Ministry of Health Issues Guidelines on the Prescription and Use of Buprenorphine (Subutex)

03 Nov 2005

The Ministry of Health, together with the National Workgroup on Opiate Dependence and Abuse, has developed a set of guidelines for doctors in a concerted effort to stem the illicit use or diversion of the drug, buprenorphine (Subutex). The guidelines lay out good clinical practices and administrative controls to ensure appropriate prescription by doctors.

MOH has also informed all doctors that they must comply with the following requirements if they wish to prescribe buprenorphine:

1. Each patient who is being treated for drug addiction will be cared for by a principal doctor to ensure proper care coordination and supervision. If the principal doctor is unable to provide care for the patient (e.g. because of overseas travel etc), he or she must assign a reserve doctor to continue looking after the patient.

2. All doctors who wish to treat opiate-dependent patients with opioid replacement therapy should ensure that they have the necessary training and resources (including manpower and time) to adequately counsel and manage his patient.

3. Each doctor who wishes to prescribe buprenorphine must attend an 8-hour training programme on opioids withdrawal and replacement therapy conducted by the Community Addictions Management Programme (CAMP) of the Institute of Mental Health. Guidelines on the treatment of opiate dependence would be given at the training programme. Doctors are expected to familiarize themselves with these guidelines and to comply with them.

4. All prescriptions of Subutex are to be logged into a central cross-reference checking system to prevent a patient going from doctor to doctor for multiple prescriptions. This Central Addiction Registry for Drugs, Singapore (CARDS) is an on-line registry which allows the central monitoring of all buprenorphine prescriptions to patients. Doctors will be given a user ID and password to access CARDS.

Buprenorphine has been shown to be effective in the treatment of individuals who are dependent on opiates (e.g. heroin). The controlled therapeutic administration of Subutex helps to reduce the use of illicit opiates in such individuals and helps to improve social functioning. However, there have been reports of patients injecting buprenorphine in order to experience the "high" that is associated with opiate use.

Intravenous use of buprenorphine may lead to medical complications such as blood-borne infections like hepatitis B and C, and limb gangrene. The mixture of buprenorphine with other depressants such as alcohol or benzodiazepines (e.g. Dormicum) may also result in death.

With these new requirements and guidelines, the Ministry hopes to reduce the potential for abuse and diversion of Subutex.

Any breach of these requirements and guidelines could be taken into account by the Singapore Medical Council when taking disciplinary action against medical practitioners who are found to be prescribing Subutex inappropriately. MOH has also reminded all doctors that under Regulation 19 of the Misuse of Drugs Regulations, a doctor who attends to a person who he considers or has reasonable grounds to suspect is a drug addict shall, within 7 days of the attendance, furnish details of the person to the Director of Medical Services (DMS) and the Director of the Central Narcotics Bureau (CNB).

Moving forward, MOH will explore with CNB to classify buprenorphine as a Controlled Drug under the Misuse of Drugs Act. This could serve as a deterrent for illicit suppliers of Subutex.