CONTENTS / Page
Principles of Good Prescribing / 2
Introduction / 3
Aims of Prescribing / 3
Care Coordination / 4
Care Plan / 5
Ongoing care and monitoring / 5
Safety and Good Practice / 6
Appointments and Review Procedures / 6
Driving / 6
Pharmacy liaison / 7
Wording a prescription correctly / 7
Supervised Consumption Policy / 8
Managing “on top” use / 9
Holiday Prescription Guidelines / 9
Recording cancelled prescriptions / 10
Discontinuation of a prescription / 10
Methadone Prescribing / 12
Buprenorphine (Subutex & Suboxone) Prescribing / 13
Choosing between methadone and buprenorphine / 14
Benzodiazepine Prescribing / 15
Lofexidine Prescribing / 17
Naltrexone Prescribing / 19
Prescribing In Pregnancy and Breastfeeding / 20

Principles of Good Prescribing (Summary)

  • Prescribing should take place within a framework. Address co-existing physical, emotional, social and legal problems at the same time.
  • Prescribe with a firm harm reduction approach.
  • Before prescribing, assess the patient fully, screen to confirm substance use and agree a care plan.
  • Regularly monitor and review during treatment including screening.
  • See patients usually on a three monthly basis.
  • Inform patients about driving regulations and the need to contact the DVLA.
  • Pharmacy liaison is very important as the pharmacist is usually the only health care professional who will have daily contact with the patient.
  • Ensure prescriptions are written correctly to achieve continuity of treatment.
  • Discontinuation of a prescription is a serious intervention and should ideally be a multi-disciplinary decision.
  • Continued illicit drug/or alcohol use will lead to a review of the prescription.
  • Decisions to work outside the prescribing policy should be a multi-disciplinary decision but must ultimately be supported by the prescriber. Document all decisions.
  • On top use should not be ignored. It can be dealt with through psychological therapy, pharmacological therapy or a mixture of both.

Introduction

Prescribing is a component of a treatment package rather than being a treatment on its own. Community prescribing may comprise:

  • Stabilisation or maintenance on substitute opioids.
  • Withdrawal from opioids with non-opioid medication e.g. lofexidine.
  • Stabilisation and withdrawal from sedatives, benzodiazepines and alcohol.
  • Relapse prevention prescribing with acamprosate or disulfiram.
  • Symptomatic and maintenance prescribing for stimulant users.

Cornwall Drug Services operate with a firm harm reduction approach in line with Department of Health and NTA guidelines.

Aims of Prescribing

  • Prescribe substitute medication to stabilise patient’s withdrawal symptoms.
  • Reduce or eliminate the use of illicit/non-prescribed drugs.
  • Reduce the dangers associated with drug misuse e.g. reducing injecting and sharing of injecting paraphernalia.
  • Reduce criminal activity associated with drug misuse.
  • Reduce the risk of prescribed drugs being diverted.
  • Improve the patients’ overall functioning from a personal, social, family and community perspective.
  • In the case of alcohol and benzodiazepines, achieve safe detoxification minimising adverse events.
  • Engage and retain drug users in their treatment programme.

Care Co-ordination

Care co-ordinator’s responsibilities:

  • To co-ordinate the monitoring of the patient for signs of over-sedation during titration and treatment. This will be supplemented by the pharmacist, who will withhold doses in accordance with an agreed protocol if the patient presents to the pharmacy intoxicated
  • To request the prescription via a letter or written request (handwritten is acceptable) with start date, pharmacy and details of the prescription. All such details must also be recorded in the case file.
  • To ensure that appointments are booked with the prescriber and to keep the prescriber informed of patient’s presentation.

