Treatment Of Pain

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, ADVANCED PRACTICE REGISTERED NURSES CHAPTER 1000-04 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.