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Florida ARNP's OPIOID PRESCRIBING

casias12 casias12 (Member) Nurse

casias12 specializes in Cardiology nurse practitioner.

Summary: HB 423 passed in Florida this year, and will allow for precribing controlled substances by ARNP/PA's in Florida beginning January 1, 2017. While it includes all scheduled drugs, my question pertains to opioids.

I just attended a course which was supposed to answer all of the questions, but I left with more questions than answers.

The basics of the law are:

1) Must be MSN or higher.

2) CS II are limited to 7-day supply. All others, CS III-V are without limits or forumlary.

The most concerning statement they made in the conference, over and over and over, was that the law does not support prescribing for non-malignant, chronic pain. However, this is the update on the Florida BON website that discusses this. Am I missing something?

From Florida BON website. (Bold added). Florida Board of Nursing >> *UPDATE* – Register As A Controlled Substance Prescriber - Licensing, Renewals & Information

In accordance with section 456.44(2), Florida Statutes, an allopathic physician licensed under Chapter 458, an osteopathic physician licensed under Chapter 459, a podiatric physician licensed under Chapter 461, a dentist licensed under Chapter 466, a physician assistant licensed under Chapter 458 or Chapter 459, or an advanced registered nurse practitioner certified under part I of Chapter 464 who prescribes any controlled substance listed as Schedule II, Schedule III, or Schedule IV narcotics as defined in s. 893.03, FOR THE TREATMENT OF CHRONIC NONMALIGNANT PAIN, must designate himself or herself as a controlled substance prescribing practitioner on the practitioner profile.

And at the bottom of the announcement from the same web page

Chronic nonmalignant pain” is defined as pain unrelated to cancer which persists beyond the usual course of disease or the injury that is the cause of the pain or more than 90 days after surgery.

And here is the portion of the law regarding this, lines 230-237. Click on pictures to see entire document.

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Buyer beware specializes in GENERAL.

OP:

I will just say this:

Just try as a patient to get even a 7 day supply of opioid drugs from most physicians in Florida these days for ANY reason especially if they don't know you. You can forget it.

Those days are over.

You know the historical drill, I hope, of the drug armageddon that has gone on here and continues to go on.

The pill mill "businessmen" along with their physician accomplices are now charged with murder and/or sitting in jail.

OP consider this law as a protective one for all concerned.

Yes, it's paternalistic but so it goes.

Take care of the people who want you not the ones who need you as a one stop destination for someone's drug needs.

The last thing you want to deal with is a good intentioned murder wrap.

Do youself a favor. If you feel comfortable do it as sanctioned by law.

Otherwise send them to the dolorologist kicking and screaming that they'e going to kill you if need be.

It beats personal and professional doom.

casias12 specializes in Cardiology nurse practitioner.

I've never tried to get opioids from a physician, so I don't know what it is like. But I do know many physicians who prescribe regularly, even for chronic non-malignant pain.

That being said, a prudent clinician is going to assess the patient to determine the type of pain, and clearly document it. Then create a plan that includes alternative non-opioid treatment. Having a pain contract with the patient has to include requirements on the patient's part to trial non-opoioid options. Failing to follow the contract leads to dismissal.

The standard in Florida is 3 month visits. Then, if its Schedule II, provide the patient with (3) 1-month prescriptions, each with the statement, "do not fill until ".

But I do think that patient should be referred to pain management after some reasonable period of time. Just like we refer to cardiology, nephrology and wound care centers, pain needs a specialist who follows evidence-based practice and knows the pitfalls.

Do you hold a DEA prescribing license?

If so for acute ER opioid medication is max 15. Private practice you can write up to 240

casias12 specializes in Cardiology nurse practitioner.

Do you hold a DEA prescribing license?

If so for acute ER opioid medication is max 15. Private practice you can write up to 240

Not yet. I can get it in January.

15 what? 240 what? That doesn't make any sense.

Each state governs prescribing practice. In Florida, MD's have to write a paper script for up to 30 days at a time for chronic pain management. But, they only have to do a face-to-face every 90 days. So most of them write (3) one month scripts, with each one stating "do not fill until" on the script. Some have the patient come in every month to pick up the script from the desk.

lhflanurseNP specializes in Adult Nurse Practitioner.

If you haven't already done so, please attend one of the many classes that are being held that go over controlled substances for the upcoming changes to the Florida NP scope of practice. Class II can only have a 7 day limit when written by NP or PA. There are also rules about how and when to do controlled drugs.

casias12 specializes in Cardiology nurse practitioner.

If you haven't already done so, please attend one of the many classes that are being held that go over controlled substances for the upcoming changes to the Florida NP scope of practice. Class II can only have a 7 day limit when written by NP or PA. There are also rules about how and when to do controlled drugs.

Guess you didn't read my first post.

I just went to one. It was total garbage, full of misinformation and not state specific. Total waste of a day and $200.

State-specific rules are, state-specific. That's why I was hoping to find some FL NP's planning to prescribe in Florida who have looked into the laws in-depth.

Quantity 15 or quantity 240.

Hmm. I've never seen a quantity limit in Florida, just the rules that I stated in my previous post.

casias12 specializes in Cardiology nurse practitioner.

