30 Miss. Code. R. 2840-1.5 - Prescribing Controlled Substances and Medications by APRNs:

A. Scope.

These regulations apply to all individuals authorized to practice as an APRN in the State of Mississippi. Pursuant to these regulations, authorized APRNs may prescribe Schedules II, III, IV, or V. Application for this privilege requires an additional fee. Additionally, an application must be submitted to the Drug Enforcement Administration (DEA).

B. Prescription Guidelines - All Medications.

1) No APRN shall prescribe any medication without a good faith agreement subsequent to examination and medical indication thereof.

(a) Every written prescription delivered to a patient or delivered to any other person on behalf of a patient, must be signed on the date of issuance by the APRN. Electronic prescription transmissions are allowed using standards established and approved by the United States Department of Health and Human Services - Agency for Healthcare Research and Quality (HHS- AHRQ). This does not prohibit the transmission of electronic prescriptions and telefaxed (but not emailed) prescriptions to the pharmacy of the patient's choice. Electronic transcription that complies with federal DEA language is allowed. All prescriptions shall contain a designation indicating whether it shall be dispensed as written or whether substitution is permissible.

(b) Every written prescription issued by an APRN should clearly state whether or not each medication should be refilled, and if so, the number of authorized refills and/or the duration of therapy.

(c) Written prescriptions issued by an APRN, bearing more than one noncontrolled medication, shall clearly indicate the intended refill instructions for each medication.

(d) Any unused lines on a multi-line prescription blank shall be clearly voided by the issuing APRN.

(e) An APRN shall not permit any prescription to be signed by any other person in the place of or on behalf of the APRN.

(f) An APRN shall not pre-sign blank prescription pads or order forms under any circumstances.

2) Drug Maintenance, Labeling, Dispensing and Distribution Requirements.

(a) An APRN may receive and distribute not-for-sale prepackaged devices or samples for which the APRN has prescriptive authority.

(b) The patient's record shall reflect the lot number, expiration date, and instructions for use of any not-for-sale prepackaged device or sample.

(c) An APRN may delegate a licensed nurse to provide for the patient the not- for-sale prepackaged device or sample.

(d) An APRN shall not sell or trade any not-for-sale prepackaged device or sample.

(e) An APRN shall not distribute out-of-date not-for-sale prepackaged devices or samples. Out-of-date prepackaged devices and samples shall be promptly removed and properly disposed.

(f) The drug storage area shall be locked and maintained in a sanitary environment.

(g) An APRN shall not accept the return of any drugs.

(h) All drug products shall be maintained, stored, and distributed in such a manner as to maintain the integrity of the product.

(i) An APRN shall not distribute except as provided herein.

3) Maintenance of Patient Records.

(a) An APRN, who prescribes any device or medication, including controlled substances, shall maintain a complete record of the patient's examination, evaluation, and treatment plan.

1. Documentation of the patient shall include the diagnosis and reason for any prescriptions. Further, the APRN shall document the name, dose, strength, quantity, and the date prescribed of any prescription.

2. The patient record required by these regulations shall be maintained at the practice site of the APRN.

3. The patient record required by these regulations shall be maintained by the APRN for a minimum period of two (2) years.

(b) The Board has the authority to conduct random audits of patient records at APRN practice sites. These records shall be made available for inspection by representatives of the Board pursuant to authority granted in Miss. Code Ann. Section 41-29-125.

4) APRNs shall enroll in and utilize the Mississippi Prescription Monitoring Program (MPMP).

C. Registration for Controlled Substances Prescriptive Authority.

1) Every APRN authorized to practice in Mississippi who prescribes any controlled substance within Mississippi or who proposes to engage in the prescribing of any controlled substance within Mississippi must be registered with and act in abidance with the U.S. Drug Enforcement Administration in compliance with Title 21 CFR Part 1301 Food and Drugs.

2) An APRN shall submit to the Board evidence of personal and/or facility DEA Registration for approval.

3) Pursuant to authority granted in Miss. Code Ann. Section 41-29-125, the Mississippi Board of Nursing hereby adopts, in addition to required regulations with the Board, the registration with the U.S. Drug Enforcement Administration. In the event, however, the APRN has had limitations or other restrictions placed upon his or her state certification wherein he or she is prohibited from handling controlled substances in any or all schedules, said APRN shall be prohibited from registering with the U.S. Drug Enforcement Administration for a Uniform Controlled Substances Registration Certificate without first being expressly authorized to do so by order of the Mississippi Board of Nursing.

4) Persons registered to prescribe controlled substances may order, prescribe, administer, distribute, or conduct research with those substances to the extent authorized by their registration and in conformity with the other provisions of these regulations and in conformity with provisions of the Mississippi Uniform Controlled Substances Law, Miss. Code Ann. Section 41- 29-101 et seq.