Action / Completed?
4-way information-sharing agreement in place?
Patient registered with a GP?
Dispensing pharmacy identified and contacted?
Tier 3 comprehensive assessment performed?
Patient’s general health status assessed?
Objective proof of dependent substance misuse?
Assessment undertaken and toxicological screening documented?
Treatment programme agreed with care co-ordinator?
Written care plan agreed and signed by patient?
Patient clear on service policy on missed appointments etc?
Patient’s literacy confirmed?
Patient medication choice fully informed and side effects explained?
Patient’s own GP informed of prescribing plan?
Patient’s own GP informed of final dose after titration?
Patient registered with National Drug Treatment Monitoring System?

The Care Plan

The care plan forms the basis for treatment and sets out the expectations of both the service user and the service. It should include other appropriate agencies and carers. Agreed treatment goals are central to care planning.

Treatment goals / Treatment outcome measures
Engagement with service / Attending appointments
Harm reduction / Modified injecting behaviour
Reduced drug use
Health promotion / Hepatitis B /C /HIV testing
Hepatitis A&B vaccination
Safer sex
Increased knowledge of drug use/ harm reduction
Aware of overdose prevention and management
Engagement with GP re health problems
Stabilisation of drug use / Improved social relationships
Improved housing
Reduced debt
Increased daily activity
Maintenance on medication / Reported cessation of problem drug use.
Negative toxicology
Detoxification / Cessation of substitute prescribing
Cessation of drug use
Abstinence / Drug free after 1,3,6 months
Completing relapse prevention intervention

Where supplementary prescribing by a non-medical prescriber is intended, a clinical management plan must be in place. This can be incorporated within the care plan to reduce duplication.

Ongoing care and monitoring

Provide the following information to the patient with the written care plan:

  • Information on the drug prescribed, its effects and side effects
  • Warnings about overdose and how to manage others who overdose.
  • Information regarding help and advice regarding blood borne virus screening, safer injecting and sexual practices.

Those who are Hepatitis B or C positive should be provided with information about alcohol usage.

Safety and Good Practice

  • Monitor during treatment with regular random urine screening and/or oral fluid tests. This should be at least two screens per year but will be more for patients who are not stable or in early treatment.
  • Appropriate dispensing arrangements should be in place. Send prescriptions to pharmacies and only give directly to patients in exceptional circumstances. Pharmacies may collect prescriptions.
  • Advise the patient on safe storage of their prescription especially if children live at or visit the same premises.
  • Review ineffective prescriptions with the multi-disciplinary team and, if necessary, stop them.
  • Keep records of the prescription including date issued, dates to start, drugs prescribed, dosage and prescription numbers.
  • Only the patient should collect the medication from the pharmacy. If a third party needs to collect the prescription the care co-ordinator or the prescriber must authorize this in writing (e.g. by fax to the pharmacy)

Appointments and Review Procedures

The patient will usually be seen by the prescriber three monthly. This may be less frequent for stable patients with the agreement of the multi-disciplinary team, while for patients with complex needsit will need to be more frequent.

The care co-ordinator should see patients at least three monthly if a patient is completely stable on their prescription. After initiation of prescribing, the patient should be seen at least weekly for the first fortnight and after this typically every 2-4 weeks depending on the agreed care plan.

If the patient misses two consecutive appointments (without good reason) it is a strong indicator for stopping the prescription, or putting it ‘on hold’. Consult the multi-disciplinary team before reaching a decision.

Continued illicit drug use will lead to a review of the prescription and/or the psychological approach adopted.

Driving - (See the CD-rom for patient and prescriber information)

Pharmacy liaison

  • The prescriber or care co-ordinator should help the patient find a pharmacy as pharmacies are not obliged to supervise the consumption of controlled drugs and those that do may have reached capacity.
  • Liaise regarding start dates and other relevant details
  • Communicate in good time to allow the Pharmacist an adequate period to secure stocks.

Prescription regulations

The doctor who signs the prescription carries ultimate responsibility for prescribing. Prescriptions must be:

  • Signed by the prescriber with his/her usual signature.
  • Dated, but a computer generated date is acceptable. Post-dating of prescriptions may be necessary but a prescription for a controlled drug must be dispensed within 28 days of the date it is signed or the commencement date if the prescriber specifies one.

