Department of Health and Vanderbilt University

Chronic Pain Guidelines SymposiumElizabeth Lund, Executive Director, Board of Nursing

Linda Johnson, APN Consultant/Over Prescribing Team

Objectives

Compare the prescribing requirements for APNs and PAs

Understand CSMD registration

List five prescribing guidelines for the treatment of chronic pain

Explain the consequences of overprescribing

Board Requirements

APNs with a Certificate of Fitness

Physician Assistants

Protocols regarding prescribing required between APN and supervising physician on file at practice site

Protocols to provide selected medical/surgical services between PA and designated primary supervisor on file at practice site

Notice and Formulary filed with BON

PA Supervising Physician Form (attachments 4 & 5) filed with COPA

Change in supervisor or formulary must be within 30 days

Change in designated primary supervisor within 15 calendar days; other changes within 30

http://tn.gov/health/article/nursing-application

http://www.state.tn.us/sos/rules/0880/0880.htm

Supervision Requirements

Protocols on site Chart Review

100% for controlled drugs

20% of all charts Ensure chart review

done If review not done,

consider another supervisor

Number of APNs & PAs with authority to prescribe

Only APNs with a Certificate of Fitness to prescribe are eligible to be issued a DEA number

APN = 9842 PA = 1769

APN Prescribing Authority by Role

NP CRNA CNS NM TOTAL

Authority to Prescribe

8,419 1,132 121 170 9,842

No Authority to Prescribe

52 1,369 19 7 1,447

Total 8,471 2,501 140 177 11,289

New to prescribing controlled substances?

Remember

30You MUST register in CSMD within 30 days of obtaining a DEA

http://tn.gov/health/article/CSMD-faq

But I only prescribe controls a few times a year…

“If you provide direct care and prescribe controlled substances to patients in Tennessee

for more than 15 days per year or you are a dispenser in practice providing direct care to patients in Tennessee for more than 15 days

per year, you are required to register with the CSMD.”

Public Chapter 898

Requires PAs & APNs with a certificate of fitness and their extenders to identify the supervising provider in the CSMD by entering the provider’s

driver's license number

CSMD Registration

Registration cannot be completed until a supervisory relationship is entered

For each work location, enter “Supervisor’s Driver License Number” and click “Add”

Check appropriate Work LocationClick Add Selected Supervisor

Save

Entered but not confirmed

Supervisor Review Pending

Supervisory Relationship Pending

Contact your supervising physician to inform that additional action in

the CSMD is needed

For Those Registered In CSMD

Patient records cannot be accessed until a

supervisory relationship is entered and confirmed

for each practice location

CSMD Requires

Report change in supervising physician within

30 days

Tell Your Board Too!

Updating CSMD does not relieve your responsibility to notify the licensing board of change(s) in supervising physician

APN 30 days

PA 15 days primary

supervisor 30 days for all

other reportable changes

Public Chapter 396

Requires CSMD to identify the top fifty (50) prescribers of controlled substances and

Send a letter through registered mail to the prescriber and to the physician supervisor

Comparison of Top 50 to Prescribers with DEA

Based on DEA data as of 7/31/2015 Based on CSMD for calendar year 2014

66%

10%

24%

2015 Top 50 Prescribers

22%

5%

71%3%

DEA Registrants

APN PA

Practitioners (MD, DO, Podiatrist, Veterinarians, Ophthalmologist, Dentist) Optometrist

APN Prescriber with Two Supervisors

APN Smith supervised by Dr. Doe at Retail Clinic (no controlled substances prescribed) and

Dr. Deer at Pain Clinic (controlled substances prescribed)

File Notice and Formulary with BON, include both Drs. Doe & Deer

Enter Dr. Deer as supervisor in CSMD

Enter Dr. Deer’s d.l. #

Supervisory relationship in CSMD approved by Dr. Deer

PA Changes Supervisor

PA Paddington’s primary supervising physician Dr. Bird retires and is replaced by Dr. Bear

Paddington prescribes controlled substances at the Bear Orthopedic Clinic

PA Paddington notifies the PA Committee by letter of the change in primary supervisory physician (15 days)

PA Paddington deletes retired Dr. Bird on CSMD, enters Dr. Bear and Bear’s d.l. #.

