Community Program for
Opioid
Pharmacotherapy
2012 Annual Report
Pharmaceutical Services Branch
Suggested citation
Department of Health 2013, Western Australian Community Program for Opioid
Pharmacotherapy 2012 Annual Report, Pharmaceutical Services Branch, Public Health and
Clinical Services Division, Department of Health, Western Australia
1
Contents
Contents ..................................................................................................................................... 2
List of figures ............................................................................................................................. 5
Executive summary ................................................................................................................... 6
Glossary of terms ...................................................................................................................... 7
Overview ..................................................................................................................................... 9
Introduction............................................................................................................................... 9
Opioid pharmacotherapy prescribing in WA ............................................................................. 9
Methodology ............................................................................................................................. 9
2012 results .............................................................................................................................. 11
Section one – authorisations issued ....................................................................................... 11
Number of authorisations issued ........................................................................................ 11
Authorisation type and opioid pharmacotherapy ................................................................. 12
Authorisations issued by gender ......................................................................................... 12
Authorisations issued by Area Health Service .................................................................... 13
Termination of authorisations.............................................................................................. 14
Patients dosing by opioid pharmacotherapy ....................................................................... 15
Number of interim prescriptions issued ............................................................................... 15
Renewal of authorisations................................................................................................... 16
Section two – patient population ............................................................................................. 18
Age of patient cohort ........................................................................................................... 19
Age and gender of patent cohort ........................................................................................ 20
Daily dose prescribed for patient cohort.............................................................................. 21
Number of takeaways per week by opioid pharmacotherapy.............................................. 23
Number of missed doses per month ................................................................................... 24
Patient cohort movement within program by gender ........................................................... 25
Section three – authorised prescribers ................................................................................... 26
Number of active prescribers by Area Health Service......................................................... 29
Section four – authorised dosing sites .................................................................................... 32
Number of dosing sites by Area Health Service .................................................................. 33
Community pharmacies by number of patients dosing ....................................................... 37
Section five – comparison data 2007–2012............................................................................ 40
Appendices............................................................................................................................... 44
Appendix 1. Community Program for Opioid Pharmacotherapy policies ................................ 44
Legislative and administrative requirements ....................................................................... 44
Appendix 2. Health Districts by postcode ............................................................................... 49
2
Appendix 3. Projected populations per Health District for adults in 2012 ............................... 51
Appendix 4. Map of approved CPOP prescribers and dosing sites in the Perth metropolitan
area ........................................................................................................................................ 53
3
List of tables
Table 1. Number of authorisations issued by type and opioid pharmacotherapy. ................ 12
Table 2. Number and reason for termination of authorisations ...................................... 14
Table 3. Patient cohort by age group and gender. .................................................... 20
Table 4. Number of takeaways per week by opioid pharmacotherapy ............................. 23
Table 5. Number of authorisations issued by gender ................................................. 25
Table 6. Number of patients being treated per prescriber in December 2012 ..................... 26
Table 7. Treatment by prescriber and opioid pharmacotherapy ..................................... 27
Table 8. Number of authorised community prescribers by Health District ......................... 30
Table 9. Number of authorised dosing sites by Health district ....................................... 34
Table 10. Patient cohort per 10 000 population by Area Health Service ........................... 36
Table 11. Number of patients dosing at community pharmacies and other sites in December
2012.................................................................................................... 37
Table 12. Number of authorised patients dosing by health district .................................. 38
4
List of figures
Figure 1. Number of authorisations issued by opioid pharmacotherapy. ........................... 11
Figure 2. Authorisations issued by gender. ............................................................ 12
Figure 3. Authorisations issued by opioid pharmacotherapy by Area Health Service and
Department of Corrective Services. ............................................................... 13
Figure 4. Number of patients dosing per month by opioid pharmacotherapy. ..................... 15
Figure 5. Number of interim prescriptions issued by specialist prescribers. ....................... 16
Figure 6. Care plan responses collected at renewal. ................................................. 16
Figure 7. Illicit drug use responses received at renewal. ............................................. 17
Figure 8. Patients authorised or receiving opioid pharmacotherapy. ............................... 18
Figure 9. Age distribution of patient cohort by opioid pharmacotherapy. ........................... 19
Figure 10. Daily dose of Subutex® and Suboxone®. .................................................. 21
Figure 11. Daily dose of methadone. ................................................................... 22
Figure 12. Number of missed doses per month by opioid pharmacotherapy ...................... 24
Figure 13. Treatment of patients by prescriber group ................................................ 27
Figure 14. Average dose of opioid pharmacotherapy by prescriber group......................... 28
Figure 15. Number of active community prescribers by Area Health Service ..................... 29
Figure 16. Patient cohort by dosing site ................................................................ 32
Figure 17. Number of dosing sites by Area Health Service .......................................... 33
Figure 18. Number of patients authorised and dosing by pharmacotherapy 2007-2012 ......... 40
Figure 19. Patients average age by pharmacotherapy 2007-2012 ................................. 41
Figure 20. Daily dose of Subutex® and Suboxone® 2007-2012 ..................................... 41
Figure 21. Daily dose of methadone 2007-2012 ...................................................... 42
Figure 22. Proportion of patients by prescriber type 2007–2012 .................................... 42
5
Executive summary
The Community Program for Opioid Pharmacotherapy (CPOP) framework was developed to
regulate the prescribing of opioid pharmacotherapy used for the treatment of opioid dependence
in Western Australia. The Poisons Regulations 1965 set out the regulatory controls associated
with the prescribing of methadone and buprenorphine (as Subutex® or Suboxone®) for the
treatment of opioid dependence. This is a report for the program for 2012.
There were 2969 authorisations issued from 1 January 2012 to 31 December 2012 to a total of
2601 patients – 431 authorisations were for patients as new admissions, 1242 were reauthorisations and 1296 were renewals.
The Department of Health received 787 terminations which comprised of 37 patients being
treated with Subutex®, 304 patients being treated with Suboxone® and 446 patients being
treated with methadone.
The patient cohort was defined as patients authorised and receiving a dose during 2012
(n=4095). There were 791 patients with authorisations who did not dose during 2012, and 65
patients who dosed without authorisation. In the patient cohort, 62% (n=2743) was for
methadone, 34% (n=1495) for Suboxone® and 4% (n=169) for Subutex®.
The average age was 35.8 years for Subutex®, 38 years for Suboxone® and 39.8 years for
methadone.
The largest age group seeking treatment for both gender types was in the 30 to 40 years group
with 38.5 patients per 10 000 population for females and 61 patients per 10 000 population for
males.
The dose distribution for patients on Subutex® ranged from <1 mg to 32 mg with, an average
daily dose of 12 mg. The doses most frequently prescribed were 24 mg (n=17), followed by
2 mg (n=13) and 4 mg (n=12).
The dose prescribed for patients on Suboxone® ranged from 1 mg to 38 mg, with an average
daily dose of 14.2 mg. The doses most frequently prescribed were 16 mg (n=156) and 8 mg
(n=144), and 12 mg (n=110).
The average dose distribution for patients on methadone ranged from 1 mg to 230 mg, with an
average daily dose of 56.3 mg. The dose most frequently prescribed was 50 mg (n=90).
As at 31 December 2012 there were 85 authorised CPOP community prescribers in WA,
including 69 active and 16 inactive prescribers, and 33 active public sector prescribers (Next
Step and DOCS).
The largest number of patients were treated in the CPOP by community prescribers (n=2315,
55%), followed by Next Step (n=1537, 36%) and then the Department of Corrective Services
(n=401, 9%).
As at 31 December 2012, there were 345 community pharmacies authorised to participate in
the CPOP. Of these, 250 community pharmacies dosed one or more patients, and 95
pharmacies did not dose a patient during 2012. The Department of Corrective Services has two
dosing sites and dosed 549 people and Next Step Drug and Alcohol Services had one dosing
and dosed 106 people.
