TITLE 16 OCCUPATIONAL
AND PROFESSIONAL LICENSING
CHAPTER 12 NURSING
AND HEALTH CARE RELATED PROVIDERS
PART 9 MANAGEMENT
OF CHRONIC PAIN WITH CONTROLLED SUBSTANCES
16.12.9.1 ISSUING AGENCY: New Mexico Board of
Nursing.
[16.12.9.1
NMAC - N, 2/17/2006]
16.12.9.2 SCOPE: This rule applies to all
advanced practice nurses, including certified nurse practitioners, certified
registered nurse anesthetists, and clinical nurse specialists with prescriptive
authority.
[16.12.9.2
NMAC - N, 2/17/2006; A, 11/20/2012]
16.12.9.3 STATUTORY AUTHORITY: Section 61-3-1
NMSA 1978 et seq., authorized the
board of nursing to regulate the practice of nursing in the state and the Pain
Relief Act, Subsections D of Sections 24-2-1 through 24-2-6 NMSA 1978.
[16.12.9.3
NMAC - N, 2/17/2006, A, 11/20/2012]
16.12.9.4 DURATION: Permanent
[16.12.9.4
NMAC - N, 2/17/2006]
16.12.9.5 EFFECTIVE DATE: February 17, 2006,
unless a later date is cited at the end of a section.
[16.12.9.5
NMAC - N, 2/17/2006]
16.12.9.6 OBJECTIVE: It is the position of the
board that certified nurse practitioners, certified registered nurse
anesthetists and clinical nurse specialists with prescriptive authority have an
obligation to treat chronic pain and that a wide variety of medicines including
controlled substances and other drugs may be prescribed after a thorough evaluation
has been completed.
[16.12.9.6
NMAC - N, 2/17/2006; A, 11/20/2012]
16.12.9.7 DEFINITIONS:
A. “Acute Pain” means the normal,
predicted physiological response to a noxious chemical or thermal or mechanical
stimulus, typically associated with invasive procedures, trauma or disease and
generally time limited.
B. “Addiction” is a neurobehavioral
syndrome with genetic and environmental influences that results in
psychological dependence on the use of substances for their psychic
effects. It is characterized by
behaviors that include one or more of the following: impaired control over drug
use; compulsive use; continued use despite harm; and craving. Physical dependence and tolerance are normal
physiological consequences of extended opioid therapy for pain and should not
by themselves be considered addiction.
C. “Chronic pain” means pain that persists
after reasonable efforts have been made to relieve the pain or its cause and that
continues, either continuously or episodically, for longer than three
consecutive months. “Chronic pain” does
not, for the purpose of the Pain Relief Act requirements, include pain
associated with a terminal condition or with a progressive disease that, in the
normal course of progression, may reasonably be expected to result in a
terminal condition.
D. “Clinical expert” means a person who,
by reason of specialized education or substantial relevant experience in pain
management, has knowledge regarding current standards, practices and
guidelines.
E. “Drug abuser” means a person who takes
a drug or drugs for other than legitimate medical purposes.
F. “Nursing Facility” means a long term
care facility in which the patient is a current fulltime resident and whose
medications are solely administered and managed by the facility.
G. “Pain” means an unpleasant sensory and
emotional experience associated with inflammation or with actual or potential
tissue damage, or described in terms of such inflammation and damage, which
could include acute, persistent or chronic pain.
H. “Physical dependence” means a state of
adaptation that is manifested by a drug-specific withdrawal syndrome that can
be produced by abrupt cessation, rapid dose reduction, decreasing blood level
of the drug, administration of an antagonist, or a combination of these.
I. “Prescription monitoring program (PMP)”
means a centralized system to collect, monitor, and analyze electronically, for
controlled substances, prescribing and dispensing data submitted by pharmacies
and dispensing practitioners. The data are used to support efforts in
education, research, enforcement and abuse prevention.
J. “Therapeutic purpose” means the use of
pharmaceutical and non-pharmaceutical treatments and the spectrum of available
modalities that conforms substantially to accepted guidelines for pain
management.
K. “Tolerance” means a state of adaptation
in which exposure to a drug induces changes that result in a diminution of one
or more of the drug’s effects over time.
[16.12.9.7
NMAC - N, 2/17/2006; A, 11/20/2012; A, 9/12/2017]
16.12.9.8 RULES: The following rules shall be used
by the board to determine whether an advanced practice nurse’s prescriptive
practices are consistent with the appropriate treatment of pain.
A. The treatment of
pain with various medicines or controlled substances is a legitimate nursing
practice when accomplished in the usual course of professional practice. It does not preclude treatment of patients
with addiction, physical dependence or tolerance who have legitimate pain. However, such patients do require very close
monitoring and precise documentation.
B. Pain management
for patients should include a contractual agreement, the use of drug screens
prior to treatment with opiates and during the course of treatment to identify
actual drugs being consumed and to compare with patients self-reports. If concerns about misuse are identified, the
patient will be referred for appropriate consultation, and scheduled for
re-evaluation at appropriate time intervals.
