December 13, 2013  – FRIDAY THE THIRTEENTH – Counting today there are three days until Indiana’s Emergency Pain Regulations go into effect (on Sunday, December 15, 2013).

The Painful Truth (my opinion) today examines the last three sections 10, 11, & 12.

SECTION TEN deals with Physician Assistants (PA) and Advanced Practice Registered Nurses (APRN).

The Painful Truth notes the EMERGENCY REGULATIONS are from the Medical Licensing Board of Indiana, which only has jurisdiction over PHYSICIANS. Physician Assistants and Advanced Practice Registered Nurses each have separate licensing boards.

Regarding Physician Assistants, Section 10 notes that PA duties and responsibilities must be “within the supervising physician’s scope of practice.”

The Painful Truth believes the Regulations could be interpreted as delineating a physician’s scope of practice. By this interpretation, physician assistants would be required to follow the Board of Medical Licensure’s Regulations.

The Painful Truth also believes that, since they do not place limits on opioid prescribing, the Regulations could be interpreted as not delineating a physician’s scope of practice. By this interpretation, physician assistants would not be required to follow the Board of Medical Licensure’s Regulations.

Regarding Advanced Practice Registered Nurses, Section 10 does not mention “scope of practice.” Thus, APRNs (considered more independent of physician supervision than PAs) would not be required to follow the Board of Medical Licensure’s Regulations.

Lending more credence to the concept that the Regulations do not apply to PAs and APRNs is language from Senate Bill 246 that was passed in this year’s Indiana State Legislature:

The state board of pharmacy or any licensing board, commission, or agency that controls, authorizes, or oversees controlled substance registrations under IC 35-48-3 shall adopt rules necessary to complement the rules adopted by the medical licensing board under this chapter.

If PAs and APRNs were subject to the rules of the Medical Licensing Board, there would be no need for a law requiring their boards to adopt complementary rules. Note: As of today – December 12, 2013 – no other boards have adopted any complementary rules.

The Indiana Board of Pharmacy will consider emergency rules at its meeting in January 2014.

The Painful Truth reminds physicians that requisite supervisory agreements allow PHYSICIANS to place limits on prescriptive practices for the PA’s and APRN’s they supervise. To illustrate this point, The Painful Truth received an email on December 12, 2013 sent by the Indiana Professional Licensing Agency stating:

“Professionals that hold a license to practice should review all collaborative agreements with Advance Practice Nurses and Physician’s Assistants to assure that they are in compliance with the new rule.”

SECTION ELEVEN describes circumstances allowing waivers of the initial INSPECT and initial drug monitoring test.

The Painful Truth believes Section Eleven was included to ease transition to regulatory compliance for patients currently receiving chronic opioid therapy.

The requirement for an initial INSPECT is waived if, prior to December 15, 2013, a patient has reached the thresholds described in SECTION 3

i.e., prescribed more than sixty opioid-containing pills a month; or a morphine equivalent dose of more than fifteen milligrams per day; for more than three consecutive months.

Regardless, an INSPECT must be done by November 1, 2014.

The requirement for an INITIAL drug monitoring test at the outset of an opioid treatment plan (SECTION 8) is waived if, prior to January 1, 2015, a patient has reached the threshold described in SECTION 3

i.e., prescribed more than sixty opioid-containing pills a month; or a morphine equivalent dose of more than fifteen milligrams per day; for more than three consecutive months.

The Painful Truth believes INSPECT reports and drug screens should be done “early and often.” Include reports from border states (e.g. Kentucky’s KASPER) when available. Also note that (as stated in section THREE) if a physicians does a dug screen or INSPECT… “any subsequent requirements are determined by when the initial evaluation would have been required and not at the earlier date it actually was conducted.”

SECTION TWELVE simply and clearly says that the Emergency Pain Regulations are effective on December 15, 2013.

The Painful Truth reminds physicians that there are three vital elements to success when prescribing opioids for chronic pain.

1.  The wellness of the patient
2.  The safety of the community
3.  The security of your practice

If any of these three “balls” are dropped, the outcome can be disastrous. Thorough knowledge of these Emergency Regulations and diligent adherence to their conservative interpretation will make the juggling easier.

Now go treat some pain…