New
Mexico Register / Volume XXXV, Issue 10 / May 21, 2024
TITLE 16 OCCUPATIONAL
AND PROFESSIONAL LICENSING
CHAPTER 12 NURSING
AND HEALTH CARE RELATED PROVIDERS
PART 9 MANAGEMENT
OF CHRONIC PAIN WITH CONTROLLED SUBSTANCES
16.12.9.1 ISSUING AGENCY: New Mexico Board of
Nursing.
[16.12.9.1 NMAC -
Rp, 16.12.9.1 NMAC 5/21/2024]
16.12.9.2 SCOPE: This rule applies to all
advanced practice nurses, including certified nurse practitioners, certified
registered nurse anesthetists, and clinical nurse specialists with prescriptive
authority.
[16.12.9.2 NMAC -
Rp, 16.12.9.2 NMAC 5/21/2024]
16.12.9.3 STATUTORY AUTHORITY: Section 61-3-1
NMSA 1978 et seq., authorized the
board of nursing to regulate the practice of nursing in the state and the Pain
Relief Act, Sections 24-2D-1 through 24-2D-7 NMSA 1978.
[16.12.9.3 NMAC -
Rp, 16.12.9.3 NMAC 5/21/2024]
16.12.9.4 DURATION: Permanent.
[16.12.9.4 NMAC -
Rp, 16.12.9.4 NMAC 5/21/2024]
16.12.9.5 EFFECTIVE DATE: May 21, 2024, unless a
later date is cited at the end of a section.
[16.12.9.5 NMAC -
Rp, 16.12.9.5 NMAC 5/21/2024]
16.12.9.6 OBJECTIVE: It is the position of the
board that certified nurse practitioners, certified registered nurse
anesthetists and clinical nurse specialists with prescriptive authority have an
obligation to treat chronic pain and that a wide variety of medicines including
controlled substances and other drugs may be prescribed after a thorough
evaluation has been completed.
[16.12.9.6 NMAC -
Rp, 16.12.9.6 NMAC 5/21/2024]
16.12.9.7 DEFINITIONS:
A. Definitions beginning with “A”:
(1) “acute pain”,
means the normal, predicted physiological response to a noxious chemical or
thermal or mechanical stimulus, typically associated with invasive procedures, trauma or disease and generally time limited;
(2) “addiction”, is a neurobehavioral
syndrome with genetic and environmental influences that results in
psychological dependence on the use of substances for their psychic
effects. It is characterized by
behaviors that include one or more of the following: impaired control over drug
use; compulsive use; continued use despite harm; and craving. Physical dependence and tolerance are normal
physiological consequences of extended opioid therapy for pain and should not
by themselves be considered addiction.
B. Definitions beginning with “B”: [RESERVED]
C. Definitions beginning with “C”:
(1) “chronic pain” means
pain that persists after reasonable efforts have been made to relieve the pain
or its cause and that continues, either continuously or episodically, for
longer than three consecutive months.
“Chronic pain” does not, for the purpose of the Pain Relief Act
requirements, include pain associated with a terminal condition or with a
progressive disease that, in the normal course of progression, may reasonably
be expected to result in a terminal condition;
(2) “clinical expert” means
a person who, by reason of specialized education or substantial relevant
experience in pain management, has knowledge regarding current standards, practices and guidelines.
D. Definitions beginning with “D”: “drug abuser” means a person who takes a drug or drugs for
other than legitimate medical purposes.
E. Definitions beginning with “E”: [RESERVED]
F. Definitions beginning with “F”: [RESERVED]
G. Definitions beginning with “G”: [RESERVED]
H. Definitions beginning with “H”: [RESERVED]
I. Definitions beginning with
“I”: [RESERVED]
J. Definitions beginning with
“J”: [RESERVED]
K. Definitions beginning with “K”: [RESERVED]
L. Definitions beginning with “L”: [RESERVED]
M. Definitions beginning with “M”: [RESERVED]
N. Definitions beginning with “N”: “nursing facility” means a
long term care facility in which the patient is a current fulltime resident and
whose medications are solely administered and managed by the facility.
O. Definitions beginning with “O”:
(1) "opioid analgesic"
means buprenorphine, butorphanol, codeine, hydrocodone, hydromorphine,
levorphanol, meperidine, methadone, morphine, nalbuphine, oxycodone,
oxymorphone, pentazocine and propoxyphene as well as their brand names, isomers and combinations;
(2) "opioid antagonist"
means a drug approved by the federal food and drug administration that when
administered negates or neutralizes in whole or in part the pharmacological
effects of an opioid analgesic in the body, including naloxone and such other
medications approved by the board of pharmacy for the reversal of opioid
analgesic overdoses.