6
Glossary of terms
Term
Definition
AHS
Area Health Service
Application
An ‘Application to prescribe a pharmacotherapy –
CPOP’ form for an opioid dependent person,
submitted to the Department of Health by
authorised prescribers when initiating or changing
opioid pharmacotherapy in the CPOP.
Authorisation
Written approval from the Chief Executive Officer
or delegate for an authorised prescriber to
prescribe an opioid pharmacotherapy for an opioid
dependent person in accordance with the criteria
set out in the Clinical policies and procedures for
the use of methadone and buprenorphine in the
treatment of opioid dependence.
Authorised community pharmacy
Community pharmacy authorised by the Chief
Executive Officer or delegate to participate in the
CPOP.
Authorised prescriber
Medical practitioner who is authorised by the Chief
Executive Officer or delegate to treat opioid
dependence with opioid pharmacotherapy in
Western Australia.
Clinical Advisory Service (CAS)
A 24 hour service for all clinical matters relating to
the program provided by the Drug and Alcohol
Office.
Community Program for Opioid
Pharmacotherapy (CPOP)
Framework developed to regulate the prescribing
of opioid pharmacotherapy medicines for the
treatment of opioid dependence in Western
Australia – commenced in 1997 as the Community
Methadone Program.
CPOP authorisation data
Data included in the ‘Application to prescribe a
pharmacotherapy – CPOP’ form for an opioid
dependent person submitted for authorisation by
authorised prescribers and extracted from the
Monitoring of Drugs of Dependence System
(MODDS).
DOCS
Department of Corrective Services. This also
includes Acacia Prison, which is managed by
Serco Asia Pacific under contract with DOCS.
Methadone syrup/solution
Methadone syrup 5 mg/mL and methadone
solution 5 mg/mL as Biodone Forte®.
7
Term
Definition
MODDS
Monitoring of drugs of dependence database
New admission
A patient admitted into the CPOP for the first time.
NMAHS
North Metropolitan Area Health Service.
Opiate pharmacotherapy dosing data
Data included in the Pharmacy Report Forms
submitted monthly by every dosing site in Western
Australia participating in the program and
extracted from the Monitoring of Drugs of
Dependence System (MODDS).
Opioid pharmacotherapy
Collective term for methadone, Subutex® and
Suboxone®, the three medicines approved for use
in the CPOP.
Re-authorisation
Authorisation where there has been a change in
prescriber, opioid pharmacotherapy or a break in
treatment and/or authorisation has expired.
Renewal
An authorisation where there has not been any
change in the prescriber’s medical practice or
opioid pharmacotherapy.
SMAHS
South Metropolitan Area Health Service.
Suboxone®
Buprenorphine with naloxone sublingual tablet or
film available in two strengths – 2 mg and 8 mg
with a 4:1 ratio of buprenorphine to naloxone.
Subutex®
Buprenorphine sublingual tablet available in three
strengths – 0.4 mg, 2 mg and 8 mg.
Termination
Notification of cessation of treatment with opioid
pharmacotherapy for a specified patient by an
authorised prescriber.
Treatment provider
Prescriber authorised to participate in CPOP who
may practice at Next Step, in the community or
Department of Corrective Services.
WACHS
Western Australian Country Health Service.
WA Clinical policies and procedures
for the use of methadone and
buprenorphine in the treatment of
opioid dependence
Document which sets out the policies of the
program for the prescribing of opioid
pharmacotherapy in Western Australia
underpinned by the Poisons Regulations 1965.
Regulation 51A refers to the ‘Policies Manual’
8
Overview
Introduction
Prior to 1997 the provision of opioid pharmacotherapy for the treatment of opioid dependence
was only available through a single government service operated by the WA Alcohol and Drug
Authority. The Community Program for Opioid Pharmacotherapy (CPOP) commenced in 1997
as the Community Based Methadone Program (CMP) in Western Australia (WA) and was
restricted to methadone syrup. It was renamed CPOP when buprenorphine, as Subutex®
sublingual tablets, became available for the treatment of opioid dependence in 2001.
Buprenorphine with naloxone (4:1 ratio) as Suboxone ® sublingual tablets became available in
May 2006 and Suboxone® sublingual film in September 2011.
The methadone and buprenorphine used in the CPOP is funded by the Commonwealth
Government through outlets authorised by the Department of Health, Western Australia. Supply
is predominately through community pharmacies.
This is the seventh report of the CPOP and covers the period 1 January 2012 to 31 December
2012.
Opioid pharmacotherapy prescribing in WA
The WA Clinical policies and procedures for the use of methadone and buprenorphine in the
treatment of opioid dependence (Policies Manual) sets out the policies and procedures for the
prescribing of methadone syrup/solution, Subutex® and Suboxone® sublingual tablets/film in WA
(Appendix 1). The policies are underpinned by the Poisons Regulations 1965. Treatment with
methadone syrup/solution, Subutex® and Suboxone® sublingual tablets/film for opioid
dependence can only be initiated by an authorised CPOP prescriber. Each patient requires prior
authorisation from the Chief Executive Officer for treatment with an opioid pharmacotherapy and
supply is only through an authorised dosing site.
Methodology
The Department of Health maintains records relating to the CPOP in the Monitoring of Drugs of
Dependence System (MODDS), which includes the CPOP authorisation data and the opiate
pharmacotherapy dosing data provided by participating pharmacies or dosing sites.
The patient application form for CPOP authorisation contains the following information used in
this report:




patient’s address postcode, date of birth, gender
authorised CPOP prescriber details
authorised dosing site details
opioid pharmacotherapy, form, and maximum dose.
9
For the purpose of the report, age was calculated as at 31 December 2012.
The opiate pharmacotherapy dosing data contains the following information used in this report:





opioid pharmacotherapy received
month and year of treatment
dose (as at the last day of dosing during the month)
number of missed doses during the specified month
number of takeaways received during the specified month.
Data were extracted from the CPOP authorisation and opiate pharmacotherapy dosing data for
the period 1 January 2012 to 31 December 2012.
As there is a time lag in the collection of data from dosing sites, the opiate pharmacotherapy
dosing data was extracted from MODDS on 16 July 2013.
Patients were assigned to an Area Health Service (AHS) and Health District based on the
postcode of the address listed on the authorisation application form as at the extraction date.
Postcodes were allocated to an AHS and Health District based on information provided by the
Epidemiology Branch of the Department of Health. Postcodes per Health District are included in
Appendix 2.
Age specific rates per 10 000 population were calculated using Rates Calculator Version 9.5.4
(Jim Codde, 1993–2005) provided by the Epidemiology Branch of the Department of Health.
Projected populations by Health District are in Appendix 3.
10
2012 results
Section one – authorisations issued
Number of authorisations issued
As at 31 December 2012, there had been 10 208 patients admitted to the program since the
commencement of the community-based program in 1997. There had been 3378 (22.3%)
patients authorised to receive Subutex®; 8130 (53.6%) patients authorised to receive
methadone; and 3652 (24.1%) patients authorised to receive Suboxone®. Since the
commencement of the program there had been 29 641 authorisations issued. The majority of
the authorisations issued have been for methadone (n=18 553, 62.6%), followed by Subutex®
(n=5637, 19.9%) and Suboxone® (n=5451, 18.4%)
There were 2969 authorisations issued from 1 January 2012 to 31 December 2012, to a total of
2601 patients. An authorisation is issued for a patient entering the program and each time the
patient changes treatment provider and/or opioid pharmacotherapy. Therefore a patient may
receive more than one authorisation during the year and be counted in more than one opioid
pharmacotherapy group.
Figure 1. Number of authorisations issued by opioid pharmacotherapy.
Subutex, n=115,
4%
Suboxone,
n=1081, 36%
Methadone,
n=1773, 60%
Figure 1 shows the breakdown of the 2969 authorisations issued during 2012 in the CPOP.
Methadone (n=1773, 60%) continues to be used in preference to buprenorphine as Subutex® or
Suboxone® (n=1196, 40%).
11
Authorisation type and opioid pharmacotherapy
Table 1. Number of authorisations issued by type and opioid pharmacotherapy.
