APRN Regulations in California

Nurse Practice Act in California entrusts APRNs to do an advance evaluation of patients. Advanced Practice Registered Nurse (APRN) is also responsible for ordering and analyzing diagnostic processes. Nurse practitioners (NP) are those registered as nurses having satisfied the additional education that enables them to be prepared to deliver diverse services such as diagnosing and treating acute and chronic diseases (Cimiotti et al., 2019). Moreover, the nurses are given the mandate to come up with the main and differential diagnoses in various states. The APRN has also been assigned the responsibility to prescribe, dispense drugs, order and furnish the therapeutic procedures as illustrated in the Act differently in various states (Neff et al., 2018). This also incorporates assigning or delegating some of the processes of therapy to be handled by the assistive personnel. The state licensure controls the processes and practice of APRN. Nursing practice in California must engage in certain practices and procedures as prescribed by the state law, with the NPs having undergone the required education and training. 

The Agencies that Regulate/ Oversee APRN Prescribing in California 

The administrators of the health board and health professionals together have developed standardized procedures that guide NPs. An NP can furnish prescription drugs and substances as long as it matches the standardized procedures or protocol (Phillip, 2015). The NP should determine a periodic assessment by a supervising physician or surgeon who must not be present physically, but can be reached via phone whenever a patient is examined (Cimiotti et al., 2019). The NP has a collaborating or supervising physician who is certified, trained and authorized to treat and manage patients. The NP, under those circumstances, can prescribe buprenorphine-containing substances provided they are consistent with federal law. 

An NP in California is privileged to prescribe drugs under schedule II, III and IV. Drugs in the schedule I are life threatening and often misused, thus, attracting high levels of regulation. The authority to prescribe can only be given when a person has the NP title as well as the furnishing number. The state collaboratively utilizes standardized procedures with the physician to prescribe controlled drugs (Chapman, Toretsky, & Phoenix, 2019). Thus, NPs in California can freely prescribe control drugs like hallucinogens, cannabis, and narcotics. This mandate is not the same as the regulation practice of the nurse. The nurse must register and be given a registration number by the DEA to attain such a privilege. 

Educational requirements for prescribing as an APRN in California 

Every state in the US has its own board of nursing that gives a framework and licenses regarding the requirements of NPs. In the state of California, a full practice authority is mandated, authorizing NPs to prescribe but under a physician's oversight role. Educational requirements needed for NPs are an RN license, a graduate degree as well as national certification (Cimiotti et al., 2019). The licensure law and state practice give all the NPs the authority to assess patients, do diagnosis, order and interpret tests, begin and regulate treatments such as prescribing medicines subject to the exclusive licensure oversight of the state board of nursing. 

NPs in California need to successfully complete a bachelor's degree in nursing practice to have the needed credentials. The degree makes the nurse qualified to join a graduate degree program that is needed for all healthcare practitioners. Neff et al. (2018) elaborate that the national certification that the NPs are required to complete happens after they have done the National Council Licensure Examination to attain a California license that is issued respectively (Chapman, Toretsky, & Phoenix, 2019). Background scrutiny is done for all the applicants to establish if they are truly meeting the credentials and eligible to be NPs in California. 

The Differences in Regulations in California and New York 

The prescriptive authority for nurse practitioners in California is a physician or surgeon who offers oversight. As far as the prescriptive authority in the state of New York is concerned, newly certified NPs should have a written collaborative agreement and protocol with a physician and secure DEA registration (Valentine, 2016). The NP can prescribe medication or medical instruments in California provided he or she has acquired a furnishing number (Neff et al., 2018). As for New York, the NP with above 3600 hours of qualifying experience could choose to have a collaborative relationship that gives moderately more professional independence than a written agreement. 

In California, nurse practitioners just need collaborative rights to prescribe drugs and devices. Once there is a collaborative agreement with the physician, the NP has the right to prescribe substances within schedule II, III and IV without any fear (Chapman, Toretsky, & Phoenix, 2019). The NPs can also examine a patient, diagnose them, and prescribe substances without physician supervision in California. New York Law limits the use of the "nurse" title to individuals that have been licensed by the State Education Department (SED) as a nurse practitioner, licensed practical nurse, registered professional nurse, or clinical nurse specialist. One has to be registered and licensed as a nurse with SED to practice in New York (Valentine, 2016). A licensed professional like a physician may not allow tasks that fall on their docket to be done by another licensed professional who is not qualified to handle the task within his or her licensed scope of practice. 

An outline of the actions required to prescribe in your identified state 

First, one would need to apply for APRN licensure and a furnishing license. A furnishing number is required for the nurse to be allowed to prescribe in California. The pharmacology component of one's NP program curriculum (educational requirements) should satisfy the state requirements to prescribe Schedule II drugs (Cimiotti et al., 2019). Secondly, one would have to acquire a DEA number. NPs are allowed to prescribe having only the furnishing number. However, the controlled substances may not be prescribed unless one has a DEA Number. 