Dr. Bear approves PA Paddington

Who’s responsible for the PA Supervisory Physician Form?By law: YOU ARE!

A physician assistant to whom the authority to prescribe legend drugs and controlled substances has been delegated by the supervising physician shall file a notice with the committee containing the name of the physician assistant, the name of the licensed physician having supervision, control and responsibility for prescriptive services rendered by the physician assistant and a copy of the formulary describing the categories of legend drugs and controlled substances to be prescribed and/or issued, by the physician assistant. The physician assistant shall be responsible for updating this information;

T.C.A. § 63-19-107(2)(B)

PA/APN Your Formulary MATTERS

THOU SHALL NOT prescribe Schedules II, Ill and IV controlled substances unless such prescription is specifically authorized

by the formulary or expressly approved after consultation with the supervising physician before the initial issuance of

the prescription or dispensing of the medication;

Schedule II and III Opioids

1 supply

Schedule II or III opioids listed on the formulary shall only be prescribed for a maximum of a non-refillable, thirty-day course of treatment, unless specifically approved after consultation with the supervising physician before the initial issuance of the prescription or dispensing of the medication.

EVERY Renewal

Minimum 2 continuing

education hours

on controlled substances prescribing including Tennessee Chronic Pain Guidelines every biennial period.

Prior to Initiating Opioid Therapy

Think about…

Tennessee Chronic Pain

Guidelines

Just Because Someone Else Decided To Prescribe Opioids, Does Not Mean You Should

A patient having been prescribed opioids by a previous provider is not, in and of itself, a reason to continue opioids.

Pregnancy Is Special

All newly pregnant women should have a urine drug test administered by the

appropriate women’s health provider.

Are Opioids really necessary?

If yes, DOCUMENT!

The patient's medical history

Physical examination

Laboratory tests

Imaging results

Electro-physiologic testing

Other elements supporting the plan of care should be documented in the medical record prior to initiating opioid therapy

Not for Chronic PainWrong Reason

Methadone/Buprenorphine

Benzos and Opioids don’t mixBenzodiazepines should be generally avoided in combination with chronic opioid therapy. When the opioid dose reaches

120mg MEDD and the benzodiazepines are being

used for mental health purposes, the provider shall REFER to a mental health professional to assess necessity of benzodiazepine medication.

If An Opioid Is Prescribed:

Go with lowest dose

When to refer a patient to a Pain Management Specialist?

Refer

If you are not practicing as a pain specialist

refer above 120 MEDD

equals

Disciplined License Scenario

Practiced in pain clinic 2 years. “Trained” by the medical director regarding treatment of chronic pain.

Questioned the dosage of prescriptions for certain patients but continued to prescribe.

Not allowed to renew RN license or APN certificate, assessed costs of case

Board ActionsOverprescribing Cases

n= 98

48

30

5

5

9

BME/OsteoBONPAPharmOther

BME ActionOverprescribing

BME

31%

40%

16%

11%2%

MD/DO (n=48)

probation (n=14)reprimand (n=18)revoke (n=7)surrender (n=5)suspend (n=1)

BON Action (APN)Overprescribing

19%

8%

27%

23%

12%

12%APN (n=30)

probation (n=5)reprimand (n=2)revoke (n=7)surrender (n=6)suspend (n=3)other(n=3)

Months licensed prior to violationn=24

0 5 10 15 20 25 300

20

40

60

80

100

120

# of APNs

46% violated within 20 months of licen-sure

April 2013 thru June 2015

Behind the Statistics: Louie Miceli

https://www.youtube.com/watch?v=UO4fje2mC_w&feature=player_embedded