Authorisation
Number of authorisations
Total
type
Subutex®
Suboxone®
Methadone
New admission
6
221
204
431
Re-authorisation
61
476
705
1242
Renewals
48
384
864
1296
Total
115
1081
1773
2969
Table 1 provides a breakdown of the type of authorisation issued by the type of opioid
pharmacotherapy. A new admission is a patient who was authorised in CPOP for the first time.
Re-authorisation occurs where there has been a change in the prescriber, opioid
pharmacotherapy or a break in treatment and/or the authorisation has expired and requires a
new application. Renewal is required when there has been no change in the prescriber’s
medical practice or pharmacotherapy for a patient authorised in the CPOP. A patient may have
received multiple authorisations during the year by moving to a new prescriber or changing
opioid pharmacotherapy.
Authorisations issued by gender
Percentage of authorisations
Figure 2. Authorisations issued by gender.
100%
80%
n=47
(42%)
60%
40%
20%
n=65
(58%)
n=653
(63%)
n=1025
(63%)
n=379
(37%)
n=600
(37%)
Suboxone
Methadone
0%
Subutex
Female
Male
Figure 2 shows the gender breakdown for the different opioid pharmacotherapies. Of the 112
patients with authorisations issued in 2012 for Subutex®, 58% (n=65) were for females and 42%
(n=47) were for males; for Suboxone®, 37% (n=379) were for females and 63% (n=653) were
for males; and for methadone, 37% (n=600) were for females and 63% (n=1025) were for
males. In contrast with methadone and Suboxone®, there were a higher percentage of females
12
authorised for Subutex®, which is due to the conditional use of this medicine during pregnancy
and breastfeeding for female patients. Female patients who become pregnant or are
breastfeeding are switched from Suboxone® to Subutex® in line with the Policies Manual. The
47 male patients received Subutex® in line with the accepted exception conditions on the
application form for Subutex®, which include continuing treatment without takeaways, known
allergy to Suboxone®, and low dose treatment (6 mg or less).
Authorisations issued by Area Health Service
No of authorisations
Figure 3. Authorisations issued by opioid pharmacotherapy by Area Health Service and
Department of Corrective Services.
800
700
600
500
400
300
200
100
0
38%
36%
39%
40%
17%
18%
54%
NMAHS
Subutex
35%
12%
SMAHS
WACHS
Suboxone
8%
0% 3%
DOCS
Methadone
Figure 3 shows the distribution of authorisations issued according to the patient’s postcode by
opioid pharmacotherapy across the AHS and the DOCS. Most of the CPOP authorisations were
issued to patients residing within North and South Metropolitan Health Services, providing the
combined totals of: Subutex® (n=99, 89%), Suboxone® (n=816, 79%) and Methadone (n=1211,
74%).
13
Termination of authorisations
Authorised prescribers are required to notify the Department of Health when a patient is no
longer receiving treatment from the prescriber. A termination notification is not required when
changing pharmacies. The termination form provides the prescriber with a list of 11 reasons for
the termination.
Table 2. Number and reason for termination of authorisations
Reason
Subutex®
Suboxone®
Methadone
Total
Mutual agreement
4
21
29
54
Left against advice
0
14
16
30
Did not commence
1
4
5
10
Ceased to pick up
3
93
114
210
Involuntary discharge
0
3
2
5
Deceased
1
2
20
23
Intrastate transfer
6
41
66
113
Interstate transfer
1
8
31
40
Detoxified
7
41
41
89
Imprisoned
1
20
43
64
Others
13
57
79
149
Total
37
304
446
787
Table 2 provides a summary of the termination reasons notified to the Department of Health by
opioid pharmacotherapy prescribers. There were 787 termination forms received by the
Department of Health from prescribers providing information relating to the reason for
termination.
14
Patients dosing by opioid pharmacotherapy
Figure 4. Number of patients dosing per month by opioid pharmacotherapy.
No of patients
2400
2000
1600
1200
800
400
0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct
Suboxone
Subutex
Nov Dec
Methadone
Note: a patient may be counted more than once during a month as they may change opioid
pharmacotherapy and or dosing site.
In January 2012 there were a total of 3655 dosing in the CPOP. In December 2012 there were
3669 patients dosing in CPOP, an increase of 14 patients. Between 1 January 2012 and 31
December 2012 the number of patients dosing methadone decreased (n=45), the number of
patients dosing Subutex® decreased (n=2) and Suboxone® increased (n=61).
Number of interim prescriptions issued
There are instances when a patient may need to travel unexpectedly or their dosing prescription
may have expired. If their CPOP prescriber is not available to issue a prescription then the
Clinical Advisory Service (CAS) or the Community Pharmacotherapy Program (CPP) can be
contacted to provide ongoing treatment for patients participating in the CPOP. An interim
prescription is written by the specialist prescriber at CPP only when the patients authorised
prescriber is not available and it is safe to do so. The prescription can be for up to one month
and the patient must be seen by their authorised CPOP prescriber when available for ongoing
treatment as soon as possible. As at 31 December 2012, there were 929 interim prescriptions
written by specialist prescribers.
15
Figure 5. Number of interim prescriptions issued by specialist prescribers.
Subutex,
n=11, 1%
Suboxone,
n=258, 28%
Methadone,
n=660, 71%
Renewal of authorisations
As at 31 December there were 922 renewals processed. An authorised prescriber is required to
complete an application for authorisation renewal when a patient has been in continuous
treatment with an opioid pharmacotherapy for two years. The prescriber indicates on the
renewal the care plan for the patient during the next six months. They will either: continue
maintenance treatment – no change, commence withdrawal, or plan to withdraw from treatment.
This is a new data element, and 83% of the patients who were renewed for a further two years
where continuing in maintenance treatment for the next six months.
Figure 6. Care plan responses collected at renewal.
Plan Withdrawal,
n=65, 7%
Commence
Withdrawal,
n= 88, 10%
No Plan
Reported,
n=14, 2%
Continue
Maintenance,
n=755, 83%
16
Figure 7. Illicit drug use responses received at renewal.
Not Reported,
n=17, 2%
Illicit Drugs ,
n=65, 7%
No Illicit Drug,
n=840, 91%
Figure 7 shows that of the 922 renewals received illicit drugs use was reported in 7% of cases.
17
Section two – patient population
Data were extracted from the opiate pharmacotherapy dosing records in the MODDS database
and compared with the CPOP authorisation records. Figure 4 shows the number of patients for
each authorisation and dosing combination from 1 January 2012 to 31 December 2012.
There were 4886 patients authorised during 2012. Of these, 83.8% (n=4095) of patients were
authorised and dosed during 2012, and 16.2% (n=791) of patients were authorised but did not
dose during 2012.
In 2012 there were 65 patients who dosed without a current authorisation. In all cases the
authorisation had expired. The Department of Health has followed up these patients and they
have been excluded from further analysis in this report.
The patients who were authorised and dosing during 2012 (n=4095) will be the patient cohort
referred to in the remainder of this section.
Figure 8. Patients authorised or receiving opioid pharmacotherapy.
Authorised (n=4886)
Patients
authorised and
not dosing
n=791
Dosing (n=4160)
Patients authorised
and dosing
Total(n=4095)
Methadone(n=2743)
Subutex(n=169)
Suboxone(n=1495)
Patients not
authorised and dosing
n=65
Figure 8 shows the total number of authorised patients (n=4,886), the total number of patients
dosing (n=4160) and the patient cohort (n=4095). In the patient cohort, 62% (n=2743) was for
methadone, 34% (n=1495) for Suboxone® and 4% (n=169) for Subutex®. The total number of
patients in the cohort counted by opioid pharmacotherapy breakdown (n=4407) is a larger
number than the patient cohort, as patients can be counted more than once due to changing
opioid pharmacotherapy during the year.
18
Age of patient cohort
No of patients
Figure 9. Age distribution of patient cohort by opioid pharmacotherapy.