5) APRNs may only write prescriptions for or order the use of or administration of any schedule of controlled substances in accordance with the regulations set forth herein. However, in the absence of an individual DEA registration, the following shall be permissible for the nurse operating under the facility DEA registration:

(a) Certified nurse midwives may determine the need for, order, and administer controlled substances in the practice of nurse midwifery within a licensed health care facility.

(b) Certified nurse anesthetists may determine the need for, order, and administer controlled substances in the practice of nurse anesthesia within a licensed health care facility.

(c) Certified nurse practitioners may determine the need for, order, and administer controlled substances in the practice of nurse practitioner within a licensed health care facility.

D. Prescription Regulation - Controlled Substances.

1) It is the ultimate responsibility of the APRN who is authorized to prescribe controlled substances to determine the type, dosage form, frequency of application and number of refills of controlled substances prescribed to a patient.

(a) The APRN shall not delegate this responsibility.

(b) APRNs with controlled substance prescriptive authority may receive samples of controlled substances; however, these must be maintained in a double locked cabinet with an accurate log.

2) All prescriptions for controlled substances must be prescribed in strict compliance with Miss. Code Ann. Sections 41-29-101 through 41-29-311 as amended and Title 21 of U.S. Code of Federal Regulations, Part 1306.

3) Mississippi Prescription Monitoring Program (MPMP) Requirements.

(a) Utilization Required.

1. The APRN shall utilize the MPMP for an initial prescription for a controlled substance.

2. The APRN shall utilize the MPMP at each patient encounter in which an opioid and/or benzodiazepine prescription is prescribed.

(b) Time Frame of MPMP Report.

1. The APRN utilizing the MPMP upon initial patient encounter shall utilize a patient prescription history of at least the previous six (6) months.

2. In all other instances in which utilization of the MPMP is required, the APRN shall utilize a patient prescription history of at least the previous three (3) months.

(c) Exceptions.

1. The APRN may elect to forego utilization of the MPMP for a prescription of Testosterone, Atropine/Diphenoxylate, Pregabalin, Gabapentin, or Pseudoephedrine.

2. The APRN may elect to forego utilization of the MPMP while practicing in the inpatient or emergency room setting; however, this exception does not apply to prescribing a controlled substance upon discharge.

(d) The APRN may have a properly registered designee run the MPMP report for the APRN's review.

4) The APRN shall maintain documentation evidencing utilization of the MPMP in the patient's record. A copy of the MPMP report itself and/or reflection of MPMP utilization in notes may satisfy this requirement.

5) Benzodiazepines

(a) The APRN shall utilize the MPMP at each patient encounter in which an opioid and/or benzodiazepine prescription is ordered.

(b) The APRN shall limit the prescribing of benzodiazepines to a one (1) month supply with no more than two (2) refills, or a ninety (90) day supply with no refills.

(c) The APRN shall perform point of service drug testing prior to the initial prescription of benzodiazepines for treatment of chronic medical and/or psychiatric conditions. In-office drug screening must be done at least three (3) times per calendar year for patients prescribed benzodiazepines for chronic medical and/or psychiatric conditions which are non-cancer/non-terminal.

i. Point of service drug tests shall, at a minimum, test for opioids, benzodiazepines, amphetamines, cocaine, and cannabis.

ii. Point of service drug testing is not required in the inpatient and hospice settings.

(d) The APRN should avoid, whenever possible, the prescribing of opioids, benzodiazepines, and/or Carisoprodol concomitantly.

6) Opioids.

(a) The APRN shall utilize the MPMP at each patient encounter in which an opioid and/or benzodiazepine prescription is ordered.

(b) The APRN should continue opioid therapy only if the patient experiences clinically meaningful improvement in pain and function that outweighs risks to patient safety.

(c) The APRN should avoid, whenever possible, the prescribing of opioids, benzodiazepines and/or Carisoprodol concomitantly.

(d) Treatment of chronic non-cancerous and/or non-terminal pain.

1. The APRN should follow the Center for Disease Control's (CDC) Guideline for Prescribing Opioids for Chronic Pain.

2. The APRN shall perform point of service drug testing prior to the initial prescription of Schedule II opioids for treatment of chronic non- cancerous and/or non-terminal pain. In-office drug screening must be done at least three (3) times per calendar year for patients prescribed opioids for chronic medical and/or psychiatric conditions which are non- cancer/non-terminal.

a. Point of service drug tests shall, at a minimum, test for opioids, benzodiazepines, amphetamines, cocaine, and cannabis.

b. Point of service drug testing is not required in the inpatient and hospice settings.

(e) Treatment of acute non-cancerous and/or non-terminal pain.

1. The APRN should prescribe immediate-release opioids instead of extended-release/ long-acting opioids when treating acute non- cancerous and/or non-terminal pain.

