Sch 8poison(s) for which permit is requested:

Schedule 8 poison(s) for which permit is requested:

| NAME OF POISON(S) | EXPECTED MAXIMUM DAILY DOSE |

I have/have not previously applied for a permit to administer, prescribe or supply a Schedule 8 poison to this patient.

Please note that evidence-based practice guidelines recommend that specialist advice should be sought for patients requiring opioid doses exceeding oral morphine [quantity] mg daily, oxycodone [quantity] mg daily or equivalent, for the treatment of chronic non-cancer pain, or when prescribing opioids to a patient with a history of drug dependency or aberrant drug-related behaviours. Opioids should only be prescribed as part of a comprehensive pain management plan. When applying for a permit to treat a patient with an opioid, applicants may be requested by the Secretary to provide the Secretary with evidence of a pain management plan or specialist review.

The morbidity and mortality risks associated with long-term opioid therapy should be discussed with the patient, in particular the increased mortality risks correlated with the prolonged use of opioids at doses exceeding [quantity] mg daily in morphine equivalents.

Signature of registered medical practitioner/nurse practitioner

Date

PART B: FOR TREATMENT OF AN OPIOID DEPENDENT PERSON WITH METHADONE OR BUPRENORPHINE

I, [full name of registered medical practitioner/nurse practitioner] of [address of registered medical practitioner/nurse practitioner, including postcode, phone and fax numbers] certify that this patient shows evidence of dependence on an opioid drug and that, in my opinion, methadone/buprenorphine is required in support of treatment.

Personal Details:

Full name of patient

Address of patient

Date of birth

DPU client number (if known)

Sex

Aliases (if any)

Mother's full maiden name

Aboriginal or Torres Strait Islander origin

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, Aboriginal and Torres Strait Islander

No

Not stated

Medical Details of Patient:

Starting drug

Starting methadone/buprenorphine dose

Anticipated date of first dose

Period for which permit sought (if short-term)

Has the patient been treated previously with methadone or buprenorphine for opioid dependency? Yes/No