160
140
120
100
80
60
40
20
0
17
21
25
29
33
37
41
45
49
53
57
61
65
Age
Subutex
Methadone
Suboxone
Figure 9 shows the age distribution of patients in the cohort by opioid pharmacotherapy. The
average age was 35.8 years for Subutex®, 38 years for Suboxone® and 39.8 years for
methadone. The most common age was 31 years for Subutex®, 34 years for Suboxone® and 33
years for methadone. The minimum ages of patients receiving opioid pharmacotherapies were
23 years for Subutex®, 17 years for Suboxone® and 18 years for methadone. The maximum
ages of patients were 59 years for Subutex®, 69 years for Suboxone® and 67 years for
methadone.
19
Age and gender of patent cohort
The age specific rate per 10 000 people was calculated by analysing the patient cohort by age
group and gender. The population denominator is the number of people in the age range
specified.
Table 3. Patient cohort by age group and gender.
Age category
Patient
Rate per 10 000
frequency
population
Female
≥18 and <25
47
4.0
≥25 and <30
173
18.9
≥30 and <40
660
38.5
≥40 and <50
432
25.1
≥50 and <60
216
14.0
≥60
11
0.5
Total female
1540
Male
≥18 and <25
62
4.9
≥25 and <30
225
22.7
≥30 and <40
1112
61.0
≥40 and <50
712
39.9
≥50 and <60
397
25.3
≥60
47
2.2
Total male
2555
Table 3 shows that 38% (n=1540) of the patient cohort is female and 62% (n=2555) is male. In
both gender groups, the highest rate per 10 000 population is in the age group between 30 to
40 years old (female=38.5 and male=61.0).
20
Daily dose prescribed for patient cohort
No of patients
Figure 10. Daily dose of Subutex® and Suboxone®.
180
160
140
120
100
80
60
40
20
0
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Dose (mg)
Subutex
Suboxone
The dose distribution for patients on Subutex® ranged from <1 mg to 32 mg, with an average
dose of 12 mg. The largest number of patients for Subutex® were on a dose of 24 mg (n=17),
followed by 2 mg (n=13) and 4 mg (n=12).
The dose distribution for patients on Suboxone® ranged from 1 mg to 38 mg, with an average
dose of 14.2 mg. The largest number of patients were receiving 16 mg (n=156), followed by 8
mg (n=144) and 12 mg (n=110).
Suboxone® is available as 8 mg and 2 mg sublingual tablets and film and Subutex® is available
as a 400 microgram, 2mg and 8mg sublingual tablet. The maximum daily dose approved for
buprenorphine as Subutex® and Suboxone® is 24 mg as per the WA Clinical policies and
procedures for the use of methadone and buprenorphine in the treatment of opioid dependence.
If a patient received a dose every second day then the maximum dose in one day should not
exceed 32 mg. For example, a patient dosing 14mg daily would be recorded as 28mg if dosed
every second day. However, the pharmacy dosing reports provided to the Department of Health
do not indicate if the dosing is daily, second or third daily dosing. All analysis on dosing is based
on an assumption of daily dosing.
21
No of patient
Figure 11. Daily dose of methadone.
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90 100 110 120 130 140 150
Average Dose (mg)
Methadone
Figure 11 shows the average daily dose (the sum of the reported doses, divided by the number
of months dosed) of methadone received by patients. The dose distribution for patients on
methadone ranged from 1 mg to 230 mg with an average dose of 56.3 mg daily. The largest
number of patients were on 50 mg (n=90) daily. The maximum dose of methadone that can be
prescribed without special approval is 120 mg. There were 26 patients receiving a dose greater
than 120 mg where authorisation has been approved following receipt of an ‘Application to
prescribe outside the guidelines’ for an opioid dependent person.
22
Number of takeaways per week by opioid pharmacotherapy
A pharmacy dosing report is completed each month by pharmacies participating in the CPOP
and sent by fax or email to the Department of Health. This report provides the total number of
takeaways dispensed during the month for each patient. This number was divided by 4 to
provide an average number of takeaways per week. Patients who received less than an
average of 1 takeaway per week were placed in the <1 category. This category also includes
patients who received takeaways only during extended holiday periods such as Christmas and
Easter, or other exceptional circumstances.
Table 4. Number of takeaways per week by opioid pharmacotherapy
Patient frequency
Average number
of takeaways
Subutex Suboxone
Methadone
Total
0
87
798
1235
2120
<1
5
71
151
227
1
44
318
468
830
2
24
229
459
712
3
9
61
341
411
4
0
11
70
81
5
0
5
14
19
6
0
2
3
5
7
0
0
2
2
Total
169
1495
2743
4407
Table 4 shows 48.8% (n=2103) of patients did not receive a takeaway and 6.6% (n=284)
received on average less than one takeaway per week.
The program allows a maximum of two takeaways per week for Suboxone ®. There were 6.3%
(n=89) patients receiving more than the policy supports.
There were 38% (n=66) patients who had received one or more takeaways for Subutex®. This
group includes those patients receiving low dose (6 mg or less for 6 months only), pregnant and
breastfeeding women and those allergic to Suboxone ®.
The program allows a maximum of three takeaways per week for methadone. There were 4.6%
(n=124) receiving more than the policy supports.
For those patients receiving more than the maximum number of takeaways an application is
completed by the prescriber and forwarded to the Community Pharmacotherapy Program (CPP)
for consideration and support before prescribing.
23
Number of missed doses per month
The pharmacy dosing reports forwarded monthly to the Department of Health from community
pharmacies provide the number of missed doses during the month for each patient dosing. The
average number of missed doses per month was calculated by adding the number of missed
doses for each month a patient dosed and dividing by the number of dosing months.
No of patient
Figure 12. Number of missed doses per month by opioid pharmacotherapy
2000
1800
1600
1400
1200
1000
800
600
400
200
0
62%
26%
40%
37%
14% 8%
53%
35%
0
4%
8%
≥1 and ≤5
>5 and ≤10
9% 4%
>10
Average number of missed doses per month
Subutex
Suboxone
Methadone
Figure 12 shows that of the total patients in treatment, a large proportion did not miss a dosing
day during their treatment period for all three opioid pharmacotherapies: methadone 62%
(n=1709), Suboxone® 40% (n=605) and Subutex® 53% (n=90) of patients.
The remainder of patients in treatment were grouped according to the number of doses missed.
Patients who missed one to five doses were: methadone 26% (n=723), Suboxone® 37%
(n=556) and Subutex® 35% (n=59). Patients who missed more than five to ten doses were:
methadone 8% (n=209), Suboxone® 14% (n=203) and Subutex® 8% (n=13). Patients who
missed more than 10 doses were: methadone 4% (n=102), Suboxone® 9% (n=131) and
Subutex® 4% (n=7).
The reporting of missed doses should be viewed with caution, as at the time of submitting the
pharmacy monthly dosing report to the Department of Health, a pharmacist may not be aware if
the patient has missed a dose or ceased treatment. In some instances the reported missed
dose may be incorrect as the patient may have moved pharmacies.
24
Patient cohort movement within program by gender
Each patient in the cohort was classified according to the number of authorisations issued
during 1 January 2012 to 31 December 2012. A new authorisation is issued when a patient
changes opioid pharmacotherapy, treatment provider or the previous authorisation has expired.
An authorisation that is renewed without a break in treatment does not constitute a new
authorisation and has not been included in this analysis.
Table 5. Number of authorisations issued by gender
Classification
Female
Female
Male
frequency percentage frequency
Male
Frequency
percentage total
1 Authorisation
1246
80.9%
2075
81.2%
3321
2 Authorisations
222
14.4%
382
15.0%
604
3 Authorisations
61
4.0%
79
3.1%
140
4 Authorisations
10
0.6%
16
0.6%
26
>4 Authorisations 1
0.1%
3
0.1%
4
Total
100.0%
2555
100.0%
4095
1540
Table 5 shows the frequency of authorisations issued per patient in 2012 by gender. It highlights
the extent of switching between opioid pharmacotherapies and movement between prescribers
by patients within the program. Around 81% of both males (n=2075) and females (n=1246) had
one authorisation only.