Thirdly, one has to complete an approved continuing education prescribing course. This is a minimum 3-hour approved CE course, which fulfills a particular set of educational objectives to be allowed to prescribe Schedule II controlled drugs. The course that needs to be completed is provided through the California Association for Nurse Practitioners (Chapman, Toretsky, & Phoenix, 2019). Finally, the nurse has to apply for a Schedule II furnishing license. This entails the Board of Nursing recognizing someone after completing the prescribing education. 

Summary of the Controlled Substances regulations in California and the process for obtaining DEA registration 

There are stricter regulations to prescribe controlled substances such as narcotics by the NP in California. Whenever the controlled substances are prescribed according to the standardized rules, the prescribing NP may not face any disciplinary action (DEA, 2016). The NP in collaboration with the physician should demonstrate the utmost care needed when administering controlled substances like narcotics (Phillips, 2015). The law needs administration of controlled substances in cases where addiction from the illness have been aggravated by serious accidents as well as the existence of an incurable illness. 

An NP in California may obtain a DEA registration in many ways. One of the means is by completing the Official Order Forms that are found in any closer office of the DEA headquarters within the state. The individual requests the form, which is sent to him or her through an email within ten working days (Cimiotti et al., 2019). Another means of getting the order forms is by filling the requisition forms, DEA form 222a and sending it via mail to the DEA headquarters (Chapman, Toretsky, & Phoenix, 2019). An NP can acquire the Official Order Forms without any payment and without them; an NP cannot apply or have the DEA number. Official Order forms could also be downloaded from the DEA's website. 

Effectively Communicating with Patients about Opioid Therapy 

The patients that have been dependent on opioids may not consider a change from the onset. However, through motivational interviewing, their perspectives may be shifted and they themselves can be made ready for change. Motivational interviewing incorporates principles of communication so that the patient is helped to consider tapering opioids (Dowell, Tauben, & Merrill, 2016). Effective communication with patients could be attained through motivational interviewing to determine their concerns and goals and recommend solutions for them. 

The first aspect in motivational interviewing would be to uncover patient concerns using open-ended questions. The best approach would be to be a good listener, meditate and show the recommended empathy to the patient. The patient should feel the concern you have for him or her and see you as one who is interested to help them overcome (Carlson, Wise, & Gilson, 2019). Following this, the practitioner should be able to separate the goals and values that the patient aspires to have from their present behavior, which can be achieved through reflection and meditation. 

Many of the patients have mixed feelings regarding opioids, particularly if they are on long-term opioid therapy. Thus, it is good to be reflective and determine the thoughts of patient on opioids. It is also necessary to determine whether they feel the therapy is helpful or otherwise. Dowell, Tauben, and Merrill (2016) reiterate that any mixed feelings can be taken back to the patient while demonstrating concern. The practitioner should refrain from direct confrontation so that the patient does not withdraw himself from the therapy process (Talusan et al., 2016). The patient should be given a listening ear and be handled in a friendly manner. This can be achieved by reacting to the patient in a more neutral manner that does not demean him or her, for instance, by reframing the conversation. 

The patient's concerns and goals must be recognized before handling them. Empathy and normalization help to appreciate the concerns and feelings of the patient so that he or she cooperates. There are ways to communicate to patients even if the practitioner recognizes that opioids should not be recommended for them (Dowell, Tauben, & Merrill, 2016). The patient should understand that opioids do not effectively alleviate fibromyalgia pain as much as it may expose him to dependence as well as overdose (Carlson, Wise, & Gilson, 2019). In conclusion, good communication with patients regarding opioids is critical to influencing change in them. The counselor must be optimistic about the patient irrespective of the current behavior. 

The practitioner should take note of a resistance talk with the patient once it presents itself. The goal of the practitioner would be to achieve common ground with the patient so that they both understand one another. He needs to uncover the worries of the patient of not depending on opioids and analyze them before helping him see the various perspectives that are beneficial (Talusan et al., 2016). The patient should feel that the practitioner is on his side and they are in a comfortable place. Any affirmative statements of the patients would be helpful if repeated so that they understand that the practitioner is on their side (Dowell, Tauben, & Merrill, 2016). A lot of education should be avoided in a motivational interview so that many suggestions are squeezed from the patient as much as possible. 

CDC Guideline for Prescribing Opioids for Chronic Pain 

Chronic pain is a renowned public health concern. There are effective alternatives suggested to manage chronic pain, and opioids have often been prescribed as one of them. Today, care providers have demonstrated their views on opioids, the addiction possibility and have identified a deficient training in pain management as it relates to using opioids (Dowell, Haegerich, & Chou, 2016). Even with the increased use of opioids in recent years, the pains are still insisting as well as deaths that occur because of overdose. 

