Drugs of Dependence Unit
Phone: 1300 652 584
AUTHORITY APPLICATION
MATOD PROGRAM
[Medication Assisted Treatment for Opioid Dependence]
TO PRESCRIBE OR SUPPLY S8 OPIOIDS TO TREAT DRUG DEPENDENCE (Section 18A Controlled Substances Act 1984 (SA))

Important Information for applicants:
Practitioners who are Accredited for the purposes of the South Australian MATOD program may be granted Authority to prescribe methadone and buprenorphine. All non-accredited practitioners may be granted Authority to prescribe ONLY Suboxone® (buprenorphine + naloxone) film for up to 10 patients.

NEW c 	Complete sections 		RENEWAL  c    Include Section E		TERMINATION  c   Include section F
		A, B, C, D, and G		
 SECTION A: PRESCRIBER DETAILS 	

Surname: 					First Name: 

Address: 					Phone: 				Fax / Email: 

Prescriber #: 					AHPRA#:		 	Specialty: 

 SECTION B: PATIENT DETAILS 	

Surname: 				First Name: 			Date of Birth: 		Gender: 

Address: 

Other names used:			Aboriginal:	Torres Strait Islander:	Country of Birth:

 SECTION C: TREATMENT DETAILS 	

Source of dependence:			Primary drug of abuse: 	Heroin		Other	(specify)

History of IVDU?	Location					Any hospital attendance for overdose?

Other drug use / dependency:			1	2	3	4	5

			Amphetamines		c	c	c	c	c
			Benzodiazepines	c	c	c	c	c
			Cannabis		c	c	c	c	c
			Alcohol			c	c	c	c	c
			OTC preparations	c	c	c	c	c
			Other illicit -		c	c	c	c	c
			Specify

Start date of treatment:

Drug to be prescribed:				Accredited Prescribers only:

Suboxone film				Methadone liquid	Subutex tablets		Buprenorphine depot

Dose:		daily		alternate day		Non-supervised doses:		per week	per month

Prescribing should be in accordance with the Drugs of Dependence Unit’s ‘Policy for non-supervised dosing of methadone and buprenorphine in drug treatment programs’ unless otherwise approved by the Drugs of Dependence Unit.

		
 SECTION D: PHARMACY DETAILS 	

Dosing Pharmacy:								Phone:

Address:									Fax:

 SECTION E: RENEWAL Urine analysis may be used to monitor compliance by providing evidence that the patient is taking the prescribed drugs. 	

Number of Urinalysis attached:

Comments:

SECTION F: TERMINATION DETAILS 	

Date of last dose:			Dose:
Reason:	Successful completion 					Ceased to pick up:
		Transfer (specify)					Deceased:
		Treatment terminated					Date of Death:
	- involuntary	
	- by mutual agreement					Cause of Death:
Comments:
SECTION G: PRESCRIBER DECLARATION 	

I have explained the nature of treatment and the potential side effects to the patient, and he/she has consented to the treatment.  I confirm that the information I have provided in this application is true, accurate and complete to the best of my knowledge. I understand that my application may not be processed if all the information requested on this form is not completed.

Signature:	Date:

Privacy Statement:
The information set out in this form is required by the Minister responsible for the Controlled Substances Act 1984 to consider granting an authority to prescribe a Schedule 8 drug as required under the law. Personal and health information is protected by the Privacy Act 1988 and can only be collected, used and disclosed for authorised purposes. Information provided in this form will be included in the patient’s ScriptCheckSA record and will be accessible to other prescribers and pharmacists treating the patient to support their clinical decision making. Information (including personal information) must not be accessed, used or disclosed for any purpose, other than as allowed by the Controlled Substances Act 1984 and the Controlled Substances (Poisons) Regulation 2011. Penalties may apply for unauthorised access, use or disclosure of information in ScriptCheckSA. For further advice or clarification, please email HealthDrugsofDependenceUnit@sa.gov.au