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Application for a permit to treat a patient with Schedule 8 drugs

This is an application for a permit to administer, supply or prescribe Schedule 8 poison(s) (other than treatment of an opioid dependent person with methadone or buprenorphine) under regulation 11(1) of the Drugs, Poisons and Controlled Substances Regulations 2017/section 34A of the Drugs, Poisons and Controlled Substances Act 1981.If you are intending to apply for a permit to treat an opioid dependent person with methadone liquid or buprenorphine sublingual or buprenorphine long-acting injection (LAIB) for opioid dependence, please complete the Application for a permit to treat an opioid dependent person with methadone or buprenorphine.
•You are reminded that you must take all reasonable steps to check SafeScript prior to prescribing monitored medicines.
•For help using SafeScript please download the FAQ document Using SafeScript - most commonly asked questions for prescribers.
•For general information about SafeScript please visit SafeScript information for prescribers.
•For information about Schedule 8 treatment permits and requirements in Victoria please visit Schedule 8 treatment permits - requirements in Victoria.
Fields marked with * are required
Schedule 8 permit exceptions for patients who are NOT drug-dependent
Please note Schedule 8 permits are no longer required if the patient is NOT drug-dependent and one of the scenarios below are applicable:

Opioid analgesics

•For the treatment of medical conditions where an opioid analgesic is required, provided the total daily dose of the following opioid(s) does not exceed 100mg in morphine equivalent dose (MED): ◦HYDROMORPHONE oral, max. dose 20mg daily ◦MORPHINE oral, max. dose 100mg daily ◦OXYCODONE oral or suppository, max. dose 65mg daily◦TAPENTADOL oral, max. dose 300mg daily◦BUPRENORPHINE patch, max. dose 40mcg/hr weekly◦FENTANYL patch, max. dose 25mcg/hr every three days
An Opioid Calculator is available to help you calculate your patient's total morphine equivalent dosage (MED)
•Opioid analgesic in the treatment of pain caused by cancer or complication arising from cancer; and the diagnosis of pain caused by cancer or complications arising from cancer is made by a registered medical practitioner.

Psychostimulants

•Paediatricians treating a patient less than 18 years old with a psychostimulant drug approved by the Therapeutic Goods Administration for the treatment of attention deficit hyperactivity disorder. • Consultant psychiatrists treating a patient with a psychostimulant drug approved by the Therapeutic Goods Administration for the treatment of attention deficit hyperactivity disorder.

Palliative care - for the intention of palliative care treatment where:

•the person to be administered, supplied or prescribed the Schedule 8 poison is suffering an incurable, progressive, far-advanced disease or medical condition; and •the prognosis is of limited life expectancy due to the disease or medical condition; and •the administration, supply or prescribing of the Schedule 8 poison is intended to provide palliative treatment.

Schedule 8 cannabis or Schedule 8 tetrahydrocannabinol for human therapeutic use

•the practitioner has obtained Commonwealth approval through the Special Access Scheme or Authorised prescriber scheme to administer, supply or prescribe Schedule 8 cannabis or Schedule 8 tetrahydrocannabinol for human therapeutic use for the patient; or •the practitioner is administering, supplying or prescribing Schedule 8 cannabis or Schedule 8 tetrahydrocannabinol for human therapeutic use that is included in the Australian Register of Therapeutic Goods.

If you still require a permit, including if you have reason to believe your patient is drug-dependent, please Continue to complete this application form. Otherwise, please CLOSE / EXIT this form if you do not need a permit.

Purpose of Application

Application for a permit to treat a patient with Schedule 8 drugs
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Choose the option for your patient

Drug-dependent patientFor circumstances that might (or should) be a reason to believe that a patient is a drug-dependent person, please visit: Drugs of dependence and drug-dependent persons Please indicate your reason(s) to believe that this patient is a drug-dependent person * (select all that apply):
* For further information regarding the diagnostic criteria of drug dependence, please refer to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) and the International Classification of Diseases 11th Revision (ICD-11).

A Schedule 8 permit is not required. For more information, please visit Schedule 8 treatment permits - requirements in Victoria.Please CLOSE / EXIT the application form.