2. The APRN shall not prescribe greater than a ten (10) day supply of opioids for acute non-cancerous and/or non-terminal pain, along with an additional ten (10) day supply of opioids, if deemed clinically necessary. The APRN shall conform with Title 21 CFR Section 1306.12 refilling prescriptions; issuance of multiple prescriptions and shall document justification for an additional supply of medication beyond the initial ten (10) day supply.

3. The APRN shall prescribe the lowest effective dose of immediate- release opioids and shall prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

(g) The APRN shall not prescribe Methadone to treat chronic pain, acute non-cancerous pain, and/or non-terminal pain.

E. Use of Diet Medication.

1) The APRN shall not prescribe any Schedule II controlled substance for the exclusive treatment of obesity, weight control, or weight loss.

2) An APRN shall not utilize controlled substances or legend drugs for purposes of weight loss unless it has an FDA approved indication for this purpose and then only in accordance with all of the following enumerated conditions.

3) Controlled substance anorectics should be used with caution in the treatment of obesity or weight loss. An APRN may prescribe said medications for the purpose of weight loss in the treatment of obesity only as an adjunct to a regimen of weight reduction based on caloric restriction, provided, that all of the following conditions are met:

(a) Before initiating treatment utilizing a controlled substance, the APRN determines through review of his or her own records of prior treatment, or through review of the records of prior treatment which a treating physician or weight-loss program has provided to the APRN, that the patient has made a substantial good-faith effort to lose weight in a treatment program utilizing a regimen of weight reduction based on caloric restriction, nutritional counseling, behavior modification, and exercise, without the utilization of controlled substances, and that said treatment has been ineffective.

(b) Before initiating treatment utilizing a controlled substance, the APRN obtains a thorough history, performs a thorough physical examination of the patient, and rules out the existence of any recognized contraindications to the use of the controlled substance to be utilized. "Recognized contraindication" means any contraindication to the use of a drug which is listed in the United States Food and Drug Administration (hereinafter, "FDA") approved labeling for the drug.

(c) The APRN shall not utilize any controlled substance when he or she knows or has reason to believe that a recognized contraindication to its use exists.

(d) The APRN shall not utilize any controlled substance for diet medication in the treatment of a patient whom he/she knows or should know is pregnant.

(e) The APRN shall not initiate and shall discontinue controlled substances which are classified as amphetamine or amphetamine-like anorectics and/or central nervous system stimulants, hereinafter referred to as "stimulant," immediately upon ascertaining or having reason to believe:

1. That the patient has failed to lose weight while under treatment with said stimulant over a period of thirty (30) days, which determination shall be made by weighing the patient at least every thirtieth (30^th) day, except that a patient who has never before received treatment for obesity utilizing a stimulant, and who fails to lose weight during his or her first such treatment attempt may be treated with a different controlled substance for an additional thirty (30) days, or

2. That the patient has developed tolerance (a decreasing contribution of the drug toward further weight loss) to the anorectic effects of said stimulant being utilized, or

3. That the patient has a history of or shows a propensity for alcohol or drug abuse, or

4. That the patient has consumed or disposed of any controlled substance other than in strict compliance with the treating APRN's directions.

(f) The APRN shall not issue a prescription for a stimulant for any greater than a thirty (30) day supply and is to be prescribed for short-term use only as defined by current standards of care.

(g) As to all other legend drugs or controlled substances which are not considered stimulants, but which have received FDA-approved indication for long term use for weight loss, the APRN shall prescribe said medications in strict compliance with the FDA-approved labeling. In addition to the requirements enumerated in (e) (1) - (4) above, each prescription shall be issued for no more than a total of three (3) months' supply (including refills) and further, before subsequent new prescriptions can be issued, the patient shall receive a thorough reevaluation of the effectiveness of the medication, including a physical examination to document any potential harmful side effects.

F. Freedom of Choice.

1) An APRN shall not be influenced in the prescribing of drugs and devices by a direct or indirect financial interest in a pharmaceutical firm, pharmacy, or other supplier. Whether the firm is a manufacturer, distributor, wholesaler, or re-packager of the product involved is immaterial.

2) An APRN may own or operate a pharmacy if there is no resulting exploitation of patients. Patients are entitled to the same freedom of choice in selecting who will fill their prescription needs as they are in the choice of an APRN.

3) If a patient requests a written prescription in lieu of an oral prescription or electronic submission, this request shall be honored.

G. Violation of Regulations.

1) The prescribing of any controlled substance in violation of the above rules and regulations shall constitute a violation of Miss. Code Ann. Section 73-15-29(1)(f), (k) and (l) and shall be grounds for disciplinary action.

2) The prescribing, administering, or distributing of any legend drug or other medication in violation of the above rules and regulations shall constitute a violation of Miss. Code Ann. Section 73-15-29(1) (f), (k) and (l), and shall be grounds for disciplinary action.

Notes

30 Miss. Code. R. 2840-1.5

Miss. Code Ann. § 73-15-17 (1972, as amended).

Adopted 8/22/2019 Amended 9/17/2021 Amended 7/11/2024