The prescription for CD schedules 2 and 3 should also state:

  • The form and where appropriate the strength of the preparation.
  • The total quantity or the number of dose units, in words and figures.
  • The dose.
  • Instructions to cover when the pharmacy is closed e.g. Sundays and Bank Holidays.

Missed Collections of Instalments

Where instalments to be dispensed are for more than one day, prescribers are advised to include the phrase:

‘if a collection is missed the remainder of the instalment [i.e. the instalment less the amount prescribed for the day(s) missed] may be supplied’

This will allow the pharmacist to dispense the remaining day(s) doses to a patient who fails to collect on the designated day but attends the following day. Without this phrase the whole instalment would be forfeited.

However should a patient fail to pick-up the instalments for more than 2 consecutive days then the prescription should be suspended and the care-co-ordinator contacted.

Missed doses can lead to loss of tolerance and prescribers should be kept informed of missed doses. Patients who repeatedly miss doses should have their treatment reviewed. If on less than daily dosing the first step would be to revert to daily dispensing.
Supervised Consumption Policy (Summary)

  • Supervised consumption should occur for a minimum of three months at the start of treatment unless there are exceptional circumstances.
  • Restart supervised consumption if a patient resumes a prescription after a break, receives a significant increase in their dose or transfers to daily collection from less frequent pick-up arrangements.
  • Certain patient groups should remain in supervised consumption during their treatment programme.
  • Supervised consumption is only available for methadone mixture and buprenorphine tablets.

In certain circumstances e.g. women near term or with infants younger than 3 months, those with verified employment or in full time education special arrangements may be made to allow take home doses before three months have elapsed. As this is outside policy discuss at a multi-disciplinary team meeting and note the decision to prescribe in the patient’s records.

After three months review the need for supervision and the collection interval with the care co-ordinator. Before offering a patient take home doses, ensure:

a)Patients must demonstrate consistent negative screens for illicit drugs (at least three consecutive negative screens - excluding cannabis),

b)Regular attendance at pharmacy and appointments,

c)Achievement of care plan goals.

d)No criminal activity,

e)No other users in household,

f)No evidence of injecting and / or high-risk poly drug use through self-reporting, physical examination and/or testing.

Exclusion criteria: Continue supervised consumption if:

  • Patients demonstrate continued drug misuse outside their care plan.
  • Patients have a significant unstable psychiatric illness.
  • There is concern that the prescribed drug is being diverted or used inappropriately.
  • There are child protection issues.

During the initial titration of a methadone or buprenorphine prescription it is vital that post contact arrangements are in place to assess the patient. This will allow the assessor to determine:

  • Whether the dose is adequate using an appropriate withdrawal symptoms assessment tool.
  • Whether the dose is too high.

Managing “on top” use

  • Try to ascertain whether use is indeed in addition to the prescription. Sometimes the prescription is traded for street drugs. Reconsider daily supervised consumption.
  • Clarify the treatment aims and dosing strategy with the patient. Those who are clearly motivated to cease on top use or who report heroin use to manage withdrawal symptoms may benefit from higher dose regimes. Weigh potential benefit of higher doses against additional risk.
  • Refer clients on 100mg methadone but still unstable, or using on top, to secondary care for review and probable subsequent treatment.
  • Alcohol misuse contributes to overdose risk and enhances the respiratory depressant effects of heroin. In the face of alcohol misuse weigh risks versus benefits and only continue prescribing together with interventions targeted at alcohol.
  • Benzodiazepine use is linked to poorer treatment outcomes and overdose risk. Benzodiazepines and allied hypnotics should be prescribed with caution including, when necessary, daily dispensing. Treatment will usually be short-term.