25
Section three – authorised prescribers
In 2012, there were 85 authorised community CPOP prescribers in WA, including 69 active and
16 inactive community prescribers. Inactive prescribers were those who did not prescribe opioid
pharmacotherapy during the period 1 January 2012 to 31 December 2012. The Next Step Drug
and Alcohol Services utilised 21 active prescribers in three public clinics. The Department of
Corrective Services utilised 12 active authorised prescribers employed in the prison system.
Next Step and DOCS prescribers may be included in the community prescribers’ category if
they also practice privately.
During 2012, 13 new prescribers where authorised to participate in the CPOP.
Table 6. Number of patients being treated per prescriber in December 2012
Patient
No. of approved Percentage
Cumulative
frequency
CPOP
percentage
of patients
prescribers
≥1 and ≤5
30
35.7%
35.7%
>5 and ≤10
15
17.9%
53.6%
>10 and ≤20
16
19.0%
72.6%
>20 and ≤50
11
13.1%
85.7%
>50 and ≤100
8
9.5%
95.2%
>100and<150
0
0.0%
95.2%
>150
4
4.8%
100.0%
Total
84
100%
Table 6 shows the number of patients treated per active CPOP prescriber according to dosing
record data for December 2012. Prescribers at Next Step Drug and Alcohol Services and
Department of Corrective Services were excluded from this analysis
The number of patients per prescriber ranged from one to 369. Of the 30 authorised prescribers
treating between one and five patients, 14 authorised prescribers treated one patient only.
There were four authorised prescribers who treated more than 100 patients. The average
number of patients per prescriber was 27 and the median number of patients was 10.
26
Treatment of patients by prescriber
The number of patients treated by the different prescriber groups is shown in Figure 13. A
patient may have been treated by more than one prescriber group and is counted in each
group. It indicates the participation of the three prescriber groups involved in the treatment of
the patient cohort.
Figure 13. Treatment of patients by prescriber group
Next Step
prescriber,
n=1537, 36%
Community
prescriber,
n=2315, 55%
DOCS
prescriber,
n=401, 9%
Figure 13 shows that during 2012, 55% (n=2315) of patients in of the cohort were treated by
community prescribers, 36% (n=1537) by Next Step prescribers and 9% (n=401) by prescribers
at the Department of Corrective Services. The total (n=4253) is greater than the patient cohort
due to the movement of patients between prescriber groups.
Table 7. Treatment by prescriber and opioid pharmacotherapy
Prescriber type
Community prescriber
DOCS prescriber
Next Step prescriber
Subutex®
Patient
frequency
%
92 3.7%
1 0.2%
75 4.6%
Suboxone®
Patient
frequency
%
940 38.2%
41 9.7%
535 32.6%
Methadone
Patient
frequency
%
1428 58.0%
382 90.1%
1030 62.8%
Table 7 shows the different opioid pharmacotherapy being used by each prescriber group.
DOCS prescribers treated 90.1% (n=382) of patients with methadone, Next Step prescribers
62.8% (n=1030) and community prescribers 58% (n=1428).
27
Figure 14. Average dose of opioid pharmacotherapy by prescriber group
Mean average dose (mg)
80.0
70.0
60.5
60.0
54.6 53.1
50.0
40.0
30.0
20.0
12.4
16.0
12.0
10.0
16.3
13.2
8.3
0.0
Subutex
Community Prescriber
Suboxone
DOCS Prescriber
Methadone
Next Step Prescriber
Figure 14 shows the different drug and doses prescribed by prescriber groups. The average
dose is calculated as the sum of the last dose of each month provided by the dosing site (in
milligrams) divided by the total number of months dosed. The average dose of Subutex®
prescribed by the community prescribers (12.4 mg) is similar to those prescribed by Next Step
(12 mg). The higher average doses of Suboxone® and methadone prescribed by Next Step may
represent a more complex patient group being treated.
28
Number of active prescribers by Area Health Service
Figure 15. Number of active community prescribers by Area Health Service
WACHS, n=47,
(45.2%)
NMAHS, n=37,
(35.6%)
SMAHS, n=20,
(19.2%)
Figure 15 shows the number of active prescribers by Area Health Service. The total number of
active community prescribers (n=104) is larger than the number of active community prescribers
(n=85), as a prescriber may practice in more than one Area Health Service, or may have moved
practice during 2012. Prescribers at Next Step Drug and Alcohol Services and Department of
Corrective Services were excluded from this analysis.
The distribution of prescribers in the Perth metropolitan area in 2012 is provided in Appendix 4.
29
Table 8. Number of authorised community prescribers by Health District
Number of approved
active CPOP
Area Health Service
Health District
prescribers
Bayswater-Bassendean
3
Joondalup
1
Kalamunda
0
Oceanic
23
Stirling Coastal
0
Stirling SEC
5
Valley and Hills
5
Wanneroo
3
Armadale
3
Bentley
3
Fremantle
5
Peel
8
Rockingham-Kwinana
1
Blackwood
1
Bunbury
6
Busselton
3
Central Great Southern
0
East Pilbara
4
Eastern Wheatbelt
0
Gascoyne
2
Geraldton
11
Kimberley
1
Leeuwin
1
Leschenaults
0
Lower Great Southern
3
Midwest
0
NMAHS
SMAHS
WACHS
30
Area Health Service
Health District
Number of approved
active CPOP
prescribers
Murchison
0
Northern Goldfields
3
South East Coastal
5
Southern Wheatbelt
1
Warren
0
Wellington
0
West Pilbara
1
Western Wheatbelt
2
Total
104
WACHS
Table 8 shows the number of active authorised community prescribers in the program.
Prescribers may be counted more than once if they practice in more than one location or have
moved practices during 2012. The number of active authorised prescribers by Health District
ranged from 0 to 23. The data does not include DOCS and Next Step prescribers.
31
Section four – authorised dosing sites
As at 31 December 2012, there were 345 community pharmacies authorised to participate in
the CPOP. There were 250 community pharmacies dosing one or more patients and 95
pharmacies had not dosed a patient during 2012. The Department of Corrective Services has
two dosing sites and Next Step Alcohol and Drug Services has one dosing site located at East
Perth. There were seven dosing sites not included in the above categories, these comprised
Regional Hospitals and Nursing Posts included in the ‘Others’ category where 45 patients
dosed during the year.
Figure 16. Patient cohort by dosing site
Next Step,
n=106, 2.4%
Others, n=45,
1.0%
DOCS, n=549,
12.2%
Community
pharmacy,
n=3794, 84.4%
Figure 16 shows the number of patients by dosing site. The total number of patients dosing
(n=4494) is greater than the number of patients in the cohort as a patient may have dosed at
more than one type of dosing site.
Community pharmacies were responsible for 84% (n=3794) of the CPOP dosing, Department of
Corrective Services for 12% (n=549) and Next Step for 3% (n=106). Other sites accounted for
1% (n=45).
32
Number of dosing sites by Area Health Service
Figure 17. Number of dosing sites by Area Health Service
WACHS, n=88,
(30.3%)
NMAHS,
n=112, (38.6%)
SMAHS, n=90,
(31.0%)
Figure 17 shows the number and percentage of dosing sites by Area Health Service. North
Metropolitan has the largest number of dosing sites 39% (n=112), followed by South
Metropolitan 31% (n=90) and WA Country 30% (n=88). Both active and inactive dosing sites
have been included. DOCS dosing sites have been excluded.
33
Table 9. Number of authorised dosing sites by Health district
Number of approved
Area Health Service
Health district
CPOP dosing centres
Bayswater-Bassendean
10
Joondalup
15
Kalamunda
7
Oceanic
38
Stirling Coastal
12
Stirling SEC
23
Valley and Hills
17
Wanneroo
15
Armadale
17
Bentley
26
Fremantle
36
Peel
12
Rockingham-Kwinana
17
Blackwood
5
Bunbury
8
Busselton
7
Central Great Southern
2
East Pilbara
3
Eastern Wheatbelt
6
Gascoyne
3
Geraldton
5
Kimberley
5
Leeuwin
3
Leschenaults
3
Lower Great Southern
9
Midwest
4
Murchison
0
NMAHS
SMAHS
WACHS
34
Area Health Service
WACHS
Health district
Number of approved
CPOP dosing centres
Northern Goldfields
6
South East Coastal
5
Southern Wheatbelt
6
Warren
5
Wellington
1
West Pilbara
8
Western Wheatbelt
14
Total
353
Table 9 shows the number of authorised dosing sites by Health District ranged from 0 to 38.
