Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications...
Transcript of Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications...
![Page 1: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/1.jpg)
Regulation ofControlled Substances
Confronting the Opioid Abuse Epidemic
Kate Goldblum, MSN, FNP-BCApril 2, 2019
![Page 2: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/2.jpg)
Disclosures
No financial conflictsNo discussion of off-label use
![Page 3: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/3.jpg)
State Regulations(NM Board of Nursing)
Describe key elements of Rule 9: Management of Chronic Pain With CS
Definitions (e.g., chronic pain)Criteria (“rules”) for prescriptive practices consistent with appropriate pain treatmentRequirements regarding Prescription Monitoring Program (PMP) participationRequirement for non-cancer pain management (NCPM) CERequirements for HCP treated with opiates
![Page 4: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/4.jpg)
State Regulations(NM Board of Pharmacy)
Identify elements of the NM Board of Pharmacy PMP applicable to APRNs who prescribe opioids
PMP account registrationUse of delegates to access PMPControlled Substance Registration (CRS)
![Page 5: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/5.jpg)
Federal Regulations
Discuss federal controlled substance regulations relevant to opioid prescribing
Initial determination & changes to specific drugs’ schedules (I, II, III, IV or V)Administrative & enforcement provisions of the Controlled Substance Act (CSA)Resources for accurate information regarding federal regulations
![Page 6: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/6.jpg)
State RegulationsNew Mexico Board of Nursing
Management of Chronic Pain With Controlled Substances
Rule 9 (16.12.9 NMAC)
![Page 7: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/7.jpg)
Pain Relief Act Amendment
Amended 1999 Act in 2012Affected all boards with jurisdiction over health care providers
Licensed to provide health careWith prescriptive authority
![Page 8: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/8.jpg)
Expanded & clarified evidentiary requirements for disciplinary actionCreated the Advisory CouncilRequired NCPM CE for licensed health care providers with DEA registration & controlled substance licensure
Pain Relief Act Amendment
![Page 9: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/9.jpg)
The Advisory Council
Includes representatives from a number of statewide professional organizations (including NMNPC) & other health care stakeholdersMeets at least quarterly & is administratively attached to the Department of Health (DOH)
![Page 10: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/10.jpg)
Advisory Council Duties
Reviews prescription drug misuse & overdose prevention in NM & at the national levelReviews current pain management practices in NM & pain management standards at the national levelMakes recommendations for pain management & clinical guidelines
![Page 11: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/11.jpg)
Rules Part 9
Amended to comply with the new requirements in 2012 Pain Relief ActAmended again in 2017 & 2018 –addressed
Requirements of 2016 SB0263Concerns raised by NMNPC re: original CE requirements
![Page 12: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/12.jpg)
NCPM CE Issues
Redundancy in bi-annual CE1/3 of entire pharmacology CE requirementCouldn’t offer non-pharmacologic content to meet the CE requirement
Goal of NCPM CE is to reduce abuse, addiction & overdoseCurrent CDC guidelines: nonopioid, nonpharmacologic treatments preferred
![Page 13: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/13.jpg)
Part 9
Sections 1-7: housekeepingSection 8: rules regarding Rx practicesSection 9: PMP requirementsSection 10: CE requirementsSection 11: notification requirementsSection 12: requirements for APRNs, RNs& LPNs treated with opiates
Part 9 (16.12.9)Management of Chronic Pain with Controlled Substances
![Page 14: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/14.jpg)
Section 8 – The Rules
Criteria used by the BON to determine if prescriptive practices are consistent with appropriate pain treatment
A, B, D, E & F address general prescriptive practicesC addresses CS prescribing for chronic pain management & includes 8 specific compliance items
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 15: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/15.jpg)
![Page 16: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/16.jpg)
![Page 17: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/17.jpg)
A: Legitimate Practice
Treatment of pain with various medicines (including CS) is legitimate
In usual course of professional practiceDoes not preclude treatment of legitimate pain if addicted, physically dependent or tolerant but must monitor closely & document precisely
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 18: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/18.jpg)
B: NCPM RequirementsPain management should include
Contractual agreementUse of drug screens before & during treatmentReferral for consultation & appropriately timed re-evaluation if provider identifies misuse concerns
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 19: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/19.jpg)
C: CS Appropriateness
Appropriate to prescribe, order, administer or dispense CS to manage chronic pain if compliant with 8 specific guidelines
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 20: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/20.jpg)
C1 History & Physical
