Section 1000-04-.08 - TREATMENT OF PAINThe purpose of this rule is to recognize that some controlled substances are indispensable 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 of Nursing that these drugs may be prescribed for the treatment of pain and other related symptoms after a reasonably based diagnosis has been made, in adequate doses, and for appropriate lengths of time, which in some cases may be as long as the pain or related symptoms persist. The Board recognizes that pain, including intractable 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 Nurse, who possesses a certificate of fitness issued by the Board and possesses a Drug Enforcement Administration (DEA) Certificate to Prescribe Controlled Substances, is expected to exercise sound judgment in treating pain and related symptoms with controlled substances.
(1) Definitions. The following words and terms, as used in this rule shall have the following meanings in the context of providing medications for pain and related symptoms. (a) Abuser of narcotic drugs / controlled substances - A person who takes a drug or drugs for other than legitimate medical purposes.(b) Intractable pain - A pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts.(c) Non-therapeutic in nature or manner - A medical use or purpose that is not legitimate.(d) Prescribing pharmaceuticals or practicing consistent with the public health and welfare - Prescribing pharmaceuticals and practicing Advanced Practice Nursing for a legitimate purpose in the usual course of professional practice.(2) An Advanced Practice Nurse who does not choose to provide long-term pain management to patients with intractable pain shall offer the patient a referral to a practitioner whose primary practice is in the treatment of severe, chronic, intractable pain with methods including the use of opiates. If the patient requests such a referral the APN shall assist in the transition to another provider for the purpose of pain management.(3) An Advanced Practice Nurse possessing a certificate of fitness issued by the Board and a DEA certificate who provides care for persons with intractable pain with or without opiates is expected to demonstrate current knowledge of long-term pain management.(4) Guidelines - The Tennessee Board of Nursing will use the following guidelines to determine whether an Advanced Practice Nurse's conduct violates T.C.A. § 63-7-115(a) (1) (A) through (G) in regard to the prescribing, administering, ordering, or dispensing of pain medications and other drugs necessary to address their side effects. (a) The treatment of pain, including intractable pain, with controlled substances serves a legitimate purpose when done in the usual course of professional practice.(b) An Advanced Practice 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, including intractable pain, in the usual course of professional practice for a legitimate purpose in compliance with applicable state and federal law.(c) 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, including intractable 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. 1. The record shall include a documented medical history and physical examination by the Advanced Practice Nurse who possesses a certificate of fitness and a DEA 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;2. 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;3. The Advanced Practice Nurse who possesses a certificate of fitness and a DEA certificate shall discuss the risks and benefits of the use of controlled substances with the patient or guardian;4. At each periodic interval in which the Advanced Practice Nurse, who possesses a certificate of fitness and a DEA 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.(d) In determining the need for any disciplinary action in regard to the Advanced Practice Nurse who possesses a certificate of fitness and a DEA 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 of Nursing 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.(e) Quantity of pharmaceuticals and 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.(f) An Advanced Practice Nurse may use any number of treatment modalities for the treatment of pain, including intractable pain, which are consistent with legitimate medical purposes.(g) These rules shall not be construed so as to apply to the treatment of acute pain with controlled substances for purposes of short-term care.Tenn. Comp. R. & Regs. 1000-04-.08
Original rule filed October 18, 2004; effective January 1, 2005.Authority: T.C.A. §§ 4-5-202, 4-5-204, 53-11-301, 63-7-115, 63-7-123, 63-7-126, and 63-7-207.