The data excludes DOCS dosing sites.
The distribution of dosing sites in the Perth metropolitan area in 2012 is provided in Appendix 4.
35
Table 10. Patient cohort per 10 000 population by Area Health Service
Patient
Rates per 10,000
Area Health Service
frequency
population
NMAHS
1594
20.4
SMAHS
1591
22.9
WACHS
688
16.5
Total
3873
Table 10 shows the number and rate per 10 000 population of the patient cohort in each of the
three area health services. Patients were assigned to an Area Health Service (AHS) based on
the postcode of the address on the authorisation application form. The patients being treated at
DOCS are not included in this analysis.
36
Community pharmacies by number of patients dosing
The dosing records for December 2012 provided to the Department of Health by community
pharmacies and others were used to group the number of patients. Patients may have moved
pharmacy or changed opioid pharmacotherapy during the month and therefore may be counted
more than once.
Table 11. Number of patients dosing at community pharmacies and other sites in
December 2012
Patient
Percentage
Cumulative
Number of
frequency
of patients
percentage
community
pharmacies and
others
≥1 and ≤5
89
37.1%
37.1%
>5 and ≤10
51
21.3%
58.5%
>10 and ≤20
55
22.9%
81.3%
>20 and ≤50
36
15.0%
96.3%
>50
9
3.8%
100.0%
Total
240
100.0%
Table 11 shows that around 40% of the community pharmacies dosed between one and five
patients (n=89). There were 24 community pharmacies which only have one patient dosing. The
number of patients dosing at a community pharmacy during the month of December 2012
ranged from one to 171.
Community pharmacies report the last dose dispensed during the reporting month. Transient
patients may be recorded as dosing at more than one pharmacy during a month. Community
pharmacies dosing transient patients will reflect a higher number recorded each month. The
average number of patients was 13.8 and median 8.0 per community pharmacy. The maximum
number of patients supported by the program per community pharmacy is 50. The nine
community pharmacies dosing more than 50 patients had made application to the CPOP
Management Committee and received approval to do so.
37
Table 12. Number of authorised patients dosing by health district
Patient
Area Health Service Health district
frequency
Rates per 10 000
population
Bayswater-Bassendean
183
28.7
Joondalup
164
12.5
Kalamunda
47
10.8
Oceanic
315
24.6
Stirling Coastal
118
19.9
Stirling SEC
327
30.1
Valley and Hills
266
21.9
Wanneroo
240
19.1
Armadale
243
16.3
Bentley
390
23.0
Fremantle
463
24.9
Peel
234
29.1
Rockingham-Kwinana
260
23.9
Blackwood
3
4.7
Bunbury
102
25.6
Busselton
83
29.5
Central Great Southern
7
8.2
East Pilbara
19
9.3
Eastern Wheatbelt
7
6.9
Gascoyne
22
30.2
Geraldton
56
18.7
Kimberley
17
5.4
Leeuwin
18
16.9
Leschenaults
21
6.7
Lower Great Southern
93
22.3
Midwest
7
6.7
Murchison
1
3.9
NMAHS
SMAHS
WACHS
38
Area Health Service
WACHS
Health district
Patient
frequency
Rates per 10 000
population
Northern Goldfields
42
14.0
South East Coastal
43
36.3
Southern Wheatbelt
13
8.1
Warren
10
12.6
Wellington
11
9.4
West Pilbara
14
5.9
Western Wheatbelt
33
12.4
Total
3872
Table 12 shows the number of authorised patients by health district ranged from one to 463
patients. This does not include DOCS patients.
39
Section five – comparison data 2007–2012
This section provides comparative information on the CPOP between 2007 and 2012. Data from
the first annual report published in 2006 has not been included. Suboxone® first became
available in Western Australia on 1 May 2006. At this time in 2006 many patients authorised
and dosing with Subutex® and receiving takeaways were transferred to Suboxone ®.
Figure 18. Number of patients authorised and dosing by pharmacotherapy 2007-2012
No of patients
3000
2000
1000
0
2007
2008
2009
2010
2011
2012
Suboxone
1062
1200
1359
1401
1412
1495
Subutex
276
229
189
180
173
169
Methadone
2469
2595
2756
2777
2722
2743
Year
Suboxone
Subutex
Methadone
Figure 18 shows a reduction in CPOP patients treated with Subutex and an increase in
patients treated with Suboxone between 2007 and 2012, in line with the policies of the
program.
40
Average age
Figure 19. Patients average age by pharmacotherapy 2007-2012
42
40
38
36
34
32
30
Suboxone
Subutex
Methadone
2007
2008
2009
2010
2011
2012
34.7
35
35.8
36.7
37.4
38
34
34.2
34.5
34.3
35.1
35.8
36.6
36
37.8
38.3
38.9
39.8
Year
Suboxone
Subutex
Methadone
Figure 19 shows that between 2007 and 2012 there was an increase in the average age of the
patients authorised and dosing in the CPOP for all three pharmacotherapies.
Average dose (mg)
Figure 20. Daily dose of Subutex® and Suboxone® 2007-2012
14.5
14
13.5
13
12.5
12
11.5
11
10.5
2007
2008
2009
2010
2011
2012
Suboxone
13.1
13.1
14
14.1
13.8
14.2
Subutex
12.2
12
13.2
12.2
12.7
12
Year
Suboxone
Subutex
41
Figure 20 shows that between 2007 and 2012 the average daily dose of Suboxone in the
CPOP has increased each year and over the six year period increased from 13.1 mg to 14.2
mg. This represents an increase of 1.1 mg (8.4%).
The average daily dose of Subutex in the CPOP has fluctuated by year, but remained stabled
over this time.
Figure 21. Daily dose of methadone 2007-2012
Average dose (mg)
58.5
58
57.5
57
56.5
56
55.5
55
Methadone
2007
2008
2009
2010
2011
2012
56.4
57.8
58.3
57.6
56.1
56.3
Year
Methadone
Figure 21 shows the average daily dose of methadone for all CPOP patients by year between
2007 and 2012. The average daily dose of methadone increased between 2007 and 2009
(1.9mg, 3.4%), and decreased between 2009 and 2011.
42
Figure 22. Proportion of patients by prescriber type 2007–2012
Percentage of patient
60
50
40
30
20
10
0
2007
2008
2009
2010
2011
2012
Year
Next Step
DOCS
Community
Figure 22 shows percentage of the total number of CPOP patients treated by each prescriber
group each year between 2007 and 2012. The proportion of patents treated by each group has
remained relatively constant over this time period.
43
Appendices
Appendix 1. Community Program for Opioid Pharmacotherapy policies
The following information is extracted from the WA Clinical policies and procedures for the use
of methadone and buprenorphine in the treatment of opioid dependence. Visit
www.dao.health.wa.gov.au for the full text.
Legislative and administrative requirements
Legislative requirements
The legislative framework for the Community Program for Opioid Pharmacotherapy is contained
in the Poisons Regulations 1965.
Medical Practitioners require prior authorisation from the Chief Executive Officer to prescribe
methadone and buprenorphine for the treatment of dependence and in addition the authorised
prescriber must obtain an individual patient authority from the Chief Executive Officer, before
prescribing methadone or buprenorphine to a drug dependent person.
The Drugs of Addiction Notification Regulations 1980 also require a medical practitioner who in
the course of her or his practice becomes aware of or suspects a person of being addicted to
drugs, to inform the Executive Director Public Health.
The following legislative requirements apply.
Authorisation as a methadone/buprenorphine prescriber in Western Australia
Medical practitioners who provide methadone and/or buprenorphine treatment for opioid
dependence must be authorised by the Chief Executive Officer under Regulation 51C of the
Poisons Regulations 1965.