Holiday Prescription Guidelines (Summary)

  • The patient should give at least 7 days notice if a holiday prescription is required for UK travel and 14 days for international travel.
  • A bulk prescription should not usually exceed two weeks’ supply because safe prescribing demands regular contact with patients. Large volume prescribing should be subject to a risk assessment.Establish safe storage in transit and at the destination.
  • In UK, where possible continue current arrangements by using a suitable pharmacy at the holiday location. Contact the local DAAT ( to find a pharmacy.
  • Export licences are required for some quantities of certain drugs.
  • Some countries prohibit importation of certain drugs. The patient should check with the appropriate consulate (contact details at
  • Give a letter of authority detailing the medication the patient is carrying.

If a patient leaves the country for more than the period covered by theirprescription, they need reassessment and drug screening on their return, prior to the initiation of a new prescription.

Recording cancelled prescriptions

When a prescription already issued to a pharmacy needs to be changed:

  • The care co-ordinator phones the pharmacy with details of the prescription to be cancelled. It should be made clear whether the new prescription supplements an existing prescription, or replaces it (e.g. if a patient is receiving 8mg buprenorphine, and a new prescription is issued for 4mg, is that an increase to 12mg or a reduction to 4mg?)
  • The cancellation of any prescription and any replacement is recorded in the client’s prescription record

The care co-ordinator is responsible for informing the prescriber about any prescriptions that are suspended or cancelled. This includes when patients are admitted to hospital.

Discontinuation of prescription

When there is a disagreement between a patient and the team over prescribing issues, aim to negotiate a new treatment agreement whenever possible. If agreement cannot be reached, a unilateral decision to reduce or stop a prescription may result. Reasons for this might be:

  • Compromised safety, either of the patient or others. This risk can usually be addressed by a return to supervised consumption.
  • On top use of alcohol or illicit drugs at a level which, when combined with a regular prescription, puts them at risk of dangerous side effects.

The discontinuation of substitute prescribing is a serious matter. The following steps should be undertaken:

  • The care co-ordinator will discuss the team view with the patient. It may be appropriate to do this together with the prescriber. If the patient does not attend appointments, this may have to be done by phone or by letter.
  • If a patient does not attend two consecutive appointments, they are informed by letter that if they do not attend a third appointment they may be discharged from the service.

All decisions to end prescribing should be communicated to the service user’s GP where they are not the prescriber and the dispensing pharmacy.

Methadone Prescribing Policy (Summary)

  • Methadone maintenance is most effective at a daily dose of 60-120mg.
  • Prescribe methadone as the standard 1mg/1ml dose. Sugar free formulations and tablets have a greater potential for injection, and are more expensive.
  • Start substitute prescribing with methadone at20-30mg a day depending on initial assessment and tolerance and titrate the dose in 10mg increments (not exceeding 30mg in a week) until withdrawal symptoms are controlled; start low and go slow.Steady state plasma levels are reached about 5 days following the last dose increase.
  • Deaths have occurred following doses as low as 20mg.
  • Prescribe supervised consumption for a minimum of 12 weeks.
  • Methadone has a clinically significant interaction with benzodiazepines and alcohol. Reassess patients who continue to misuse these drugs.
  • Discuss decisions to prescribe over 100mg daily in patients who are still unstable with a Consultant in case a move to secondary care is indicated.
  • The higher the dose the more important it is that the patient is tightly interval dispensed. For example a patient on 100mg or more should never pick-up once a week, and equally patients should never, or very rarely, have more than 1000mg in their possession at any one time (e.g. for a holiday prescription).
  • Methadone use may be a risk factor for developing torsades de pointes / QT prolongation. Monitoring (ECG) is recommended in doses above 100mg daily or where there are other risk factors for QT prolongation including:

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  • heart disease
  • liver disease
  • electrolyte imbalances
  • pimozide
  • erythromycin
  • clarithromycin
  • quinidine
  • amiodarone
  • chloroquine
  • mefloquine
  • clozapine
  • lithium
  • risperidone

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  • Methadone maintenance therapy has the most cumulated evidence as safe to use in pregnancy and breast-feeding.
  • Injectable methadone should only be initiated by a Consultant.

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