1. Department of Health and Vanderbilt University Chronic Pain Guidelines Symposium Elizabeth Lund, Executive Director, Board of Nursing Linda Johnson, APN Consultant/Over Prescribing Team

2. 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

3. 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/0880/08 80.htm

4. 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

5. 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

6. APN Prescribing Authority by Role NPCRNACNSNMTOTAL Authority to Prescribe 8,4191,1321211709,842 No Authority to Prescribe 521,3691971,447 Total8,4712,50114017711,289

7. New to prescribing controlled substances? Remember 30 You MUST register in CSMD within 30 days of obtaining a DEA http://tn.gov/health/article/CSMD-faq

8. 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.”

9. 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

10. CSMD Registration Registration cannot be completed until a supervisory relationship is entered

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

13. Check appropriate Work Location Click Add Selected Supervisor

14. Save

15. Entered but not confirmed

16. Supervisor Review Pending

17. Supervisory Relationship Pending Contact your supervising physician to inform that additional action in the CSMD is needed

18. For Those Registered In CSMD Patient records cannot be accessed until a supervisory relationship is entered and confirmed for each practice location

19. CSMD Requires Report change in supervising physician within 30 days

20. 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

21. 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

22. Comparison of Top 50 to Prescribers with DEA Based on DEA data as of 7/31/2015 Based on CSMD for calendar year 2014

23. 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

24. 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

25. 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)

26. 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;

27. Schedule II and III Opioids 1supply 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.

28. EVERY Renewal Minimum 2 continuing education hours on controlled substances prescribing including Tennessee Chronic Pain Guidelines every biennial period.

29. Prior to Initiating Opioid Therapy Think about… Tennessee Chronic Pain Guidelines

30. 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.

31. Pregnancy Is Special All newly pregnant women should have a urine drug test administered by the appropriate women’s health provider.

32. 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

33. Not for Chronic Pain Wrong Reason Methadone/ Buprenorphine

34. Benzos and Opioids don’t mix Benzodiazepines 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.

35. If An Opioid Is Prescribed: Go with lowest dose

36. 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

37. 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

38. Board Actions Overprescribing Cases n= 98

39. BME Action Overprescribing BME

40. BON Action (APN) Overprescribing

41. Months licensed prior to violation n=24 April 2013 thru June 2015

42. Behind the Statistics: Louie Miceli https://www.youtube.com/watch?v=UO4fje2mC_w&feature= player_embedded