A prescriber completes an application to become an approved methadone/buprenorphine
prescriber.
The medical practitioner is required to satisfactorily complete a training and assessment
package delivered by the Drug and Alcohol Office (DAO) and make a commitment to comply
with clinical policies and procedures, codes of practice and administrative instructions of the
program. The Drug and Alcohol Office will notify the Department of Health that the prescriber
has satisfactorily completed the training and assessment requirements.
Authorisation as a methadone/buprenorphine dispenser in Western Australia
Pharmacies participating in the dispensing of methadone/buprenorphine for opioid dependence
must be authorised by the Chief Executive Officer under Regulation 51EA of the Poisons
Regulations 1965. The pharmacy proprietor is required to complete an ‘Application to
Participate in Methadone/Buprenorphine Dispensing’. The proprietor must agree that all
pharmacists participating in the CPOP have successfully completed the training and
assessment package and that the minimum standards for the dispensing of
methadone/buprenorphine have been implemented in the pharmacy.
The Department of Health issues an authorisation for the pharmacy for participation in the
dispensing of methadone/buprenorphine and notifies the nominated wholesaler that the
44
pharmacy is participating in the CPOP and eligible for methadone/buprenorphine free of charge
(recording fee still applies).
Authority to prescribe
Authorised methadone/buprenorphine prescribers must obtain from the Chief Executive Officer
or delegate an individual patient authority for each patient being commenced on treatment
under Regulation 51CA of the Poisons Regulations 1965.
An ‘Application to prescribe a pharmacotherapy – CPOP’ form for an opioid dependent person
is completed by the prescriber. The patient must also sign the application to indicate that they
acknowledge that the information will be forwarded to the Department of Health and used for
the management of the program.
The completed ‘Application to prescribe a pharmacotherapy – CPOP’ form for an opioid
dependent person is forwarded to the Clinical Advisory Service (CAS) and the authorisation is
issued by the Department of Health. Specialist prescribers at Next Step may make direct
application to the Department of Health although they may consult the Clinical Advisory Service
if the need arises.
An authorisation number must be obtained prior to the writing of a prescription for methadone or
buprenorphine. Authorisation is for a maximum maintenance dose of 120 mg of methadone or
24 mg of buprenorphine. The number of takeaways authorised on a prescription must be in
accordance with the ‘Takeaway Policy’ (see below). On completion the application form and
record of the authority number should be filed with the patient’s records.
Please note–an ‘Application to prescribe a pharmacotherapy – CPOP’ form for an opioid
dependent person is required when initiating prescribing for a patient transferring from another
prescriber or for a patient that has previously been treated by the same prescriber but the
authorisation has expired or been terminated.
Conditions associated with the authority to prescribe opioid pharmacotherapy
The authorisation for a medical practitioner to prescribe methadone or buprenorphine is subject
to the following conditions.
Legal responsibility
The prescriber is legally responsible for the treatment of a patient until treatment is transferred
or terminated.
Patient numbers policy
The prescriber must not exceed the maximum number of patients set out below.
Patient numbers per approved prescriber
When approved as a methadone or buprenorphine treatment prescriber a medical practitioner
will be authorised to prescribe for a maximum of 150 clients at any one time. To exceed this
number a prescriber may apply in writing to the Pharmaceutical Services Branch of the
Department of Health. The Department of Health will forward the application to the CPOP
Management Committee for review. The CPOP Management Committee will make a
recommendation to the Chief Executive Officer whether to increase the prescribers’ patient
numbers to a maximum of 200. In assessing the application consideration the record of the
prescriber in complying with the policies and procedures of the Community Program for Opioid
45
Pharmacotherapies, the ability of the prescriber to maintain appropriate levels of client care for
managing more than 150 clients, available support services and any other information
considered to be relevant.
In exceptional circumstances authority may be provided by the Chief Executive Officer for an
approved prescriber to temporarily exceed their maximum patient numbers in order to ensure
continuation of care for existing patients. In the event of concerns emerging about public
amenity due to a large number of clients attending a particular medical centre or general
practice, the matter may be considered by the CPOP Management Committee which may
recommend changes to the maximum number of clients who can be treated at the service.
Patient numbers per approved pharmacy
The maximum number of clients to whom pharmacies are authorised to dispense as part of the
program is the equivalent of 50 clients per day. To exceed this number a pharmacy may apply
in writing to the Pharmaceutical Services Branch of the Department of Health. The Department
of Health will forward the application to the CPOP Management Committee for consideration.
Following a review of the pharmacy to determine capacity to manage more patients, the CPOP
Management Committee will make a recommendation to the Chief Executive Officer to increase
the pharmacy’s patient numbers. In assessing the application consideration of the record of the
pharmacy in complying with the policies and procedures of the Community Program for Opioid
Pharmacotherapy, the ability of the pharmacy to maintain appropriate levels of client care for
managing more than 50 clients and any other information considered to be relevant.
In the event of concerns emerging about public amenity due to a large number of clients
attending a particular pharmacy, the matter may be considered by the Professional Review
Group who may recommend changes to the maximum number of clients.
Maximum dose
Approval must be obtained from the Department of Health to prescribe above a dose of 120 mg
of methadone or 24 mg of buprenorphine. An ‘Application for Authority to Prescribe
Pharmacotherapy in Excess of the CPOP Policy for an Opioid Dependent Person’ form is to be
completed and sent to the Clinical Advisory Service (CAS) for endorsement prior to forwarding
to the Department of Health. If approved an authorisation is issued by the Department of Health.
Takeaway doses policy
Authorised prescribers must comply with the schedule of takeaway doses of methadone and
buprenorphine as set out in the ‘Takeaway Policy’ (See below). This schedule has been
developed to balance the benefits of providing takeaway doses with the serious potential for
misuse and the risks this presents.
Approval must be obtained from the Clinical Advisory Service (CAS) to prescribe more than the
number of takeaways set out in the schedule or to prescribe takeaway doses of Subutex ®. An
‘Application for Authority to Prescribe Takeaway Doses for an Opioid Dependent Person’ form
should be completed and sent to the Clinical Advisory Service (CAS) for consideration and
endorsement.
Prescriptions
A patient participating in the CPOP should only be prescribed one dose (excluding split doses)
of methadone or buprenorphine per day. In order to reduce the potential for dosing at multiple
sites to occur, when multiple prescriptions are written for a patient, the authorised prescriber
46
must ensure that the additional prescriptions do not authorise additional doses to be obtained
from another pharmacy on the same day.
Renewal of authority to prescribe
The Department of Health will forward to the prescriber an ‘Application for Renewal of an
Authorisation to Prescribe Methadone/Buprenorphine for an Opioid Dependent Person’ form
during the month prior to expiration of a patient’s authorisation. The prescriber must renew the
authority by completing the form and returning it to the Department.
Patients under the age of 18 years
Methadone is only registered for use in patients aged 18 or over. Buprenorphine has been
registered for administration to people aged 16 and over. Caution should be exercised in
prescribing a drug of dependence for anyone under 18 years of age. However, positive results
have been reported from the combination of buprenorphine with behavioural interventions for
the treatment of opioid-dependent adolescents. Potential medico-legal implications of
prescribing methadone or buprenorphine outside of the product information should be
considered.
Patients under 18 years of age must be referred to Next Step Youth Service for a
comprehensive, multi-disciplinary assessment. Applications for authority to prescribe for
patients under 16 years of age will require special approval from the Chief Executive Officer.
Next Step Youth Service is able to instigate treatment and stabilise the patient before referring
them back to the prescriber. Next Step Youth Services are also able to offer ongoing
consultation for medical practitioners treating young patients. In cases where the prescriber, for
reason of their location in a remote area, cannot access Next Step Youth Services the Clinical
Advisory Service should be contacted to discuss alternative assessment options.
