Ethical Guidelines 9/24/15. Controlled Substance Update Texas Nurse Prac66oners Annual Conference Objec6ves

Transcription

1 Texas Nurse Prac66oners Annual Conference 2015 Kimberly H. Oas, MSN, APRN, FNP- BC Jan Zdanuk, DNP, APRN, FNP- BC, FAANP Ethical Guidelines Speakers report no rela6onships with business or industry that would pose a conflict of interest Objec6ves Review regulatory statutes and issues specific to NP prac6ce in Texas to include BON requirements resul6ng from SB406 in 2013 and any current issues Define key prac6ce implica6ons and responsibili6es of the NP in the management of pain pa6ents 1

2 Objec6ves Iden6fy treatment goals, obstacles to efficacy and Best Prac6ce regarding pain management, including the use of controlled substances Explore medica6on classifica6on, key prescrip6ve medica6ons and prac6ce guidelines Prescrip(on Access in Texas (PAT) database Authorized users can search the last 365- days worth of prescrip6on dispensing history for Schedule II V controlled substances, 24- hours a day, seven- days a week, including: Pa6ent prescrip6on history and Provider s own prescribing history hbps:// login.aspx Prescrip(on Access in Texas (PAT) PAT is a secured, online monitoring program, which assists Texas health care and law enforcement professionals in iden6fying poten6al prescrip6on drug abuse. PAT provides controlled substance dispensing history to medical prac66oners, board inves6gators and law enforcement professionals. 2

3 What you need to prescribe in Texas RN License q 2 years APRN License q 2 years (effec6ve with your renewal) DPS Registra6on yearly if prescribing controlled substances DEA Registra6on q 3 years if prescribing controlled substances What can we prescribe by state? TEXAS Schedule 3, 3N, 4, 5 Prescribe & Administer APRNs outside of a hospital facility or qualified hospice provider sejng cannot currently prescribe schedule 2 CS 2 opium, morphine, codeine, hydromorphone (Dilaudid), methadone, meperidine (Demerol), hydrocodone (Vicodin) CS 2N amphetamine, methamphetamine, nabilone Mid- Level Prac66oners Authoriza6on by State. (2015). Retrieved from Mid- Level Prac66oners Authoriza6on by State. Accessed April 19, 2015 hbp:// DEA Controlled Substance Schedules Sch Descrip(on Examples I No currently accepted medical use in Heroin, LSD, marijauna, peyote, the US.; high poten6al for abuse methaqualone, Ecstasy II III High poten(al for abuse, which may Hydromorphene, methadone, meperidine, lead to severe psychological or physical oxycodone, fentanyl, morphine, opium, and dependence codeine, amphetamine, methamphetamine, methylphenidate, hydrocodone,hcp* Poten6al for abuse, which may lead to 90 mg codeine per dose, buprenorphine, moderate or low physical dependence benzphetamine, phendimetrazine, ketamine, or high psychological dependence anabolic steroids IV Low poten6al for abuse Alprazolam, carisoprodol, clonazepm, clorazepate, diazepam, lorazepam, midazolam, temazepam, triazolam, tramadol* V Low poten6al for abuse Cough prepara6ons containing 200 mg codeine per 100 ml or per 100 g 3

4 Hospital Based Care Sec6on (b- 1)(1) of the Medical Prac6ce Act relates to prescribing for pa6ents while in a hospital. An APRN or PA, may issue a Schedule II prescrip6on as long as it is filled at the hospital pharmacy for a LOS of at least 24 hours or is receiving services in the emergency dept. Accessed September 20, 2015 from hbps:// If a schedule II is to be filled anywhere outside the hospital, the prescrip6on must be completed by a licensed physician. Accessed September 20, 2015 from hbps:// faq_prac6ce_aprn.asp Hospice Care Sec6on (b- 1)(2) of the Medical Prac6ce Act allows for APRN and PA to write Schedule II prescrip6ons as part of the plan of care for the treatment of a person who has executed a wriben cer6fica6on of a terminal illness, has elected to receive hospice care, and is receiving hospice treatment from a qualified hospice provider. Accessed September 20, 2015 from hbps:// 4

5 Nurse Anesthe6sts and Nurse Midwives have excep6ons to this ruling (Chapter 157 of Texas Medical Prac6ce Act). DPS registra6on has been transferred over to the Texas Board of Pharmacy effec(ve Sept. 1, 2016 (SB195, 2015) All ac6ve CSR were renewed August 20, 2015 and will expire August 31, 2016 For New Applicants un(l Sept. 1, 2016 DPS Registra6on Required in TEXAS for CS hbp:// 77A- 78A.pdf Ini(al: $25. Renewal: $25. Late Fee: Addi(onal $50 Criminal background check each year Consent to Inspect: Signature of the applicant further grants the director/ designee, the right to enter and inspect premises. Records are required to be kept (Texas Controlled Substances Act). 5