IncludeEvaluation of psychological & pain statusPrior history of significant painPast history of alternate treatment for painPotential for substance abuseComorbiditiesIndication or contraindications for CS use
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 21: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/21.jpg)
C2 Tools & Tx Modalities
Be familiar with & use screening tools & a spectrum of treatment modalitiesConsider integrative approach with
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
AcupuncturistChiropractorDOMExercise physiologistMassage therapist
PharmacistPhysical therapistPsychiatristPsychologistOther APRNs
![Page 22: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/22.jpg)
C3 Written Plan
Tailor to individual needs (consider age, gender, culture & ethnicity)Include stated objectives to evaluate treatment (é’d function, degree of pain relief, etc.)Include statement of need for further testing, consultation, referral, other Tx
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 23: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/23.jpg)
C4 Pain Relief Plateaus
If pain relief “plateaus” on CS, treatment plan should include evaluation of continuing or tapering therapy
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 24: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/24.jpg)
C5 Education
Discuss risks & benefits of CS use with patient, surrogate or guardianDocument education & discussion in patient’s record
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 25: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/25.jpg)
C6 Record Maintenance
Complete & accurate records of care provided & drugs prescribedIf CS: name, quantity, dosage, (indications for use if opioid)If CS for chronic NCP – written agreement outlining pt responsibilities including 1 practitioner 1 pharmacy
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 26: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/26.jpg)
C7 Monitoring
Periodically review (at least q 3 months)Course of treatment, state of health, new information on etiology of painConsult as indicated with professional experienced in chronic pain
Drug screening expected when factors suggest é’d risk of misuse or diversion
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 27: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/27.jpg)
C8 Rx Not Required
Not required to prescribe CS if (in your opinion) patient is seeking pain meds for non-medically justified indication
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 28: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/28.jpg)
D: Basis for Evaluation
BON evaluation of care based onAppropriate dx & evaluationAppropriate medical indication for treatment prescribedDocumented persistence/change of indicationFU evaluation with appropriate continuity of care
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 29: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/29.jpg)
D: Judgment of Validity
Validity of prescribing based on treatment & documentation, not on quantity & chronicity of prescribingGoal is to control pain while addressing physical, psychological, social & work-related functioning
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 30: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/30.jpg)
E: Over & Under
BON review will include both over-prescribing & under-prescribingGuiding principle: BON review uses same standard of patient protection in both cases
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 31: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/31.jpg)
F: Discipline by BON
Practitioner who appropriately prescribes following 16.12.9.8 will be considered compliant & not subject to discipline by the BoardException: some violation of the NPA, BON rules, Pain Relief Act
Part 9 (16.12.9.8)Management of Chronic Pain with Controlled Substances
![Page 32: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/32.jpg)
PMP Requirements
Intent – balance promotion of safe CS use with need to curtail illegal & harmful activities involving CS
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 33: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/33.jpg)
APRNs with DEA & CSL
Register with NM Board of Pharmacy PMP & regularly participate in inquiry & reportingMay authorize delegates to access PMP but APRN must still review & document receipt & review of report
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 34: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/34.jpg)
Rx of Controlled Substance
Obtain & review 12-month PMP report before prescribing or dispensing a CS (schedules II-V)
For a period > 4 daysWhen there’s a gap in CS prescription of ≥ 30 daysFrom NM PMP & adjacent states when availableNM PMP connects with Military Health System (MHS) PMP
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 35: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/35.jpg)
Rx of Controlled Substance
Review PMP report a minimum of every 3 months during continuous use of CS (schedules II-V)Document report review in patient recordNot needed if ≤ 4 days or if patient in nursing facility or hospice
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 36: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/36.jpg)
Rx of Controlled Substance
Review PMP report for red flagsMultiple prescribersOpioids & benzos togetherOpioids for > 12 consecutive weeksMore than one CS analgesicOpioids totaling > 90 MME/dayPotential for abuse or misuse
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 37: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/37.jpg)
Review → Red Flags?