Schedule for takeaway doses
First six months* of treatment
Except in exceptional circumstances no takeaway doses of methadone or buprenorphine should
be prescribed until the patient has been in continuous treatment for six months. Wherever
possible the patients should be placed with a seven day pharmacy to enable daily dosing.
Alternatively a second dispensing point may be used on the seventh day if the patient attends a
six day pharmacy.
Methadone
Length of time in
treatment *
Number of takeaway does permitted
6–12 months
After six months of continuous treatment and where the patient is
assessed as stable and is working towards achieving treatment
goals, they may be eligible for one takeaway dose of methadone
per week.
12–24 months
After 12 months of continuous treatment and where the patient has
demonstrated stability with one takeaway does per week they may
be eligible for two non-consecutive takeaway doses per week.
47
Length of time in
treatment *
Number of takeaway does permitted
More than 24 months
After two years of continuous treatment and where the patient has
demonstrated stability with two takeaway doses per week they
may be eligible for three takeaway doses of methadone per week.
Only two of these may be consecutive.
Buprenorphine (Suboxone®)
Buprenorphine has a long half life (24–36 Hours) and many patients can be dosed every
second or third day thus minimizing the need for takeaway doses. The long half life of
buprenorphine can also mean that takeaway doses are more easily diverted as missing part or
all of a day’s dose does not result in severe opiate withdrawal. For this reason no more than
one takeaway dose per week is permitted for patients prescribed buprenorphine until they have
been on the program for 24 months.
Length of time in
treatment *
Daily dosing
Dosing every
second day
Dosing every third
day
Less than 6 months
Limited to exceptional circumstances
6–24 months
1 per week
1 per week
More than 24 months
2 per week
1 per week
*Note: duration refers to continuous period of dosing with either methadone or buprenorphine. It
does not refer to continuity with the same service provider.
Size of the takeaway doses
The takeaway dose must not exceed the normal supervised daily dose.
Safety of takeaway doses
The takeaway dose(s) must be given to the patient on the day before the scheduled day(s) of
absence from the usual dispensing location.
Patients are responsible for the care and proper consumption of each takeaway dose once they
have taken possession of it.
To avoid risk of consumption by children or other unauthorised people the patient should be
advised that takeaway doses should be stored in a place that is not easily accessible by people
other than themselves. Each takeaway dose should be supplied in a separate container with a
child-resistant closure and carrying the label ‘Keep out of reach of children’. To further reduce
the risk of overdose by children it should not be necessary to refrigerate takeaway doses of
methadone. Each takeaway dose of methadone should be diluted in 100 mL of water.
There should be labelling warning of the possible associated hazards when driving or operating
machinery. Other labelling and preparation requirements should be fulfilled in accordance with
the regulations of the Poisons Act 1964. To maintain safety standards and proof of ownership,
patients should be advised not to transfer takeaway doses to containers without the appropriate
labels. Takeaway doses of buprenorphine do not need to be crushed.
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Appendix 2. Health Districts by postcode
Area Health
Service
NMAHS
SMAHS
WACHS
Health district
Postcode
Oceanic
≥6000 and ≤6017
Stirling SEC
≥6021 and ≤6022, 6050, 6052, ≥6059 and
≤6061
Joondalup
≥6023 and ≤6028
Wanneroo
≥6030 and ≤6038, ≥6064 and ≤6065
BayswaterBassendean
≥6051 and ≤6054,
Valley and Hills
≥6055 and ≤6056, 6063, ≥6061 and ≤6074,
6076, ≥6081 and ≤6090, 6500
Kalamunda
≥6057 and ≤6058, 6076
Stirling Coastal
≥36018 and ≤6020, 6029
Armadale
≥6108 and ≤6126, ≥6201 and ≤6206
Bentley
≥6100 and ≤6107, ≥6147 and ≤6148, ≥6151
and ≤6152
Fremantle
≥6149 and ≤6150, ≥6153 and ≤6164, 6166
Peel
≥6207 and ≤6215
Rockingham Kwinana
6165, ≥6167 and ≤6176
Blackwood
6244, ≥6254 and ≤6256
Bunbury
≥6229 and ≤6231, 6237, ≥6271 and ≤6275
Busselton
≥6280 and ≤6282
Central Great
Southern
≥6316 and ≤6320, ≥6335 and ≤6336, ≥6341
and ≤6343, ≥6394 and ≤6395
East Pilbara
≥6721 and ≤6724, 6753, ≥6758 and ≤6762
Eastern Wheatbelt
≥6368 and ≤6369, ≥6385 and ≤6386, ≥6410
and ≤6428, ≥6472 and ≤6473, ≥6476 and
≤6484, ≥6487 and ≤6490
Gascoyne
6537, ≥6701 and ≤6707
Geraldton
≥6528 and ≤6532
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Area Health
Service
WACHS
Health district
Postcode
Kimberley
≥6725 and ≤6743, ≥6765 and ≤6770
Leeuwin
≥6284 and ≤6290
Leschenaults
≥6218 and ≤6224, ≥6226 and ≤6228, ≥6232
and ≤6236
Lower Great
Southern
≥6321 and ≤6333, ≥6337 and ≤6338, ≥6396
and ≤6397
Midwest
≥6514 and ≤6515, ≥6517 and ≤6519, ≥6522
and ≤6525, ≥6535 and ≤6536, ≥6614 and
≤6632
Murchison
6439, ≥6635 and ≤6642
Northern Goldfields
≥6429 and ≤6438, ≥6440 and ≤6442, 6444
South East Coastal
≥6346 and ≤6348, 6343, ≥6445 and ≤6450
≥6306 and ≤6315, ≥6350 and ≤6367, ≥6370
Southern Wheatbelt and ≤6375, ≥6390 and ≤6393, 6452
Warren
≥6258 and <=6262, 6398
Wellington
6225, ≥6239 and ≤6243, ≥6251 and ≤6253
West Pilbara
≥6710 and ≤6720, ≥6751 and ≤6752, 6754
Western Wheatbelt
≥6041 and ≤6044, ≥6302 and ≤6304, ≥6380
and ≤6384, ≥6401 and ≤6409, ≥6460 and
≤6471, 6475, 6485, ≥6501 and ≤6513, 6521,
≥6560 and ≤6613
Patients were assigned to an Area Health Service (AHS) and Health District based on the
postcode of the address listed on the application form. Postcodes were allocated to an AHS and
Health District based on information provided by the Epidemiology Branch of the Department of
Health.
50
Appendix 3. Projected populations per Health District for adults in 2012
Area Health Service
Health district
Population ≥18
Bayswater-Bassendean
60,619
Joondalup
124,922
Kalamunda
43,695
Oceanic
114,989
Stirling Coastal
56,957
Stirling SEC
100,664
Valley and Hills
113,882
Wanneroo
112,571
Armadale
141,667
Bentley
156,006
Fremantle
184,846
Peel
78,387
Rockingham-Kwinana
104,690
Blackwood
5,597
Bunbury
36,850
Busselton
24,148
Central Great Southern
8,111
East Pilbara
16,339
Eastern Wheatbelt
10,325
Gascoyne
8,696
Geraldton
27,535
Kimberley
31,318
Leeuwin
10,719
Leschenaults
26,281
Lower Great Southern
38,636
Midwest
11,276
Murchison
3,559
NMAHS
SMAHS
WACHS
51
Area Health Service
WACHS
Health district
Population ≥18
Northern Goldfields
31,487
South East Coastal
13,728
Southern Wheatbelt
14,402
Warren
7,934
Wellington
11,308
West Pilbara
16,804
Western Wheatbelt
26,296
Total
1,775,244
Population denominators for 2012 The average age was 35.8 years for Subutex®, 38 years for
Suboxone® and 39.8 years for methadone, were provided by the Epidemiology Branch of the
Department of Health via Rates Calculator Version 9.5.4 (Jim Codde, 1993–2005) and are
estimated projections from data obtained from the Australian Bureau of Statistics (ABS) Series
B.
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Appendix 4. Map of approved CPOP prescribers and dosing sites in the
Perth metropolitan area
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This document can be made
available in alternative formats on
request for a person with a disability.
© Department of Health 2012