N.M. Admin. Code § 16.11.2.11

Current through Register Vol. 35, No. 21, November 5, 2024

Section 16.11.2.11 - PRACTICE OF THE CERTIFIED NURSE-MIDWIFE

A. Scope of practice: Practice by CNMs encompasses independently providing a full range of primary health care services for clients from adolescence to beyond menopause. These services include primary care; sexual and reproductive health care; gynecologic health; family planning services; pre-conception care; care during pregnancy, childbirth, and the postpartum period; and care of the normal newborn up to six weeks of age. CNMs provide care for all individuals who seek midwifery care, inclusive of all gender identities and sexual orientations. CNMs provide initial and ongoing comprehensive assessment, diagnosis, and treatment. They conduct physical examinations; independently prescribe, distribute, and administer dangerous drugs, devices, and contraceptive methods, and controlled substances in Schedules II through V of Sections 30-31-1 NMSA 1978, Controlled Substances Act; admit, manage, and discharge clients; order and interpret laboratory and diagnostic tests; and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. These services are provided in partnership with clients in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals, and birth centers. A CNM practices within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client. A CNM practices in accordance with the ACNM "standards for the practice of midwifery". A CNM who expands beyond the ACNM "core competencies" to incorporate new procedures that improve care for their clients shall comply with the guidelines set out in the ACNM "standards for the practice of midwifery", standard VIII. Practice guidelines for home births should be informed by the most recent edition of the "ACNM home birth practice manual."

B.Prescriptive authority:

(1) Dangerous drugs: A CNM who prescribes, distributes, or administers a dangerous drug or device shall do so in accordance with Section 26-1 NMSA 1978, New Mexico Drug, Device and Cosmetic Act.

(2) Controlled substances:

(a) A CNM shall not prescribe nor distribute controlled substances in Schedule I of Section 26-1 1978 NMSA, Controlled Substances Act.

(b) A CNM shall not prescribe, distribute, or administer controlled substances in Schedules II-V of the Controlled Substances Act unless the CNM is registered with the New Mexico board of pharmacy and the United States drug enforcement administration (DEA) to prescribe, distribute, and administer controlled substances.

(c) A CNM who prescribes, distributes, or administers a controlled substance in Schedules II-V of Section 26-1 NMSA 1978, Controlled Substances Act, shall do so in accordance with the Controlled Substances Act.

(d) An individual employed as a CNM by the United States military, the United States veterans administration, or the United States public health service, and operating in the official capacity of that employment, who is prescribing, distributing or administering controlled substances under that facility's United States drug enforcement administration registration is exempt from the Subparagraphs (a), (b) and (c) of Paragraph (2) of this subsection.

(e) A CNM may prescribe, provide samples of, and dispense any dangerous drug to a client if, at the time of the prescription, the CNM has a valid CNM-client relationship. The relationship includes:

(i) the CNM has sufficient information to ensure that a dangerous drug or controlled substance is indicated and necessary for treatment of a condition when the CNM prescribes a dangerous drug or controlled substance;

(ii) the CNM has sufficient information to ensure that a dangerous drug or controlled substance is not contraindicated for the individual;

(iii) the CNM provides a client with appropriate information on the proper dosage, route, frequency, and duration of a drug treatment;

(iv) the CNM informs the client of possible untoward effects and side effects of a proposed treatment;

(v) the CNM provides care for a client in the event of an untoward effect or a side effect that requires care;

(vi) the CNM provides for client education regarding a condition and the condition's treatment to enhance client compliance with plan of care;

(vii) the CNM provides for appropriate follow-up care, including further testing, treatment and education, as appropriate; and

(viii) the CNM documents, at minimum, the indication, drug, and dosage of any prescribed drugs in a health record for the individual.

(3) Prescriptions: A CNM may prescribe by telephone, by written prescription, by e-mail, or through an electronic health record (EHR) system. Controlled substances may only be prescribed by written or electronic prescription. A CNM prescription shall have the CNM's name, office address, and telephone number printed on it. In the event that a CNM is writing a prescription printed with the names of more than one CNM, the name of the CNM writing the individual prescription shall be indicated. The name and address of the client, the date of the prescription, the name and quantity of the drug prescribed, and directions for use shall be included on a prescription.

(4) Labeling: When distributing a drug, a CNM shall label it with the client's name and date of birth; the date; instructions for use; and the CNM's name, address, and telephone number.

C.Guidelines for management of chronic pain or other conditions with controlled substances: The treatment of chronic pain or other conditions with various modalities, including controlled substances such as opioids, is a legitimate practice when done in the usual course of CNM practice. The goal when treating chronic pain is to reduce or eliminate pain and also to avoid development of or contribution to addiction, drug misuse and overdose. Effective dosages should be prescribed, with both under- and over-prescribing to be avoided, using client protection as a guiding principle. The CNM should provide control of the client's pain for its duration, while effectively addressing other aspects of the client's functioning, including physical, psychological, social, and work-related factors. A CNM may treat clients with substance use disorder, physical dependence, or tolerance who have pain, however such clients require very close monitoring and precise documentation.