P. Definitions beginning with “P”:
(1) “pain”
means an unpleasant sensory and emotional experience associated with
inflammation or with actual or potential tissue damage, or described in terms
of such inflammation and damage, which could include acute, persistent
or chronic pain;
(2) “physical
dependence” means a state of adaptation that is manifested by a
drug-specific withdrawal syndrome that can be produced by abrupt cessation,
rapid dose reduction, decreasing blood level of the drug, administration of an
antagonist, or a combination of these;
(3) “prescription
monitoring program (PMP)” means a centralized system to collect, monitor,
and analyze electronically, for controlled substances, prescribing and
dispensing data submitted by pharmacies and dispensing practitioners. The data are used to
support efforts in education, research, enforcement
and abuse prevention.
Q. Definitions beginning with “Q”: [RESERVED]
R. Definitions beginning with “R”: [RESERVED]
S. Definitions beginning with “S”: [RESERVED]
T. Definitions beginning with “T”:
(1) “therapeutic
purpose” means the use of pharmaceutical and non-pharmaceutical treatments
and the spectrum of available modalities that conforms substantially to
accepted guidelines for pain management.
(2) “tolerance”
means a state of adaptation in which exposure to a drug induces changes that
result in a diminution of one or more of the drug’s effects over time.
U. Definitions beginning with “U”: [RESERVED]
V. Definitions beginning with “V”: [RESERVED]
W. Definitions beginning with “W”: [RESERVED]
X. Definitions beginning with “X”: [RESERVED]
Y. Definitions beginning with “Y”: [RESERVED]
Z. Definitions beginning with “Z”: [RESERVED]
16.12.9.7 NMAC - Rp,
16.12.9.7 NMAC 5/21/2024]
16.12.9.8 RULES: The following rules shall be used by the
board to determine whether an advanced practice nurse’s prescriptive practices
are consistent with the appropriate treatment of pain.
A. The treatment of
pain with various medicines or controlled substances is a legitimate nursing
practice when accomplished in the usual course of professional practice. It does not preclude treatment of patients
with addiction, physical dependence or tolerance who have legitimate pain. However, such patients do require very close
monitoring and precise documentation.
B. Pain management
for patients should include a contractual agreement, the use of drug screens
prior to treatment with opiates and during the course of
treatment to identify actual drugs being consumed and to compare with patients
self-reports. If concerns about misuse
are identified, the patient will be referred for appropriate consultation, and
scheduled for re-evaluation at appropriate time intervals.
C. The prescribing,
ordering, administering or dispensing of controlled
substances to meet the individual needs of the patient for management of
chronic pain is appropriate if prescribed, ordered, administered or dispensed
in compliance with the following.
(1) An
advanced practice nurse shall complete a history and physical examination and
include an evaluation of the patient’s psychological and pain status. The medical history shall include any
previous history of significant pain, past history of
alternate treatments for pain, potential for substances abuse, coexisting
disease or medical conditions, and the presence of a medical indication and
supporting diagnostic documentation or contra-indication against the use of
controlled substances.
(2) An
advanced practice nurse shall be familiar with and employ screening tools, as
well as the spectrum of available modalities for therapeutic purposes, in the
evaluation and management of pain. They
shall consider an integrative approach to pain management specialists including
but not limited to an acupuncturist, chiropractor, doctor of oriental medicine,
exercise physiologist, massage therapist, pharmacist, physical therapist,
psychiatrist, psychologist or other advanced practice
registered nurse.
(3) A
written treatment plan shall be developed and tailored to the individual needs
of the patient, taking age, gender, culture, and ethnicity into consideration,
with stated objectives by which treatment can be evaluated, e.g. by degree of
pain relief, improved physical and psychological function, or other accepted
measure. Such a plan should include a statement of the need for further
testing, consultation, referral or use of other
treatment modalities.
(4) If
the patient’s pain relief plateaus on controlled substance analgesic(s), then
the treatment plan should include an evaluation of continuing or tapering the
controlled substance therapy.
(5) The practitioner shall provide education and discuss the risks and
benefits of using controlled substances with the patient or surrogate or guardian, and shall document this in the record.
(6) Complete
and accurate records of care provided and drugs
prescribed shall be maintained. When
controlled substances are prescribed, the name of the drug, quantity, and
prescribed dosage should be recorded.
Prescriptions for opioids shall include indications for use. For chronic non-cancer pain patients treated
with controlled substance analgesic(s), the prescribing practitioner shall use
a written agreement for treatment with the patient outlining patient
responsibilities. As part of a written
agreement, chronic non-cancer pain patients shall receive all chronic pain
management prescriptions from one practitioner and one pharmacy whenever
possible.
