The purpose of this rule is to recognize that some controlled
substances are appropriate for the treatment of pain and are useful for
relieving and controlling many other related symptoms that patients may suffer.
It is the position of the Board that these drugs may be prescribed for the
treatment of pain and other related symptoms after a reasonably based diagnosis
has been made, in appropriate doses, and for appropriate lengths of time. The
Board recognizes that pain and many other related symptoms are subjective
complaints and that the appropriateness and the adequacy of drug and dose will
vary from individual to individual. The advanced practice registered nurse, who
possesses a certificate of fitness issued by the Board and possesses a Drug
Enforcement Administration (DEA) registration certificate to prescribe
controlled substances, is expected to exercise sound judgment in treating pain
and related symptoms with controlled substances. The Board will use the
statewide standard of care and the following guidelines to determine whether an
advanced practice registered nurse's conduct violates T.C.A. §
63-7-115(a)(1)(C) and (F) in regard to the prescribing, administering,
ordering, or dispensing of pain medications and other drugs necessary to
address their side effects:
(1) The
treatment of pain with controlled substances serves a legitimate purpose when
done in the usual course of professional practice;
(2) An Advanced Practice Registered Nurse
duly authorized to practice in Tennessee and to prescribe controlled substances
in this state shall not be subject to disciplinary action by the Board for
prescribing, ordering, administering, or dispensing controlled substances for
the treatment and relief of pain in the usual course of professional practice
for a legitimate purpose in compliance with applicable state and federal
law;
(3) Prescribing, ordering,
administering, or dispensing controlled substances for pain will be considered
to be for a legitimate purpose if based upon accepted scientific knowledge of
the treatment of pain not in contravention of applicable state or federal law,
and if prescribed, ordered, administered, or dispensed in compliance with the
following guidelines where appropriate and as is necessary to meet the
individual needs of the patient:
(a) The
record shall include a documented medical history and physical examination by
the advanced practice registered nurse who possesses a certificate of fitness
and a DEA registration certificate and is providing the medication. Historical
data shall include pain history, any pertinent evaluations by another provider,
history of and potential for substance abuse, pertinent coexisting diseases and
conditions, psychological functions and the presence of a recognized medical
indication for the use of a controlled substance;
(b) A written treatment plan tailored for
individual needs of the patient shall include objectives such as pain relief
and/or improved physical and psychosocial function, and shall consider need for
further testing, consultations, referrals, or use of other treatment modalities
dependent on patient response;
(c)
The advanced practice registered nurse who possesses a certificate of fitness
and a DEA registration certificate shall discuss the risks and benefits of the
use of controlled substances with the patient or guardian;
(d) At each periodic interval in which the
advanced practice registered nurse, who possesses a certificate of fitness and
a DEA registration certificate and is providing care, evaluates the patient for
continuation or change of medications, the patient record shall include
progress toward reaching treatment objectives, any new information about the
etiology of the pain, and an update on the treatment plan.
(4) An Advanced Practice Registered Nurse
with a certificate of fitness to prescribe who treats chronic pain shall follow
the Tennessee Chronic Pain Guidelines.
(a) In
determining the need for any disciplinary action in regard to the advanced
practice registered nurse who possesses a certificate of fitness and a DEA
registration certificate, each case of prescribing for chronic pain will be
evaluated on an individual basis as to whether the nurse is prescribing and
practicing in a manner consistent with public health and welfare. The Board
will evaluate for proper documentation, therapeutic prescribing in a manner
using drugs that are recognized to be appropriate pharmacologically for the
diagnosis, treatment outcomes including improvement in functioning, and
recognition that some types of pain cannot be completely relieved.
(b) The quantity of pharmaceuticals
prescribed and the chronicity of prescribing will be evaluated on the basis of
the documented appropriate diagnosis and treatment of the recognized medical
indication, documented persistence of the recognized medical indication, and
properly documented follow-up evaluation with appropriate continuing care as
set out in this rule.