CDC has prescribed a guideline to aid in opioid prescribing in primary care to enhance pain management and prevent misuse, abuse and cases of overdose by patients to relieve their pain. The guideline of CDC was a result of a comprehensive systematic literature review and input of experts and other significant stakeholders. The guideline was reviewed by the National Center for Injury Prevention and Control Board of Scientific Counselors before its publishing. The evidence that reinforced the recommendations include the recognition that opioid dependence in many healthcare settings ranged from three to twenty six percent (Dowell, Haegerich, & Chou, 2016). Many patients died because of higher dosages of opioids. There were no differences noted when more dosages were taken by patients (Talusan et al., 2016). There was also a heightened possibility of long-term utilization of opioids if they were at all used for acute pain. 

A number of recommendations were made to establish when to start utilizing or continue using opioids for chronic pain. Practitioners were to opt for opioid therapy in cases when speculated advantages for both the pain and function are projected to exceed the risks to the patient. Before the administration of opioid therapy, clinicians are expected to determine treatment goals together with all patients for pain and function and anticipate how the therapy can be stopped if the advantages do not exceed the risks (Dowell, Haegerich, & Chou, 2016). Before initiating and continuing the opioid therapy, the clinicians should also discuss the adverse impacts of opioids use such as possible fatal overdoses, serious disorders, constipation, tolerance, and many more. According to Hudspeth (2019), the clinician should select predictable pharmacokinetics and pharmacodynamics to reduce the susceptibilities to overdose. At the initial prescription of opioids, the clinician should prescribe the least effective dosage. The clinician should assess the patient and establish whether they are ready to receive specific dosages before they increase them. 

A Conclusion for Opioid Prescribing as an APRN 

Both patients and clinicians would be advantaged if they consider doing serious research on opioid use and risk mitigation approaches. In fact, there are less evidence and facts to authenticate the present client's prescribing guidelines. The guidelines prescribed in the CDC utilized the GRADE framework to group evidence into four categories from high to low-quality evidence (Talusan et al., 2016). Randomized controlled trials that could directly correspond to the decisions made by clinicians on a daily basis are limited. The GRADE framework is instrumental in guiding how to rate the evidence before making recommendations by also considering the benefits, risks and other factors associated with each decision. 

The stigma surrounding opioid misuse can cause patients to be reluctant from seeking therapy services. Nurse practitioners can be instrumental through employing effective communication to reduce such stigmatization among patients. They can adapt to be nonjudgmental, empathetic and supportive as they are of help to patients depending on opioids. Addressing opioids should begin with a comprehensive assessment and diagnosis of patients using them. The NP can only develop a proper plan and interventional strategy when they have established the true condition of the patient through motivational interviewing. This could include screening for tobacco use and other behavioral health challenges. 

The process of decision-making should be patient-centered that incorporates sharing the inputs of not just the NP but also the patients (since they have their own preferences and values). The NP can achieve this by describing alternatives for the patient and helping him explore his preferences before they decide on the treatment plan. The recommendations of the CDC are very significant when making a treatment plan for the patient. Special considerations should be taken so that the NP effectively regulates the withdrawal symptoms associated with the treatment plan. The withdrawal symptoms may be experienced for a long time, so the patient should consistently cooperate as the clinician administers the therapeutic dose on him. 

References 

Chapman, S. A., Toretsky, C., & Phoenix, B. J. (2019). Enhancing Psychiatric Mental Health Nurse Practitioner Practice: Impact of State Scope of Practice Regulations. Journal of Nursing Regulation, 10(1), 35-43. 

Cimiotti, J. P., Li, Y., Sloane, D. M., Barnes, H., Brom, H. M., & Aiken, L. H. (2019). Regulation of the Nurse Practitioner Workforce: Implications for Care Across Settings. Journal of Nursing Regulation, 10(2), 31-37. 

Neff, D. F., Yoon, S. H., Steiner, R. L., Bejleri, I., Bumbach, M. D., Everhart, D., & Harman, J. S. (2018). The impact of nurse practitioner regulations on population access to care. Nursing outlook, 66(4), 379-385. 

Phillips, S. J. (2015). 27th Annual APRN legislative update: advancements continue for APRN practice. The Nurse Practitioner, 40(1), 16-42. 

Valentine, N. M. (2016). Advancing Advanced Practice Nurses in Illinois: Challenges in the Land of the American Medical Association. 

Carlson, C., Wise, M., & Gilson, A. M. (2019). State Boards of Nursing Guidance to Mitigate Prescription Opioid Misuse and Diversion. Pain Management Nursing. 

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. 

Dowell, D., Tauben, D. J., & Merrill, J. O., (2016). Effectively Communicating with Patients about Opioid Therapy. 

Hudspeth, R. (2019). Mitigating Responses to the Opioid Crisis. Journal of Nursing Regulation, 10(1), 57-64. 

Talusan, R., Kawi, J., Candela, L., & Filler, J. (2016). Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic. Federal Practitioner, 33(11), 22.