PRESCRIBING CONTROL

DR MARK BURNS FROM THE MEDICAL PROTECTION SOCIETY (MPS) CONSIDERS PRESCRIBING RESTRICTIONS FOR MEDICAL OFFICERS OF SPECIALIST SCALE (MOSSS)

New Zealand has a shortage of vocationally registered doctors in several specialties, including psychiatry. Te Whatu Ora very frequently employs Medical Officers of Specialist Scale (MOSSs) in place of, or alongside, vocationally registered psychiatrists. These doctors are sometimes overseas-trained psychiatrists whose specialist qualification does not match that of the local college training in certain areas, and therefore the Medical Council of New Zealand considers they do not meet the requirements for a vocational scope of practice. At other times they are experienced local graduates who are no longer in training but have not yet completed their RANZCP training requirements and have not yet gained the postgraduate fellowship. Most MOSSs are ASMS members and covered by the MECA.

As they are often experienced clinicians, there can be uncertainty as to what restrictions might apply to them compared to someone who is vocationally registered. The Medical Protection Society (MPS) has recently assisted a number of psychiatry MOSSs who have had concerns raised regarding whether they should be prescribing and making Special Authority applications for certain medications.

The prescribing of stimulants has attracted media attention recently with a Health Practitioner Disciplinary Tribunal hearing against an Auckland GP with special interest in ADHD. Are there also restrictions on psychiatry MOSSs prescribing methylphenidate and dexamphetamine for ADHD and making applications for a Special Authority number? The short answer is yes, a MOSS requires written recommendation from a vocationally registered psychiatrist or paediatrician, as do all general registrants.

Methylphenidate is a controlled drug as per the Misuse of Drugs Act 1975. The gazetting notice1 describes that prescribing is restricted to “medical practitioners with a vocational scope of practice of paediatrics or psychiatry, registered with the Medical Council of New Zealand under the Health Practitioners Competence Assurance Act 2003”. However, the schedule further states “any other medical practitioner registered with the Medical Council of New Zealand … may only prescribe methylphenidate products when acting on the written recommendation of one of the vocational medical practitioners described above, for the conditions specified”. It is clear from this that a MOSS, who is not vocationally registered, can only prescribe methylphenidate for ADHD with a written recommendation of a vocationally registered psychiatrist/paediatrician.

Most commonly, psychiatry MOSSs work within a multi-disciplinary team, where there are discussions regarding management of patients that may include the presence of a suitably vocational registered psychiatrist/ paediatrician. Such discussions, however, do not fulfil these requirements, and MPS advises that there should be an explicit written statement from a vocationally registered psychiatrist/paediatrician recommending the prescription of methylphenidate or dexamphetamine. There are several ways this can be simply achieved; for example, by return email to the MOSS request or by documentation directly into the patient file.

Methylphenidate, in order to be funded, also requires a Special Authority number. The application form2 is not so clear that it must be by a vocationally registered psychiatrist/paediatrician, with the relevant excerpt stating “Applications only from a paediatrician, psychiatrist, medical practitioner on the recommendation of a paediatrician or psychiatrist (in writing) or…”. There is an absence of the explicit words ‘vocationally registered’ when referring to the psychiatrist. However, Pharmac has recently clarified for us that the special authority criteria for the stimulant medicines are intended to mirror the regulations as gazetted. The references to psychiatrist and paediatrician in the Special Authority application are to be interpreted as meaning those who are vocationally registered in those scopes of practice. Problems have arisen for MOSSs who log in to the Electronic Special Authority (ESA) system to fill out the form and apply for a Special Authority online. They are able to complete the form online and obtain automatic approval. Access to this system does not, however, reflect any sort of authority to make such an application. A MOSS making such an application still requires the written recommendation of a vocationally registered psychiatrist/paediatrician.

In addition to restrictions on prescribing stimulants, psychiatry MOSSs should be aware of restrictions on the prescribing of Clozapine. Although it’s not a controlled drug, Clozapine has prescribing restrictions under s23 of the Medicines Act 1981.3 Clozapine may only be prescribed by a medical practitioner who is vocationally registered or by one that is prescribing under the supervision of a vocationally registered psychiatrist, or if the patient’s illness is well-controlled by clozapine and the prescribing decision is taken in collaboration with the community mental health team. The latter provision covers the more recent years’ arrangements for stable patients on clozapine returning to primary care. However, these restrictions make clear that any titration of clozapine by a psychiatry MOSS needs to be under supervision of a vocationally registered psychiatrist.

Te Whatu Ora clinics need to ensure that they have appropriate processes in place to satisfy these requirements. MOSSs are at risk of prosecution under the Misuse of Drugs Regulations if they prescribe stimulants without the appropriate written recommendation or may be subject to disciplinary processes by the Medical Council. Vocationally registered psychiatrists may be in supervisory or leadership roles in Te Whatu Ora clinics that employ MOSSs and may be involved in orientation processes for these new-toNew Zealand practitioners. Such psychiatrists are also well advised to familiarise themselves with these prescribing restrictions.

1. HTTPS://GAZETTE.GOVT.NZ/NOTICE/ID/2015-GO760

2. HTTPS://SCHEDULE.PHARMAC.GOVT.NZ/

3. HTTPS://WWW.MEDSAFE.GOVT.NZ/PROFS/RISS/RESTRICT.ASP