Take “appropriate steps” to avoid, mitigate or resolve potential problem(s)Use professional judgment based on prevailing standards of practice
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 38: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/38.jpg)
Potential Actions
Counsel patient on risks/benefitsRx & train on naloxoneOffer or arrange for treatment for substance use disorderConsult with or refer to pain management specialistDocument actions taken
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 39: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/39.jpg)
In Opioid Tx Programs
Review PMP reportOn initial enrollment in Tx programEvery 3 months while on opioid treatment medications in schedules II-VDocument receipt & review of report in patient record
Part 9 (16.12.9.9)Management of Chronic Pain with Controlled Substances
![Page 40: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/40.jpg)
PMP Reports to BON
Compliance with obtaining PMP reports is improvingBUT – providers (including APRNs) have a long way to goQuarterly reports to BoardPrescriber Feedback Reports (PFRs) to practitioners
![Page 41: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/41.jpg)
CE Requirements
DEA & CS registrations → CE requiredCE must address NCPM
Part 9 (16.12.9.10)Management of Chronic Pain with Controlled Substances
![Page 42: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/42.jpg)
NP Requirements
Current requirements (every 2 years)5 contact hours related to APRN’s practice10 contact hours of pharmacology5 contact hours of NCPM
Some of the NCPM CE will necessarily be pharmacology due to specific requirements in Rule 9
Part 9 (16.12.9.10)Management of Chronic Pain with Controlled Substances
![Page 43: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/43.jpg)
Required Content
Review of 16.12.9Understanding of pharmacology & risks of controlled substancesBasic awareness of the problems of abuse, addiction & diversionAwareness of state & federal regulations for prescription of CS
Part 9 (16.12.9.10)Management of Chronic Pain with Controlled Substances
![Page 44: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/44.jpg)
Notification
BON shall notify of the Pain Relief Act & Part 9 of the NM nursing board rule
Health care providers under jurisdiction of NMBONHealth care provider being investigated by BON in relation to provider’s pain management practices
Part 9 (16.12.9.11)Management of Chronic Pain with Controlled Substances
![Page 45: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/45.jpg)
HCP Opiate Treatment
HCPs with chronic pain & being treated with opiates
APRNsRNsLPNsCertified hemodialysis techniciansCertified medication aides
Part 9 (16.12.9.12)Management of Chronic Pain with Controlled Substances
![Page 46: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/46.jpg)
Requirements for HCP
Evaluated at a pain clinic or by a pain specialistCleared by practitioner before returning to or continuing in practiceRemain under care as long as on opiates & continuing to practiceNeuropsychological evaluation prn
Part 9 (16.12.9.12)Management of Chronic Pain with Controlled Substances
![Page 47: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/47.jpg)
What is NMNPC Doing?
Offer NCPM CE every 2 years (live & enduring CE)Maintain representation on the Advisory CouncilMonitor & disseminate Advisory Council recommendationsMonitor & address BON rule develop-ment
![Page 48: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/48.jpg)
Advisory Council – 2018
Boards should adopt the Benzodiazepine Prescribing Guidelines developed & approved by the Council & include appropriate benzodiazepine education in requirements for NCPM education.Increase distribution of naloxone in a variety of settings & circumstances.
![Page 49: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/49.jpg)
Looking to the Future
Expect more changes (CE on benzodiazepines)
NMNPC courses already included Holy Trinity problem (opioids, benzos and carisoprodol)
NMNPC will monitor rule changes inbenzo CE requirement
![Page 50: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/50.jpg)
State RegulationsNM Board of Pharmacy
Prescription Monitoring Program
Elements Applicable to APRNs
![Page 51: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/51.jpg)
PMP Accounts
NM licensed practitionersNM registered pharmacistsDelegates of practitioner or pharmacistLaw enforcement or regulatory board agents vetted by PMP to warrant accessMandatory for practitioners with CS registration
NM Board of PharmacyPrescription Monitoring Program
![Page 52: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/52.jpg)
PMP Statistics
Decreasing # of practitioners (all types) who aren’t using PMPIncreasing # of practitioners (all types) using the PMP at least 25% of the timeOver 4000 requests/day processed
NM Board of PharmacyPrescription Monitoring Program
![Page 53: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/53.jpg)
User Account Registration
NM licensed practitionerDEA registration numberControlled substance license
NM Board of PharmacyPrescription Monitoring Program
![Page 54: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/54.jpg)
Registration
Fill out online registration form
Verify email addressUpload required documentsComplete mandatory training
https://newmexico.pmpaware.net
http://nmpmp.org/Training.aspx
NM Board of PharmacyPrescription Monitoring Program
![Page 55: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/55.jpg)
Delegate Registration
Delegate of practitionerRegistration (same process as practitioner)List supervisor(s) email address; supervisor must already have account
Delegates can obtain reports but practitioner must reviewMay have up to 4 delegates
NM Board of PharmacyPrescription Monitoring Program
![Page 56: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/56.jpg)
Which Comes First?
