GP Program - Medication assisted treatment for opioid dependence

Prescribing medications for opioid dependence

South Australia has approximately 3000 people prescribed methadone liquid or buprenorphine with naloxone in film form (Suboxone®) to assist with the management of their opioid dependence.

Approximately two thirds of these patients are managed by community prescribers - the majority of these are general practitioners (GPs).

Prescribing medications for opioid dependence is not complicated, however, there are some specific issues around the medications themselves, and about caring for people with opioid dependence that need to be considered when prescribing this treatment.

Prescribing buprenorphine with naloxone in film form (Suboxone®) for opioid dependence (non-accredited prescribing)

In South Australia a medical practitioner does NOT need to be accredited to prescribe buprenorphine with naloxone in film form for up to ten patients for opioid dependence.

Medical practitioners need to obtain a Section 18A Controlled Substances Act 1984 (SA) authority (PDF 185KB) from the SA Health Drugs of Dependence Unit prior to prescribing a drug of dependence for the treatment of opioid dependence. This authority must be obtained before treatment commences.

The Drugs of Dependence Unit can be contacted on 1300 652 584 Monday to Friday 9.00 am to 5.00 pm.

The following resources provide further information about prescribing this drug.

• Fact Sheet: Buprenorphine/naloxone for opioid dependence: Important points to know about buprenorphine/naloxone (Suboxone®) (PDF 199KB)
• Buprenorphine/naloxone (Suboxone®) Prescriber Initial Medical Assessment Checklist (PDF 612KB)

This document can be used as a checklist of steps to be taken when patients are being initiated into medication assisted treatment with buprenorphine/naloxone (Suboxone®)

Additional clinical resources are provided below.

A medical practitioner must become ACCREDITED if they wish to:

• prescribe buprenorphine/naloxone film for more than ten patients at one time 

OR

• prescribe:
  • methadone liquid
  • buprenorphine as a single agent (Subutex®) or
  • DEPOT buprenorphine.

For more information go to GP Program - SA - MATOD Prescriber training and annual education event page or contact the GP Program Project Coordinator: (08) 7425 5045.

Email: HealthDASSAGPProgram@sa.gov.au

Further information and advice

• Drug and Alcohol Clinical Advisory Service (DACAS)

DACAS provides a telephone and email service for South Australian health professionals seeking clinical information and clarification around clinical procedures, guidelines and evidence-based practice.

Telephone: (08) 7087 1742 from 8:30am — 10pm 7 days/week including public holidays or e-mail your enquiry to:  HealthDACASEnquiries@sa.gov.au.
Out of these hours, medically urgent calls from a hospital based Medical Consultant or country hospital medical officer/GP will always receive a response.

This service does not provide proxy medical cover and cannot assume responsibility for direct patient care.

Office hours

• Drugs of Dependence Unit telephone 1300 652 584 (office hours)
  Provides advice on prescribing from a regulatory view point.

Other services

• Alcohol and Drug Information Service (ADIS) telephone 1300 13 1340
  any day between 8.30am and 10pm for information, counselling and referral (South Australian callers - local call fee).

Clinical guidelines

• The National Guidelines for Medication-Assisted Treatment of Opioid Dependence covers the use of methadone, buprenorphine, buprenorphine/naloxone and naltrexone. Information on the assessment of opioid withdrawal, including the Subjective Opiate Withdrawal Scale (SOWS), the Objective Opiate Withdrawal Scale (OOWS) and the Clinical Opiate Withdrawal Scale (COWS) is included in Appendix 2.
• National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn (PDF 584KB). Maintaining or initiating MATOD is the preferred approach to management of opioid dependence in pregnancy. DASSA should be contacted for advice and/or management if your opioid dependent patient is pregnant.
• Interim Brief clinical guidelines for the use of depot buprenorphine (Buvidal® and Sublocade®) in the treatment of opioid dependence for South Australian Community MATOD prescribers (PDF 837KB).  These guidelines are to be used in conjunction with the full Product Information, Consumer Information materials and demonstration videos provided by each of the depot BPN manufacturers. These resources and additional information are available online in the module 'Theory — Depot Buprenorphine — SA' hosted by AOGP. 

Assessment and induction onto MATOD

• MATOD — Medical Assessment (PDF 58KB)
  This clinical form enables the recording of the assessment of a patient for possible commencement of medication assisted treatment for opioid dependence.
• MATOD Initial Medical Assessment Checklist — Accredited Prescriber of methadone and buprenorphine (PDF 480KB)
  This document can be used as a checklist of steps to be taken when patients are inducted into medication-assisted treatment with methadone or buprenorphine formulations by accredited prescribers.
• Buprenorphine/naloxone (Suboxone®) Prescriber Initial Medical Assessment Checklist (PDF 612KB)
  This document can be used as a checklist of steps to be taken when patients are being initiated into medication-assisted treatment with buprenorphine/naloxone (Suboxone®).
• Methadone and Buprenorphine Programs - Patient Agreement (DOC 29KB)
  The ‘Essential information for patients commencing or recommencing on maintenance pharmacotherapy’ section must not be altered.
  Your practice details need to be inserted and the details on the lower half of the form can be modified to fit with your practice requirement.
• Community pharmacy vacancy list
  To obtain information about which community pharmacies have vacancies for patients and other details of community pharmacies involved in the program, please ring the Alcohol and Drug Information Service (ADIS) on 1300 13 1340.
• Maintenance Pharmacotherapies - Identification Form
  This form can be used for making up an ID card for patients going to a community pharmacy.