C. The prescribing,
ordering, administering or dispensing of controlled substances to meet the
individual needs of the patient for management of chronic pain is appropriate
if prescribed, ordered, administered or dispensed in compliance with the
following.
(1) An
advanced practice nurse shall complete a history and physical examination and
include an evaluation of the patient’s psychological and pain status. The medical history shall include any
previous history of significant pain, past history of alternate treatments for
pain, potential for substances abuse, coexisting disease or medical conditions,
and the presence of a medical indication and supporting diagnostic
documentation or contra-indication against the use of controlled substances.
(2) An
advanced practice nurse shall be familiar with and employ screening tools, as
well as the spectrum of available modalities for therapeutic purposes, in the
evaluation and management of pain. They
shall consider an integrative approach to pain management specialists including
but not limited to an acupuncturist, chiropractor, doctor
of oriental medicine, exercise physiologist, massage therapist, pharmacist,
physical therapist, psychiatrist, psychologist or other advanced practice
registered nurse.
(3) A
written treatment plan shall be developed and tailored to the individual needs
of the patient, taking age, gender, culture, and ethnicity into consideration,
with stated objectives by which treatment can be evaluated, e.g. by degree of
pain relief, improved physical and psychological function, or other accepted
measure. Such a plan should include a statement of the need for further
testing, consultation, referral or use of other treatment modalities.
(4) If
the patient’s pain relief plateaus on controlled substance analgesic(s), then
the treatment plan should include an evaluation of continuing or tapering the
controlled substance therapy.
(5) The practitioner shall provide education and
discuss the risks and benefits of using controlled substances with the patient
or surrogate or guardian, and shall document this in the record.
(6) Complete
and accurate records of care provided and drugs prescribed shall be
maintained. When controlled substances
are prescribed, the name of the drug, quantity, and prescribed dosage should be
recorded. Prescriptions for opioids
shall include indications for use. For
chronic non-cancer pain patients treated with controlled substance analgesic(s),
the prescribing practitioner shall use a written agreement for treatment with
the patient outlining patient responsibilities.
As part of a written agreement, chronic non-cancer pain patients shall
receive all chronic pain management prescriptions from one practitioner and one
pharmacy whenever possible.
(7) The
management of patients needing chronic pain control requires monitoring by the
attending or the consulting practitioner.
The practitioner shall periodically review the course of treatment for
chronic non-cancer pain, the patient’s state of health, and any new information
about the etiology of the chronic non-cancer pain at least every three
months. In addition, a practitioner
should consult, when indicated by the patient’s condition, with health care
professionals who are experienced (by the length and type of their practice) in
the area of chronic pain control; such professionals need not be those who
specialize in pain control. Consultation
should occur early in the course of long-term treatment,
and at reasonable intervals during continued long-term treatment for assessment
of benefit and need. Drug screening is
expected and should be conducted when other factors suggest an elevated risk of
misuse or diversion.
(8) If,
in a practitioner’s opinion, a patient is seeking pain medication for reasons
that are not medically justified, the practitioner is not required to prescribe
controlled substances for the patient.
D. The board will
evaluate the quality of care on the following basis: appropriate diagnosis and
evaluation; appropriate medical indication for the treatment prescribed;
documented change or persistence of the recognized medical indication; and,
follow-up evaluation with appropriate continuity of care. The board will judge
the validity of prescribing based on the advanced practice nurse’s treatment of
the patient and on available documentation, rather than on the quantity and
chronicity of prescribing. The goal is
to control the patient’s pain for its duration while effectively addressing
other aspects of the patient’s functioning, including physical, psychological,
social, and work-related factors.
E. The board will
review both over-prescription and under-prescription of pain medications using
the same standard of patient protection as a guiding principle.
F. An advanced
practice nurse who appropriately prescribes controlled substances and who
follows this section would be considered to be in compliance with this rule and
not be subject to discipline by the board, unless there is some violation of
the Nursing Practice Act, board rules and Pain Relief Act (24-2 D, 1 to 24-2 D,
6 NMSA 1978).
[16.12.9.8
NMAC - N, 2/17/2006, A, 11/20/2012; A, 9/12/2017]
16.12.9.9 PRESCRIPTION
MONITORING PROGRAM (PMP) REQUIREMENTS: The intent of the New Mexico board of nursing
in requiring participation in the PMP is to assist advanced practice nurses in balancing the safe use of
controlled substances with the need to impede harmful and illegal activities involving these
pharmaceuticals.
A. Any advanced
practice nurse who holds a federal drug enforcement administration registration
and a New Mexico controlled substance registration shall register with the
board of pharmacy to become a regular participant in PMP inquiry and reporting.
B. An advanced
practice nurse may authorize delegate(s) to access the prescription monitoring
report consistent with board of pharmacy regulation 16.19.29 NMAC. While an advanced practice nurse’s delegate
may obtain a report from the state’s prescription monitoring program, the
advanced practice nurse is solely responsible for reviewing the prescription
monitoring report and documenting the receipt and review of a report in the
patient’s medical record.