6 DEA Registra6on Ini6al Renewal Cost: $731. for 3 years TEXAS APRN Contact Hours required effec6ve January 1, 2015 with every licensure cycle 3 Contact Hours on prescribing controlled substances (if prescribing controlled substances) 5 Contact Hours in pharmacotherapeu6cs 2 Contact Hours in Nursing Jurisprudence and Ethics every 3 rd renewal cycle (Eff ) 2 Contact Hours on Geriatric care of older adults every licensure cycle (if applicable) 20 Contact Hours for APRN Renewal Nursing Jurisprudence and Ethics All day Workshop: Protec6ng Your Pa6ents and Your Prac6ce 7CNE $109. TX BON Online Interac6ve Course: Nursing Regula6ons for Safe Prac6ce 2CNE $25. TX BON Online Texas Nursing and Jurisprudence and Ethics Course. 2 CE. $19. 6ll 12/31/ TX15 Online Texas Nursing and Jurisprudence and Ethics. 2 CE. $ Express.com Texas BON hbp:/// 6

7 Roles and Responsibili6es of Provider Consider pa6ent needs, type of pain Old Carts Onset, Loca6on, Dura6on, Character, Aggrava6ng factors, Relieving factors, Timing, Severity Diagnosis; Prognosis Co- exis6ng factors Roles and Responsibili6es of Provider Drug to drug interac6ons Assess (kidney and renal func6on ) Adherence/Aberrant behaviors Misuse, Abuse/Addic6on, Diversion Consider OTC s, herbals and supplements (Acetaminophen etc.) Roles and Responsibili6es of Provider Follow prescribing guidelines *Controlled Substances Agreement/Contract Monitor prescrip6on usage (UDT or saliva swab) Safe storage; no sharing; proper disposal 7

8 Roles and Responsibili6es of Pa6ent Ac6ve vs. passive role in treatment plan Pt. must be involved in determina)on of posi6ve treatment outcome Quality of Life is defined by the Pa6ent! What does Chronic Pain Pa6ent need to Know? 100% pain allevia6on may not be possible Decrease pain be realis6c Improve func6on be realis6c Returning to normal can mean different things to different people Provider hopping is no guarantee of success; may be detrimental to their health 8

9 Goal Sejng Up Front With Pain Pa6ents Provides framework for treatment decisions Allows for mutually agreed upon expecta6ons Involve significant others and caregivers Document Goals, progress, achievements, func6onal status, physical and psychological interven6ons and referrals Barriers to Goal Abainment Pt. knowledge, health literacy, educa6on, impairment (physical or emo6onal) Pt. biases, stress, depression, mo6va6on, fear of future failure, past failures, or provider mistrust Provider unwilling to relinquish control or do referrals Signs of Troubled Rela6onship Pt. or Aborney request for records Considera)ons: For every 1 death from Prescrip6on drugs: 10 Hospital Admissions 32 ER Visits 130 prescrip6ve users who misuse / abuse 825 non medical users Substance Abuse and Mental Health Services Administra6on Drug Abuse Warning Network

10 Risk Stra6fica6on Low Risk No family history, no past or current substance use disorders No major depression, anxiety, or other psycho- social disorders Risk Stra6fica6on Moderate Risk ( Yellow Flag Cau6on!) History of Substance Abuse Family History of problema6c drug abuse Past or current psychopathology Not ac6vely addicted Risk Stra6fica6on High Risk ( Red Flags) Ac6ve Substance Abuse Major Untreated or undertreated psychopathology Ac6vely addicted: Criminal history of drug possession or diversion Chou, E ( 2009) Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non Cancer Pain. The journal of Pain 10 (2) 10

11 When Termina6on should be a considera6on Non- compliance/non- adherence Missed appointments or abruptly leaving Drug seeking behavior Threatening or verbal abuse, hos6lity, aggression or violent behavior toward Provider or Staff Provider or Pt. feels no longer a therapeu6c rela6onship Pt. requires treatment outside of exper6se Termina6ng the Provider/Pa6ent Rela6onship *Controlled Substance Agreement/Contract If signed and witnessed up front and pt. violates there are grounds for termina6on of rela6onship by following guidelines Pt. sent a registered leber which must be signed for; Given a 30 day no6ce to find a new provider; covered for emergencies for 30 days; do not fill any RX for controlled substances Do not re- establish care Proper no6fica6on via registered mail with 30 day no6ce is NOT abandonment of pa6ent. It is not necessary to give reason. Ending the pa6ent- physician rela6onship. (2013). Retrieved from hbp:// assn.org/ama/pub/physician- resources/legal- topics/pa6ent- physician- rela6onship- topics/ending- pa6ent- physician- rela6onship. page 11