(7) The
management of patients needing chronic pain control requires monitoring by the
attending or the consulting practitioner.
The practitioner shall periodically review the course of treatment for
chronic non-cancer pain, the patient’s state of health, and any new information
about the etiology of the chronic non-cancer pain at least every three
months. In addition, a practitioner
should consult, when indicated by the patient’s condition, with health care
professionals who are experienced (by the length and type of their practice) in the area of chronic pain control; such professionals need
not be those who specialize in pain control.
Consultation should occur early in the course of
long-term treatment, and at reasonable intervals during continued long-term
treatment for assessment of benefit and need.
Drug screening is expected and should be conducted when other factors
suggest an elevated risk of misuse or diversion.
(8) If,
in a practitioner’s opinion, a patient is seeking pain medication for reasons
that are not medically justified, the practitioner is not required to prescribe
controlled substances for the patient.
D. The board will
evaluate the quality of care on the following basis: appropriate diagnosis and
evaluation; appropriate medical indication for the treatment prescribed;
documented change or persistence of the recognized medical indication; and, follow-up evaluation with appropriate continuity of
care. The board will judge the validity of prescribing based on the advanced
practice nurse’s treatment of the patient and on available documentation,
rather than on the quantity and chronicity of prescribing. The goal is to control the patient’s pain for
its duration while effectively addressing other aspects of the patient’s
functioning, including physical, psychological, social, and work-related
factors.
E. The board will
review both over-prescription and under-prescription of pain medications using
the same standard of patient protection as a guiding principle.
F. The advanced practice nurse who prescribes, within their
scope of practice, distributes or dispenses an opioid analgesic for the first
time to a patient shall advise the patient on the risks of overdose and inform
the patient of the availability of an opioid antagonist. With respect to a patient to whom an opioid
analgesic has previously been prescribed, distributed
or dispensed by the advanced practice nurse, the advanced practice nurse shall
advise the patient on the risks of overdose and inform the patient of the
availability of an opioid antagonist on the first occasion that the advanced
practice nurse prescribes, distributes or dispenses an opioid analgesic each
calendar year.
G. An advanced practice nurse who prescribes an opioid
analgesic for a patient shall co-prescribe an opioid antagonist if the amount
of opioid analgesic being prescribed is at least a five-day supply. The prescription for the opioid antagonist
shall be accompanied by written information regarding the temporary effects of
the opioid antagonist and techniques for administering the opioid
antagonist. That written information
shall contain a warning that a person administering the opioid antagonist
should call 911 immediately after administering the opioid antagonist, unless
that person is a health care provider as provided in the Pain Relief Act.
H. An advanced
practice nurse who appropriately prescribes controlled substances and who
follows this section would be considered to be in
compliance with this rule and not be subject to discipline by the board, unless
there is some violation of the Nursing Practice Act, board rules and Pain
Relief Act Sections 24-2D-1 through 24-2D-7 NMSA 1978.
[16.12.9.8 NMAC -
Rp, 16.12.9.8 NMAC 5/21/2024]
16.12.9.9 PRESCRIPTION
MONITORING PROGRAM (PMP) REQUIREMENTS: The intent of the New Mexico board of nursing
in requiring participation in the PMP is to assist advanced practice nurses in balancing the safe use of controlled
substances with the need to impede harmful and illegal activities involving these pharmaceuticals.
A. Any advanced
practice nurse who holds a federal drug enforcement administration registration
and a New Mexico controlled substance registration shall register with the
board of pharmacy to become a regular participant in PMP inquiry and reporting.
B. An advanced
practice nurse may authorize delegate(s) to access the prescription monitoring
report consistent with board of pharmacy regulation 16.19.29 NMAC. While an advanced practice nurse’s delegate
may obtain a report from the state’s prescription monitoring program, the
advanced practice nurse is solely responsible for reviewing the prescription
monitoring report and documenting the receipt and review of a report in the
patient’s medical record.
C. Before an
advanced practice nurse prescribes or dispenses for the first time, a
controlled substance in Schedule II, III, IV or V to a patient for a period
greater than four days, or if there is a gap in prescribing the controlled
substance for 30 days or more, the practitioner shall review a prescription
monitoring report for the patient for the preceding 12 months. When available, the practitioner shall review
similar reports from adjacent states.
The practitioner shall document the receipt and review of such reports
in the patient’s medical record.
D. A prescription
monitoring report shall be reviewed a minimum of once every three months during
the continuous use of a controlled substance in schedule II, III, IV or V for
each patient. The practitioner shall
document the review of these reports in the patient’s medical record. Nothing in this section shall be construed as
preventing an advanced practice nurse from reviewing prescription monitoring
reports with greater frequency than that required by this section.
