The purpose of this rule is to recognize that some controlled
substances are indispensable for the treatment of pain, and are useful for
relieving and controlling many other related symptoms that patients may suffer.
It is the position of the Board of Nursing that these drugs may be prescribed
for the treatment of pain and other related symptoms after a reasonably based
diagnosis has been made, in adequate doses, and for appropriate lengths of
time, which in some cases may be as long as the pain or related symptoms
persist. The Board recognizes that pain, including intractable pain, and many
other related symptoms are subjective complaints and that the appropriateness
and the adequacy of drug and dose will vary from individual to individual. The
Advanced Practice Nurse, who possesses a certificate of fitness issued by the
Board and possesses a Drug Enforcement Administration (DEA) Certificate to
Prescribe Controlled Substances, is expected to exercise sound judgment in
treating pain and related symptoms with controlled substances.
(1) Definitions. The following words and
terms, as used in this rule shall have the following meanings in the context of
providing medications for pain and related symptoms.
(a) Abuser of narcotic drugs / controlled
substances - A person who takes a drug or drugs for other than legitimate
medical purposes.
(b) Intractable
pain - A pain state in which the cause of the pain cannot be removed or
otherwise treated and which in the generally accepted course of medical
practice no relief or cure of the cause of the pain is possible or none has
been found after reasonable efforts.
(c) Non-therapeutic in nature or manner - A
medical use or purpose that is not legitimate.
(d) Prescribing pharmaceuticals or practicing
consistent with the public health and welfare - Prescribing pharmaceuticals and
practicing Advanced Practice Nursing for a legitimate purpose in the usual
course of professional practice.
(2) An Advanced Practice Nurse who does not
choose to provide long-term pain management to patients with intractable pain
shall offer the patient a referral to a practitioner whose primary practice is
in the treatment of severe, chronic, intractable pain with methods including
the use of opiates. If the patient requests such a referral the APN shall
assist in the transition to another provider for the purpose of pain
management.
(3) An Advanced
Practice Nurse possessing a certificate of fitness issued by the Board and a
DEA certificate who provides care for persons with intractable pain with or
without opiates is expected to demonstrate current knowledge of long-term pain
management.
(4) Guidelines - The
Tennessee Board of Nursing will use the following guidelines to determine
whether an Advanced Practice Nurse's conduct violates T.C.A. §
63-7-115(a) (1) (A) through
(G) in regard to the prescribing,
administering, ordering, or dispensing of pain medications and other drugs
necessary to address their side effects.
(a)
The treatment of pain, including intractable pain, with controlled substances
serves a legitimate purpose when done in the usual course of professional
practice.
(b) An Advanced Practice
Nurse duly authorized to practice in Tennessee and to prescribe controlled
substances in this state shall not be subject to disciplinary action by the
Board for prescribing, ordering, administering, or dispensing controlled
substances for the treatment and relief of pain, including intractable pain, in
the usual course of professional practice for a legitimate purpose in
compliance with applicable state and federal law.
(c) Prescribing, ordering, administering, or
dispensing controlled substances for pain will be considered to be for a
legitimate purpose if based upon accepted scientific knowledge of the treatment
of pain, including intractable pain, not in contravention of applicable state
or federal law, and if prescribed, ordered, administered, or dispensed in
compliance with the following guidelines where appropriate and as is necessary
to meet the individual needs of the patient.
1. The record shall include a documented
medical history and physical examination by the Advanced Practice Nurse who
possesses a certificate of fitness and a DEA certificate and is providing the
medication. Historical data shall include pain history, any pertinent
evaluations by another provider, history of and potential for substance abuse,
pertinent coexisting diseases and conditions, psychological functions and the
presence of a recognized medical indication for the use of a controlled
substance;
2. A written treatment
plan tailored for individual needs of the patient shall include objectives such
as pain relief and/or improved physical and psychosocial function, and shall
consider need for further testing, consultations, referrals, or use of other
treatment modalities dependent on patient response;
3. The Advanced Practice Nurse who possesses
a certificate of fitness and a DEA certificate shall discuss the risks and
benefits of the use of controlled substances with the patient or
guardian;
4. At each periodic
interval in which the Advanced Practice Nurse, who possesses a certificate of
fitness and a DEA certificate and is providing care, evaluates the patient for
continuation or change of medications, the patient record shall include
progress toward reaching treatment objectives, any new information about the
etiology of the pain, and an update on the treatment plan.
(d) In determining the need for any
disciplinary action in regard to the Advanced Practice Nurse who possesses a
certificate of fitness and a DEA certificate, each case of prescribing for
chronic pain will be evaluated on an individual basis as to whether the nurse
is prescribing and practicing in a manner consistent with public health and
welfare. The Board of Nursing will evaluate for proper documentation,
therapeutic prescribing in a manner using drugs that are recognized to be
appropriate pharmacologically for the diagnosis, treatment outcomes including
improvement in functioning, and recognition that some types of pain cannot be
completely relieved.
(e) Quantity
of pharmaceuticals and chronicity of prescribing will be evaluated on the basis
of the documented appropriate diagnosis and treatment of the recognized medical
indication, documented persistence of the recognized medical indication, and
properly documented follow-up evaluation with appropriate continuing care as
set out in this rule.
(f) An
Advanced Practice Nurse may use any number of treatment modalities for the
treatment of pain, including intractable pain, which are consistent with
legitimate medical purposes.
(g)
These rules shall not be construed so as to apply to the treatment of acute
pain with controlled substances for purposes of short-term care.