If you haven't already done so, please attend one of the many classes that are being held that go over controlled substances for the upcoming changes to the Florida NP scope of practice. Class II can only have a 7 day limit when written by NP or PA. There are also rules about how and when to do controlled drugs.

Guess you didn't read my first post.

Quantity 15 or quantity 240.

Hmm. I've never seen a quantity limit in Florida, just the rules that I stated in my previous post.

I understand.

In Nevada CII drugs can be written for 30 days and Max 240 quantity.

Gotcha. Still trying to figure out your first response. You use ER. Does this mean extended realease? If so, acute and extended release don't really go together. And 240 is a butt-load of ER pills for a month. If someone is prescribing ER opioids 8 times a day, they need a visit from the DEA.

What happens with acute pain? Say, for instance, a patient has a fairly large abdominal surgery, hernia repair or something, and goes home to recoup. 15 pills wouldn't even scratch the surface if they are taking hydrocodone 4-5 times a day for a couple of weeks. It's clearly not a chronic pain, so is the limit still 15 pills at a time?

lhflanurseNP specializes in Adult Nurse Practitioner.

casias12...in Florida we are restricted to a 7 day limit on Class II drugs. While this seems limited...and it is...some states do not allow NPs to write for Class II drugs at all. It never ceases to amaze me the differences in state practice laws...go figure!

casias12 specializes in Cardiology nurse practitioner.

casias12...in Florida we are restricted to a 7 day limit on Class II drugs. While this seems limited...and it is...some states do not allow NPs to write for Class II drugs at all. It never ceases to amaze me the differences in state practice laws...go figure!

You really don't want to read my first post, do you. Your like someone who looks up halfway through a meeting and asks a question that was already addressed. Go back to texting or whatever you were doing before you tried to shame me.

First. It's not Class. It's Schedule.

Second. My inquiry is not about schedules of opioids. It is about the use of controlled substances in chronic, non-malignant pain.

So, let's move away from SCHEDULE II drugs, and maybe talk about a very common medication prescribed for the elderly. Tamadol. According the the statute, this can be prescribed for 30 days by NP's in Florida. But that would likely be for chronic, non-malignant pain.

As I pointed out, the worthless education seminar I paid for claimed this was not in our scope. But the statute says otherwise. So, do you prescribe it for an elderly person with chronic joint pain, or not?

WKShadowNP specializes in Hospital medicine; NP precepting; staff education.

casias12...in Florida we are restricted to a 7 day limit on Class II drugs. While this seems limited...and it is...some states do not allow NPs to write for Class II drugs at all. It never ceases to amaze me the differences in state practice laws...go figure!

.

Thank you for your thoughtful reply. I like this discussion because it highlights what I need to observe in my state. I cannot write for schedule IIs and with hydrocodone being relegated to this category it leaves me to write only tramadol or Tylenol #3. I will not prescribe for chronic pain if I can avoid it.

casias12 specializes in Cardiology nurse practitioner.

.

Thank you for your thoughtful reply. I like this discussion because it highlights what I need to observe in my state. I cannot write for schedule IIs and with hydrocodone being relegated to this category it leaves me to write only tramadol or Tylenol #3. I will not prescribe for chronic pain if I can avoid it.

It has been a challenge to get this discussion going on this forum. I don't come to this forum often, but so far, the discussion has been lame at best. Maybe there aren't any NP's in Florida how visit this site, or just aren't interested in this recent change to our prescribing rights.

It has been an interesting year in Florida on this topic. The law was signed in April, with the ability to prescribe beginning in January, 2017.

I've had several discussions with other NP's, and attended a canned course that was supposed to be FLorida-specific. However, the speaker admitted several times she really didn't know the answer for Florida, but would answer any questions that came up if you emailed your question later. 1100 NP's attended the single-day event. I imagine she was flooded with questions, and probably won't answer them individually, if at all.

But, reading into the intent of the law, I think that the reason for the 7-day restriction is misunderstood by many. First, the lobbyists wanted to promote the appearance of "reasonable request", to lawmakers. We were given the ability to write for schedule II, but lawmakers felt better that there was a reasonable limit.

It's as if they thought, "well 7 days should be safe enough". Yeah, but 7 days of opioids can kill as easy as 2 days worth or 30 days worth. And, think about how short-sighted this was. Let's give NP's new to prescribing the ability to test the waters with CSII for acute pain. These patients who are likely opioid-naive, possible young and immature, and maybe, just maybe shopping for their first high.

Managing seasoned veterans with chronic conditions and years of opioid use under their belt is much safer, in my opinion, but I wasn't there when the intent of the law was discussed.

But what this does is provide NP's with an ability to treat patient more efficiently. There are many scenarios where NP's work without a physician at their elbow. Maybe you are a full-time NP in a practice in rural Florida that has a part-time physician. Maybe you have a patient on tramadol for 4 months, and they visit the office with the story that they feel somewhat improved, but the effect is waning. This is not a drug-seeking patient, just someone lookng for a little relief. So, after careful deliberation and discussion, you move the patient up to hydrocodone. With this law, you can prescribe for 7 days trial, and start the patient today. Have the physician sign for 3 - 30 day scripts when he/she comes in the office, and have the patient come back and pick them up. When they come in, ask them how it is working, and make a note of that.

At least as I understand the law. Good management of chronic pain in an internal medicine setting, and within the bounds of the law.

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