Please contact the GP Program Project Officer for copies of the following resources on (08) 7425 5045 or email: HealthDASSAGPProgram@sa.gov.au

• Letter of Introduction of Patient to Pharmacist (PDF 17KB)
  This letter can be used after you have telephoned the pharmacist about a new patient. It is best to give the pharmacist as much clinical information as possible.
• Patient handbooks — Prescribers can obtain copies of the following handbooks by contacting the GP Program Project Officer on (08) 7425 5045 or e-mail: dassa.gpprogam@health.sa.gov.au.
  • Suboxone Sublingual film buprenorphine hydrochloride/naloxone hydrochloride: A Guide to Treatment.

Accredited prescribers only:

• • The Methadone Handbook (Fifth Edition)
    

• • Subutex: A Guide to Treatment.
• Methadone Buprenorphine Not for Kids (PDF 67KB)
  This brochure outlines what should be done if Methadone or Buprenorphine is taken by someone not prescribed the medication. Free copies of the brochure are available to prescriber holding authorities from the Alcohol and Drug Information Service (ADIS) on 1300 13 1340.

Drug of Dependence - MATOD forms and policy

• MATOD Authority Application (PDF 2.2MB)

To be used by both accredited and non-accredited prescribers.
To obtain the legally required Section 18A Controlled Substance Act 1984 (SA) authority to prescribe a drug of dependence for the treatment of opioid dependence, an initial application form must be filled in on both sides, signed by the prescriber and patient and faxed to the Drugs of Dependence Unit (DDU) at 1300 658 447. Then telephone DDU on 1300 652 584 (office hours) who will provide the authority number which can be written on the prescription.

• Guidelines for prescribing take away doses
• Risk Assessment Tool — Assessing the potential harms of providing take away doses
• Drugs of Dependence Policy and Legal Obligations
• Medication Assisted Treatment for Opioid Dependence (MATOD) Program

Management tools

• Information for Medical Practitioners acting as Locum for a prescriber of Medication Assisted Treatment for Opioid Dependence (MATOD) (PDF 120KB)
  This circular assists the prescriber who acts as locum for a community prescriber involved in providing Medication Assisted Treatment for Opioid Dependence (MATOD). Medications used for MATOD include methadone, buprenorphine [Subutex®] and buprenorphine-naloxone [Suboxone®].
• Medications for Symptomatic Opiate Withdrawal (SOW) Management (PDF 52KB)
  In many instances, withdrawal may need to be managed with symptomatic medication rather than with buprenorphine. This list outlines what is used currently at DASSA for symptomatic relief of opioid withdrawal. Of course, in most situations buprenorphine-assisted detox is preferable.
• Prescription Review (PDF 51KB)
  This form is used for recording review consultations with patients established on opioid pharmacotherapy.
• Maintenance Pharmacotherapy - Stabilisation / Withdrawal (including cows - Clinical Opiate Withdrawal Scale) (PDF 97KB)
  This form is used in the first days of stabilisation and includes a running sheet on one side, together with a COWS assessment tool for each day for recording the patient’s subjective assessment of withdrawal.
• Methadone — drug to drug interactions (including QTc Prolongation) (DOC 52KB)
  This information sheet provides information about drug-to-drug interactions include QTc prolongation, for health practitioners involved in patient care where methadone is prescribed. Please insert your practice details into the document.
• Urine drug screening: its use in determining patient progress (PDF 88KB)
  Provides information on your patients substance use related problems.
• Benzodiazepine Dose Equivalents (PDF 187KB)
  This list allows the clinician to convert doses among benzodiazepines.
• Opioid dose Equivalence: Calculation of oral Morphine Equivalent Daily Dose (oMEDD). Please note the caveats that accompany the table.
  Table and full reference is available at the Faculty of Pain Medicine ANZCA.
• Contact information for MATOD patients
  You may wish to include this in your patient’s file, put a copy in your practice policy folder, and/or laminate a copy for your consulting room.
• Monitoring of patient prescriptions from other doctors (PDF 42KB)
  It is important to be aware of other drugs the patient may be using when prescribing methadone or buprenorphine due to possible drug interactions. Patients may provide information about their other drug use along with Urine Drug Screens (UDS).
  There are systems in place that may provide you with additional sources of information about your patient. Patients may provide more accurate information if they know that you can check the information they give you.
  
  The systems listed in the attached document above appear to be extensive, however, once the initial paperwork has been completed, accessing the information is relatively straightforward. The GP Program Project Officer has put together packs with all the relevant forms and additional information that you may require. Please contact the GP Program Project Officer for a copy of this pack on (08) 7425 5045 or email: HealthDASSAGPProgram@sa.gov.au.
• Insomnia Management Kit
  The Insomnia Management Kit is designed to be used by GPs with patients who report sleep problems. The information in the Insomnia Management Kit will assist GPs in the assessment, diagnosis and management of patients presenting for the first time with a sleep problem. The Kit is composed of a series of fact sheets that can be downloaded for use with patients.
• Optimising MBS items for drug and alcohol issues (PDF 425KB)