C. Before an
advanced practice nurse prescribes or dispenses for the first time, a
controlled substance in Schedule II, III, IV or V to a patient for a period
greater than four days, or if there is a gap in prescribing the controlled
substance for 30 days or more, the practitioner shall review a prescription
monitoring report for the patient for the preceding 12 months. When available, the practitioner shall review
similar reports from adjacent states.
The practitioner shall document the receipt and review of such reports
in the patient’s medical record.
D. A prescription
monitoring report shall be reviewed a minimum of once every three months during
the continuous use of a controlled substance in schedule II, III, IV or V for
each patient. The practitioner shall
document the review of these reports in the patient’s medical record. Nothing in this section shall be construed as
preventing an advanced practice nurse from reviewing prescription monitoring
reports with greater frequency than that required by this section.
E. An
advanced practice nurse does not have to obtain and review a prescription
monitoring report before prescribing, ordering, or dispensing a controlled
substance in schedule II, III, IV or V:
(1) for a period of four days or less; or
(2) to a patient in a nursing facility; or
(3) to a patient in hospice care.
F. Upon
review of a prescription monitoring report for a patient, the advanced practice
nurse shall identify and be aware of a patient currently:
(1) receiving opioids from multiple prescribers;
(2) receiving opioids and benzodiazepines concurrently;
(3) receiving opioids for more than 12 consecutive weeks;
(4) receiving more than one controlled substance analgesic;
(5) receiving opioids totaling more than 90 morphine milligram
equivalents per day;
(6) exhibiting potential for abuse or misuse of opioids and
other controlled substances, such as over-utilization, requests to fill early,
requests for specific opioids, requests to pay cash when insurance is
available, receiving opioids from multiple pharmacies.
G. Upon
recognizing any of the above conditions described in paragraph F, the
practitioner, using professional judgement based on prevailing standards of
practice, shall take action as appropriate to prevent, mitigate, or resolve any
potential problems or risks that may result in opioid misuse, abuse, or
overdose. These steps may involve
counseling the patient on known risks and realistic benefits of opioid therapy,
prescription and training for naloxone, consultation with or referral to a pain
management specialist, or offering or arranging treatment for opioid or
substance use disorder. The practitioner
shall document actions taken to prevent, mitigate, or resolve the potential
problems or risks.
H. Practitioners
licensed to practice in an opioid treatment program, as defined in 7.32.8 NMAC,
shall review a prescription monitoring report upon a patient’s initial
enrollment into the opioid treatment program and every three months thereafter
while prescribing, ordering, administering, or dispensing opioid treatment
medications in schedule II, III, IV or V for the purpose of treating opioid use
disorder. The practitioner shall
document the receipt and review of a report in the patient’s medical record.
[16.12.9.9
NMAC - N, 11/20/2012; A, 9/12/2017]
16.12.9.10 NON-CANCER
PAIN MANAGEMENT CONTINUING EDUCATION: Any advanced
practice registered nurse (APRN) with a drug enforcement agency (DEA) registration and licensure that
permits prescribing opioids, shall obtain continuing education on the
management of non-cancer pain. These practitioners shall be required to
obtain five contact hours every renewal period to include a review of these
rules 16.12.9 NMAC for management of non-cancer pain, an understanding of the
pharmacology and risks of controlled substances, a basic awareness of the
problems of abuse, addiction and diversion, and awareness of state and federal
regulations for the prescription of controlled substances.
[16.12.9.10
NMAC - N, 11/20/2012; A, 9/12/2017; A, 5/3/2018]
16.12.9.11 NOTIFICATION:
The board shall
notify the following persons of the Pain Relief Act and Part 9 of the New
Mexico nursing board rule: 16.12.9 NMAC. The board shall notify the following persons
of the Pain Relief Act and rules:
(1) health care providers under its jurisdiction; and
(2) a health care provider being investigated by the board in
relation to the provider’s pain management services.
[16.12.9.11
NMAC - N, 11/20/2012]
16.12.9.12 ADVANCED
PRACTICE NURSES, REGISTERED NURSES, AND LICENSED PRACTICAL NURSES TREATED WITH
OPIATES: Advanced practice nurses, registered nurses,
licensed practical nurses, certified hemodialysis technicians, and certified
medication aides who have chronic pain and are being treated with opiates shall
be evaluated by a pain clinic or, by a physician, CRNA, CNP, CNS pain
specialist and must have clearance from their practitioner, before returning to
or continuing in practice and must remain under the care of a physician, CRNA,
CNP or CNS for as long as they remain on opiates and continue to practice. The treating physician, CRNA, CNP or CNS may,
at her or his discretion, order a neuropsychological evaluation to help
determine clearance for practice.
[16.12.9.12
NMAC - Rn & A, 16.12.9.9 NMAC; 11/20/2012; A, 01/19/2015]
HISTORY OF 16.12.9 NMAC: [RESERVED]