New Mexico Nurse Practitioner Council Annual Conference Friday, April 12, 2013 Santa Fe, New Mexico Management of Chronic Pain with Controlled Substances Nancy Darbro, PhD, APRN,CNS New Mexico Board of Nursing Executive Director 1
The Precipitating Problem • Since 2003, opioid medication typically used for pain management accounted for 80-90% of prescription medication overdose deaths in New Mexico. • New Mexico ranked #1 in overdose deaths • Prescriptions for Schedule II-IV controlled substances are increasing, recently, in a two year period, 57% were opioids. The Prescription Solution • 2010, DOH & UNM convened an Overdose Task Force to address the problem. • 2011, House Memorial 77 directed DOH to lead a Prescription Drug Abuse and Overdose Task Force to address the rising rate of abuse, addiction and unintentional overdose deaths due to prescription drugs 2
The Prescription Solution • Task Force: UNMH Science Center; UNM Poison Information Center, OMI, Health Care licensing boards, including BON, BOME, DEA, Behavioral Planning Council and experts in pain management. • Task Force met for two years & made recommendations to reduce deaths due to misuse/abuse of prescriptions. The Prescription Solution • Task Force discussed numerous strategies and options. • Task Force made recommendations to reduce problem of overdose deaths due to the misuse and abuse of prescriptions. • 2012 Legislature passed SB215. 3
SB 215- Passed by legislature in 2012 • An act relating to pain management: amending the Pain Relief Act; Change the name and composition of the Pain Management Advisory Council; requiring continuing education for non-cancer pain management. • Requiring regulatory agencies to amend rules to comply with requirements. 2012 NM Board of Nursing convened subcommittee • Review and revise 16.12.9.11 “ Management of Chronic Pain with Controlled Substances ” . • Final rules revisions heard and approved by Board of Nursing October 19, 2012. • Current rules in effect since November 21, 2012. 4
Management of Chronic Pain with Controlled Substances Added definitions: Acute Pain: normal, physiological response to painful stimulus, and time limited. Chronic Pain: Pain that persists after reasonable efforts to relieve the pain and that continues for longer than 3 months. Management of Chronic Pain with Controlled Substances Added definitions: Clinical Expert: person with specialized education or experience in pain management. Prescription Monitoring program (PMP): system to collect, monitor and analyze controlled substance prescribing and dispensing. 5
Management of Chronic Pain with Controlled Substances Added definitions: Therapeutic purpose: Spectrum of pharmaceutical and non-pharmaceutical treatments and modalities that conforms substantially to accepted guidelines for pain management. Patients with Substance Use Disorders, 16.12.9.8 Rules to be used to determine whether a practitioners prescriptive practices are consistent with appropriate treatment of pain. 1. contractual agreement. 2. use of drug screens prior to and during course of treatment. 6
Patients with Substance Use Disorders 3. Drug screens used to determine actual drugs being consumed and to compare with patients self reports. 4. If concerns about misuse are found, refer patient for consultation and re- evaluation at appropriate time intervals. Additional Rules 16.12.9.8 (C) 1. Practitioners shall complete a history and physical examination and include an evaluation of patients psychological and pain status. 7
Screening Tools in Evaluation and Management of Pain 1. Practitioners shall employ screening tools. 2. Shall be familiar with the spectrum of modalities for therapeutic purposes. 3. Shall consider an integrative approach, ie, acupuncturist, chiropractor, DOM, exercise physiologist, massage or physical therapist, pharmacist, psychiatrist, psychologist or other APRN. Additional rules: 16.12.9.8 • Practitioners shall provide education and discuss the risks and benefits of using controlled substances and shall document this in the record. 8
Additional rules: Record Keeping 16.12.9.8 (5) • Prescriptions for opioids shall include indications for use. • When prescribing opioids for non cancer pain, practitioners shall use a written agreement outlining patient responsibilities. • Patient responsibilities include using one practitioner, one pharmacy when possible. Additional Rules 16.12.9.8 (6) • Management of patients needing chronic pain control requires monitoring by the attending or consulting practitioner. 9
Additional Rules 16.12.9.8 (6) • Practitioners shall periodically review the course of treatment for chronic non cancer pain, the patient ’ s state of health, and any new information obtained about etiology of chronic pain at least every six months. Additional Rules 16.12.9.8 (6) • Practitioners should consult when indicated with other health care professionals experienced in the area of chronic pain control. • Consultation should occur early in the course of treatment and at reasonable intervals during continued long term treatment for assessment of benefit and need, at lease every six months. 10
Additional Rules 16.12.9.8 (6) • Drug screening is recommended and should be conducted when factors indicate an elevated risk of misuse or diversion. Additional Rules 16.12.9.9 PMP Requirements • The intent in requiring participation in the PMP is to assist practitioners in balancing the promotion of the safe use of controlled substances for the provision of nursing care and services with the need to impede illegal and harmful activities involving these pharmaceuticals. 11
Additional Rules 16.12.9.9 PMP Requirements • Practitioners with DEA registration and licensure to prescribe opioids: • 1. shall register with the BOP. • 2. shall become a regular participant in the PMP inquiry and reporting. Additional Rules 16.12.9.9 PMP Requirements • Upon prescribing, ordering administering or dispensing a controlled substance a practitioner shall obtain and review a PMP report covering at least one year and shall be aware of a person currently: • 1. receiving opiates from multiple prescribers. 12
Additional Rules 16.12.9.9 PMP Requirements • 2. receiving opiates for more than 12 consecutive weeks. • 3. receiving more than one controlled substance analgesic. • 4. receiving a new prescription for any long acting substance analgesic, including oral and transdermal (fentanyl) or methadone. Additional Rules 16.12.9.9 PMP Requirements • 5. exhibiting potential for abuse or misuse of opiates (ie over-utilization, early refills, appears overly sedated or intoxicated, is an unfamiliar patient requesting an opiate by specific name, street name, color or identifying marks, or paying cash when the patient has insurance). 13
Additional Rules 16.12.9.9 PMP Requirements • Upon recognizing the above risk factors, the practitioner shall take appropriate steps to resolve the potential problem: • 1.Request & review additional PMP reports • 2.Consult with pain management or addiction treatment specialist, or counseling the patient, to include termination. Additional Rules 16.12.9.9 PMP Requirements • 3.Practitioners shall document steps taken to resolve the potential problem. • Practitioners shall use professional judgment based on prevailing standards of treatment • PMP reports shall be requested and reviewed a minimum of every six months during the continuous use of opioids for each patient. 14
Additional Rules 16.12.9.9 PMP Requirements • After obtaining an initial PMP report on a patient, the practitioner shall use professional judgment based on prevailing standards in deciding the frequency of PMP reports. • PMP reports shall be requested and reviewed a minimum of every six months during the continuous use of opioids for each patient. • Practitioners shall document the review of these reports. Additional Rules 16.12.9.10 CE Requirements • Health care providers with a DEA registration and licensure to prescribe opioids shall obtain CE on the management of non cancer pain. • Shall obtain 5 CE of the currently required 15 CE in pharmacology in the management of non cancer or chronic pain. 15
Additional Rules 16.12.9.10 CE Requirements • CE includes a review of these rules for management of non cancer pain. • An understanding of the pharmacology and risks of controlled substances. • Awareness of the problems of abuse, addiction and diversion. • Awareness of state and federal regulations for prescription of controlled substances. Additional Rules 16.12.9.11 Pain Relief Act • Boards shall notify the following persons of the Pain Relief Act and 16.12.9 rules: • 1. Health care providers under its jurisdiction. • 2. A health care provider being investigated by the board in relation to the providers ’ pain management services. 16
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