A Schedule 8 permit is not required. For more information, please visit Schedule 8 treatment permits - requirements in Victoria.An Opioid Calculator is available to help you calculate your patient's total morphine equivalent dosage (MED).Please CLOSE / EXIT the application form.

Registered Medical Practitioner / Nurse Practitioner Details

Application for a permit to treat a patient with Schedule 8 drugs
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Your Details (Prescriber Details)

Patient Details

Application for a permit to treat a patient with Schedule 8 drugs
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Patient Details

Treatment Details

Application for a permit to treat a patient with Schedule 8 drugs
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Patient Treatment Details

Medicinal Cannabis Product
Do you have additional documentation to support your application?

Supporting documentation

Please attach your supporting documentation here
File:
Drug and dosage details * Please apply for all Schedule 8 medicines you intend to prescribe for the patient's diagnosis of
Name of drug
Dose form
Expected max. dose
Unit
Frequency
Applying for an opioid?Please note that evidence-based practice guidelines recommend that specialist advice should be sought for patients requiring opioid doses exceeding oral morphine 100 mg daily, oxycodone 65 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 100 mg daily in morphine equivalents.

Do you have any recent specialist report or additional information to support your application?

Supporting documentation

Please attach your supporting documentation here
File:
Please note you may be requested to supply specialist report or additional information to support your application.

Declaration

Application for a permit to treat a patient with Schedule 8 drugs
Fields marked with * are required

Schedule 8 permit NOT required

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Declaration

This application forms part of a legal document and penalties exist for providing false or misleading information.

I, confirm the information I provided in this application is true and complete to the best of my knowledge

Privacy Collection Notice

By completing this form, you acknowledge that you are providing the personal and health information as required under the Drugs, Poisons and Controlled Substances Act 1981 (the Act) to the Department of Health, Victoria (the Department) for the purpose of applying to, or notifying, the Department in relation to a Schedule 8 treatment permit.The information is handled by the Department in accordance with the requirements of the Act, Drugs, Poisons and Controlled Substances Regulations 2017 (Vic), Privacy and Data Protection Act 2014 (Vic), Health Records Act 2001 (Vic) and the Department’s privacy policy.The information collected by the Department:

•will be used and disclosed for the purposes of assessing the permit application or meeting notification requirements; •will be used and disclosed for monitoring and compliance purposes; •may be disclosed to other relevant health practitioners when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs; and •may be disclosed for any other purposes permitted by law including but not limited to reporting or investigation of suspected unlawful activity to: ◦regulatory and law enforcement agencies in the Commonwealth, States and Territories; and ◦Ahpra.By submitting this form, health practitioners confirm that the patient:

•is aware of the contents of this collection notice; and •has consented to the form being submitted.If you do not provide all the required information, the application may not be processed. You can download a PDF copy of the completed form or request a confirmation email at the Submission Complete page. For further information about Victorian Drugs and Poisons legislation, please visit www.health.vic.gov.au/dpcs.For further information on privacy and how to access and seek correction of personal information about you held by the Department, visit www.health.vic.gov.au/privacy.


A Schedule 8 permit is not required. For more information, please visit Schedule 8 treatment permits - requirements in Victoria.Please CLOSE / EXIT the application form.

A Schedule 8 permit is not required. For more information, please visit Schedule 8 treatment permits - requirements in Victoria.An Opioid Calculator is available to help you calculate your patient's total morphine equivalent dosage (MED).Please CLOSE / EXIT the application form.

Remember Me

Pre-fill feature available Simply tick the “Remember Me” checkbox below and this will save your details, enabling you to use these again next time, saving you time. Note: the “Remember Me” function is browser and computer-specific.If you use one computer the first time and then a different computer the next time you submit information, the previously saved details using "Remember Me" tick box will not be available. The same applies if you use the Google Chrome browser initially to complete the form, and then use Microsoft Edge browser to complete it (previous Internet Explorer), you won't be able to access the saved prescriber details.We therefore advise that you use the same computer and same web browser each time when completing the forms online.
By unticking the checkbox below the Prescriber Details that have been saved on this computer will be removed.
Prescriber Details prefilled
Department of Health (VIC) - Regulatory Services