E. An
advanced practice nurse does not have to obtain and review a prescription
monitoring report before prescribing, ordering, or dispensing a controlled
substance in schedule II, III, IV or V:
(1) for
a period of four days or less; or
(2) to
a patient in a nursing facility; or
(3) to
a patient in hospice care.
F. Upon
review of a prescription monitoring report for a patient, the advanced practice
nurse shall identify and be aware of a patient currently:
(1) receiving
opioids from multiple prescribers;
(2) receiving
opioids and benzodiazepines concurrently;
(3) receiving
opioids for more than 12 consecutive weeks;
(4) receiving
more than one controlled substance analgesic;
(5) receiving
opioids totaling more than 90 morphine milligram equivalents per day;
(6) exhibiting
potential for abuse or misuse of opioids and other controlled substances, such
as over-utilization, requests to fill early, requests for specific opioids,
requests to pay cash when insurance is available, receiving opioids from
multiple pharmacies.
G. Upon
recognizing any of the above conditions described in paragraph F, the
practitioner, using professional judgement based on prevailing standards of
practice, shall take action as appropriate to prevent,
mitigate, or resolve any potential problems or risks that may result in opioid
misuse, abuse, or overdose. These steps
may involve counseling the patient on known risks and realistic benefits of
opioid therapy, prescription and training for naloxone, consultation with or
referral to a pain management specialist, or offering or arranging treatment
for opioid or substance use disorder.
The practitioner shall document actions taken to prevent, mitigate, or
resolve the potential problems or risks.
H. Practitioners
licensed to practice in an opioid treatment program, as defined in 7.32.8 NMAC,
shall review a prescription monitoring report upon a patient’s initial
enrollment into the opioid treatment program and every three months thereafter
while prescribing, ordering, administering, or dispensing opioid treatment
medications in schedule II, III, IV or V for the purpose of treating opioid use
disorder. The practitioner shall
document the receipt and review of a report in the patient’s medical record.
[16.12.9.9 NMAC -
Rp, 16.12.9.9 NMAC 5/21/2024]
16.12.9.10 NON-CANCER
PAIN MANAGEMENT CONTINUING EDUCATION: Any advanced
practice registered nurse (APRN)
with a drug enforcement agency (DEA) registration and licensure that permits
prescribing opioids, shall obtain continuing education on the management of
non-cancer pain. These practitioners shall be required to
obtain five contact hours every renewal period to include a review of these
rules 16.12.9 NMAC for management of non-cancer pain, an understanding of the
pharmacology and risks of controlled substances, a basic awareness of the
problems of abuse, addiction and diversion, and awareness of state and federal
regulations for the prescription of controlled substances.
[16.12.9.10 NMAC -
Rp, 16.12.9.10 NMAC 5/21/2024]
16.12.9.11 NOTIFICATION: The board shall notify the following persons of the Pain Relief Act and
Part 9 of the New Mexico nursing board rule: 16.12.9 NMAC. The board shall notify the health care
providers under its jurisdiction of the Pain Relief Act and rules, including health
care providers under investigation by the board in relation to the provider’s
pain management services.
[16.12.9.11 NMAC -
Rp, 16.12.9.11 NMAC 5/21/2024]
16.12.9.12 ADVANCED
PRACTICE NURSES, REGISTERED NURSES, AND LICENSED PRACTICAL NURSES TREATED WITH
OPIATES: Advanced practice nurses, registered nurses,
licensed practical nurses, certified hemodialysis technicians, and certified
medication aides who have chronic pain and are being treated with opiates shall
be evaluated by a pain clinic or, by a physician, CRNA, CNP, CNS pain
specialist and must have clearance from their practitioner, before returning to
or continuing in practice and must remain under the care of a physician, CRNA,
CNP or CNS for as long as they remain on opiates and continue to practice. The treating physician, CRNA, CNP or CNS may,
at her or his discretion, order a neuropsychological evaluation to help
determine clearance for practice.
[16.12.9.12 NMAC -
Rp, 16.12.9.12 NMAC 5/21/2024]
HISTORY OF 16.12.9 NMAC: [RESERVED]
History of Repealed Material: 16.12.9 NMAC, Management Of Chronic Pain With Controlled Substances, filed 12/21/2005 - Repealed effective 5/21/2024.
Other History: 16.12.9 NMAC, Management Of Chronic Pain With Controlled Substances, filed 12/21/2005 Replaced 16.12.9 NMAC, Management Of Chronic Pain With Controlled Substances, effective 5/21/2024.