can do personally to improve your situation. The plan covering what care and help you need is to be produced together with you a care plan is to be set up. The social services must also follow up the plan and ensure that it works, in cooperation with you. Your administrating officer must have the training and experience needed to take care of your case. If you disagree with a decision, you can appeal to the County Administrative Court, see p.27. Some rules are also supplemented by The Social Services Ordinance (SFS 2001:937) which contains details about supported accommodation, for example. If two municipalities disagree about which is your home municipality The County Administrative Board in the new municipality shall decide which municipality is to deal with your case. It is your actual situation which forms the basis for decision-making. Your wishes must also be considered. (Ch 16 Sect. 1 The Social Services Act). If you move to another location during an ongoing care investigation, the old municipality is not allowed to reject you. The municipality that began your care investigation is obliged to complete it and decide what help you are to receive. The municipality you are living in must also help assemble details so that your case is completed. Neither of the municipalities may dump you. Until the matter has been solved regarding who has long-term responsibility for you, then it is the municipality where you are living which has the immediate responsibility during your stay in the municipality. This is based on the residence principle. The residence principle is mentioned in Ch 2 Sect 2 of the Social Services Act The municipality has ultimate responsibility to ensure that those resident in the municipality receive the support and help which they need. Read more in the chapter Dependence Problems and Housing (you can get help from the social services consultant at the County Administrative Board regarding what to do to get to the right municipality.) 29