12 Do Not Tolerate abuse or violence Discern involving law enforcement Renew Pt. rela6onship once terminated Reminder Keep interac6ons on Social Media professional at all 6mes, especially with medical personnel and pa6ents Best Prac6ces published by the AAN to treat chronic noncancer pain (Franklin, 2014) Establish Diagnosis; Document physical and psychological interven6ons Track pain and func6onal status at every visit Document daily MED in mg/dl using online opioid calculator at every visit hbp://agencymeddirectors.wa.gov/mobile.html Access prescrip6on drug monitoring program (PDMP) at a first visit for opioids and PRN Best Prac6ce Screen for past/current substance abuse, severe depression, anxiety, and PTSD prior to ini6a6on of chronic opioid analgesic therapy (COAT) Use urine drug tes6ng (UDT) prior to chronic opioid analgesic therapy (COAT) and PRN Use a Pa6ent Treatment Agreement at ini6a6on of COAT and annually 12

13 Best Prac6ce Don t use concomitant seda6ve- hypno6cs or benzodiazepines Avoid escala6ng doses above mg/d MED unless sustained meaningful improvement in pain and func6onal status is not abained and not without consulta6on with a Pain Management Specialist (Franklin, 2014) Reality 50 million Americans suffer from chronic pain 4 out of 10 don t get adequate relief 80% seek chronic pain relief in primary care sejngs Shortage of Pain management Specialist 1 for every 21,000 pa6ents Schram & Kohn, Chronic pain program in a Primary Care Sejng. Prac6cal Pain Managment2015. Challenge & Opportunity. Leverage Non Pharm op6ons to include: yoga, relaxa6on, mindfulness; CBT 13

14 Comprehensive Pain Management Program Outcomes 108 programs evaluated Sta6s6cal significance at 6 months and 1 year Supports interdisciplinary care for chronic pain management Domains Assessed Pain Severity Emo6onal Distress Interference of pain on func6on Perceived Control of Pain Treatment helpfulness Number of hours res6ng Key treatment Components Individualized behavioral medicine ( CBT) Physical Therapy Aqua6c Therapy Occupa6onal Therapy Group Educa6on Group relaxa6on Proceedings, Baylor University Medical Center,

15 Best Prac6ce Know your pa6ent Leverage mul6faceted management Be realis6c Seek assistance when appropriate NP Prac)ce Resources State Texas Nurse Prac66oners Prac6ce Commibee (TNP) Texas Board of Nursing (BON) Texas Nurses Associa6on APRN Commibee (TNA) Texas Medical Board Na6onal American Associa6on of Nurse Prac66oners (AANP) Ques(ons 15

16 References Chou, E. (2009). Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain, 10(2). Ending the pa6ent- physician rela6onship. (2013). Retrieved from hbp:// assn.org/ama/pub/physician- resources/legal- topics/pa6ent- physician- rela6onship- topics/ending- pa6ent- physician- rela6onship.page. Franklin, G. (2014). Opioids for chronic noncancer pain: A posi6on paper of the American Academy of Neurology. Neurology, 83; Mid- Level Prac66oners Authoriza6on by State. (2015). Retrieved from Mid- Level Prac66oners Authoriza6on by State. Accessed March 8, References Na6onal Plan and Provider Enumerator System. (2015). Retrieved from hbp:// Accessed March 8, Opioid Dose Calculator. (2015). Retrieved from hbp://agencymeddirectors.wa.gov/mobile.html Accessed April 20, Start a Self- Query. (2015). Retrieved from hbp:// pract/hasareportbeenfiledonyou.jsp. Accessed March 8, Substance Abuse and Mental Health Services Administra6on Drug Abuse Warning Network. (2011). Na6onal Es6mates of Drug Related Emergency Department Visits. HHS Publica)on No , Dawn Series, D- 35(August 2011). Texas Board of Nursing. (2015). APRN Frequently asked ques6ons. Retrieved September 20, 2015 hbps:// faq_prac6ce_aprn.asp We have enjoyed presen6ng this Let s get together again soon! April 22-24, 2016 at Hyab Hill Country Resort and Spa, San Antonio, Texas and Sept. 8-11, 2016 at the Grand Hyab San Antonio, Texas (River walk) ENJOY THE TNP CONFERENCE! 16