To register with the PMP must already have a controlled substance licenseTo renew a controlled substance license must already be registered with the PMP
NM Board of PharmacyPrescription Monitoring Program
![Page 57: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/57.jpg)
PMP Accounts
Delegate report requests linked to supervising practitionerMust make sure delegates log in under correct supervisor
NM Board of PharmacyPrescription Monitoring Program
![Page 58: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/58.jpg)
PMP Reports
QuarterlyBoard of NursingProvider Feedback Reports
Promote patient safety & best practices
NM Board of PharmacyPrescription Monitoring Program
![Page 59: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/59.jpg)
Quarterly ReportsTotal number of patients
Total number of opioid patients
Total opioid MMEs filled
Total number of benzodiazepine (BZD) patients
Total BZD diazepam milligram equivalents (DME) filled
Percent of opioid patients with ≥90 MME/day
Percent of opioid patients with ≥90 days of opioids in 6 months
Percent of BZD patients with prescriptions ≥30 DME/day
Percent of BZD patients with ≥90 days of BZDs in 6 months
Percent of opioid patients with concurrent BZDs ≥30 days
Controlled substance prescriptions per prescribing day, 3 months
Percent of estimated required reports requested
PMP reports required under Board rules (estimated)
PMP reports requested on patients
Percent of patients with a total of 5 or more practitioners or pharmacies in 6 months
![Page 60: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/60.jpg)
Federal Regulations
Controlled Substances Act
Code of Federal Regulation
Drug Schedules
![Page 61: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/61.jpg)
DEA Registration
New &/or renewalOnlinePaper submission
Must have controlled substance license first
Federal RegulationsControlled Substances
https://www.deadiversion.usdoj.gov/drugreg/index.html
![Page 62: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/62.jpg)
Buprenorphine
Waiver course available through AANPFree training partly through unrestricted grant by Indivior to AANP & ASAM
Federal RegulationsControlled Substances
![Page 63: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/63.jpg)
E Prescribing
Legal for II-V but not mandatoryMust use approved software
Federal RegulationsControlled Substances
![Page 64: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/64.jpg)
DEA – Locum Tenens
Within the state generally don’t need to change address of practiceIn a second state, need to change address to locum location then back to primary location
Federal RegulationsControlled Substances
https://www.deadiversion.usdoj.gov/fed_regs/rules/2009/fr1028.htm
![Page 65: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/65.jpg)
Schedule l
No accepted medical use in USLack of accepted safety for use under medical supervisionHigh potential for abuseExamples
HeroinLSDMarijuana
PeyoteEcstasy
Federal RegulationsControlled Substances
![Page 66: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/66.jpg)
Schedule ll & llN
High potential for abuseMay lead to severe psychological or physical dependenceExamples (II narcotics)
CodeineFentanylHydrocodoneHydromorphone
MeperidineMethadoneMorphineOxycodone
Federal RegulationsControlled Substances
![Page 67: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/67.jpg)
Schedule ll & llN
Examples (IIN stimulants)
Examples (other II substances)
AmphetamineMethamphetamineMethylphenidate
AmobarbitalGlutethimidePentobarbital
Federal RegulationsControlled Substances
![Page 68: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/68.jpg)
Schedule lll & lllN
Less potential for abuse than I or IIMay lead to moderate/low physical dependence or high psychological dependenceExamples
≤90 mg codeine/doseBuprenorphineNon-narcotics like ketamine & testosterone
Federal RegulationsControlled Substances
![Page 69: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/69.jpg)
Schedule lV
Low potential for abuse relative to IIIExamples
AlprazolamCarisoprodolClonazepamDiazepam
LorazepamMidazolamTemazepamTriazolam
Federal RegulationsControlled Substances
![Page 70: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/70.jpg)
Schedule V
Low potential for abuse relative to IVMainly preparations containing limited quantities of certain narcotics Example
Cough preparations ≤ 200mg codeine/100ml or 100gms
Federal RegulationsControlled Substances
![Page 71: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/71.jpg)
Federal Resources
Current list of CShttps://www.deadiversion.usdoj.gov/schedules/index.html
Title 21 US Code CS Acthttps://www.deadiversion.usdoj.gov/21cfr/21usc/812.htm
Frequently Asked Questionshttps://www.deadiversion.usdoj.gov/faq/index.html
Title 21 Code of Federal Regulationshttps://www.deadiversion.usdoj.gov/21cfr/cfr/index.html
Federal RegulationsControlled Substances
![Page 72: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/72.jpg)
Documenting Required CE
CE verification documentDocument showing content (if not on verification)
SUBMIT DOCUMENTS ON RENEWAL
![Page 73: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/73.jpg)
![Page 76: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/76.jpg)
NM DOH Resource
Prescription Opioid Safetyhttps://nmhealth.org/about/erd/ibeb/pos/
![Page 77: Regulation of Controlled Substances · 4/2/2019 · If CS: name, quantity, dosage, (indications for use if opioid) If CS for chronic NCP –written agreement outlining pt responsibilities](https://reader034.fdocuments.in/reader034/viewer/2022042117/5e94b0540370df66d648a212/html5/thumbnails/77.jpg)
CDC Resources
Implementing the CDC Guidelineshttps://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf
Guideline Overviewhttps://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
Checklist for Prescribing Opioidshttps://www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf
Guideline Resources: Clinical Toolshttps://www.cdc.gov/drugoverdose/prescribing/clinical-tools.html