(1) If, in a CNM's professional opinion, a client is seeking pain medication for reasons that are not medically justified, the CNM is not required to prescribe controlled substances for the client.

(2) When prescribing, dispensing, or administering controlled substances for management of chronic pain, a CNM shall:

(a) obtain a PMP report for the client covering the preceding 12 months from the New Mexico board of pharmacy and any other state's report that is applicable and available;

(b) complete a history and physical examination and include an evaluation of the client's psychological and pain status, any previous history of significant pain, past history of alternate treatments for pain, potential for substance misuse, coexisting disease or medical conditions, and the presence of medical indications or contra-indications related to controlled substances;

(c) be familiar with and employ screening tools, as well as the spectrum of available modalities for therapeutic purposes, in the evaluation and management of pain, and consider an integrative approach to pain management in collaboration with other care providers, including but not limited to acupuncturists, chiropractors, doctors of oriental medicine, exercise physiologists, massage therapists, pharmacists, physical therapists, psychiatrists, or psychologists;

(d) develop a written individual treatment plan taking age, gender, and culture into consideration, with stated objectives by which treatment can be evaluated, such as degree of pain relief, improved physical and psychological function, or other accepted measures, and include any need for further testing, consultation, referral, or use of other treatment modalities as appropriate;

(e) discuss the risks and benefits of using controlled substances with the client or legal guardian and document this discussion in the medical record;

(f) make a written agreement with the client or legal guardian outlining client responsibilities, including a provision stating that the chronic pain client will receive all chronic pain management prescriptions from one practitioner and one pharmacy whenever possible;

(g) maintain complete and accurate records of care provided and drugs prescribed, including the indications for use, the name of the drug, quantity, prescribed dosage, and number of refills authorized;

(h) when indicated by the client's condition, consult with health care professionals who are experienced in the area of the chronic pain or other conditions, though not necessarily specialists in pain control, both early in the course of long-term treatment and at least every six months;

(i) when treating a client with addiction, substance use disorder or physical dependence, use drug screening prior to and during the course of treatment to identify the drugs the client is consuming and compare the screening results with clients' self-reports (this should be included in the written agreement, see Subparagraph (f) above);

(j) note possible indications of drug misuse by a client and take appropriate steps to further investigate and to avoid contributing to drug misuse; such steps may include termination of treatment. Information about some of the indications may be available only through PMP reports. The following list of possible indications of drug misuse is non-exhaustive:

(i) receiving controlled substances from multiple prescribers;

(ii) receiving controlled substances for more than 12 consecutive weeks;

(iii) receiving more than one controlled substance analgesic;

(iv) receiving a new prescription for any long-acting controlled substance analgesic formulation, including oral or transdermal dosage forms or methadone;

(v) overutilization, including but not limited to early refills;

(vi) appearing overly sedated or intoxicated upon presentation; or

(vii) an unfamiliar client requesting a controlled substance by specific name, street name, color, or identifying marks.

(k) comply with the opioid antagonist prescribing practices as set forth in the Pain Relief Act Section 24-2D-1, et.al NMSA 1978.

D.Prescription Monitoring Program (PMP) Requirements: The department requires participation in the PMP to assist practitioners in balancing the safe use of controlled substances with the need to impede harmful and illegal activities involving these pharmaceuticals. Any practitioner who holds a federal drug enforcement administration registration and a New Mexico controlled substance registration shall register with the board of pharmacy to become a regular participant in PMP inquiry and reporting. A practitioner may authorize delegate(s) to access the prescription monitoring report consistent with board of pharmacy regulation 16.19.29 NMAC. While a practitioner's delegate may obtain a report from the state's prescription monitoring program, the practitioner is solely responsible for reviewing the prescription monitoring report and documenting the receipt and review of a report in the client's medical record.

Before a practitioner prescribes or dispenses for the first time, a controlled substance in Schedule II, III, IV or V to a client for a period greater than four days, or if there is a gap in prescribing the controlled substance for 30 days or more, the practitioner shall review a prescription monitoring report for the client for the preceding 12 months. When available, the practitioner shall review similar reports from adjacent states. The practitioner shall document the receipt and review of such reports in the client's medical record. A prescription monitoring report shall be reviewed a minimum of once every three months during the continuous use of a controlled substance in Schedule II, III, IV or V for each patient. The practitioner shall document the review of these reports in the patient's medical record. Nothing in this section shall be construed as preventing a practitioner from reviewing prescription monitoring reports with greater frequency than that required by this section.

(1) A practitioner does not have to obtain and review a prescription monitoring report before prescribing, ordering, or dispensing a controlled substance in Schedule II, III, IV or V:

(a) for a period of four days or less; or

(b) to a client in a nursing facility; or

(c) to a client in hospice care.

(d) or when prescribing, dispensing, or administering of: testosterone, pregabalin, lacosamide, ezogabine or stimulant therapy for pediatric clients less than age 14.

(2) Upon review of a prescription monitoring report for a client, the practitioner shall identify, be aware, and document if a patient is currently:

(a) receiving opioids from multiple prescribers;

(b) receiving opioids and benzodiazepines concurrently;

(c) receiving opioids for more than 12 consecutive weeks;

(d) receiving more than one controlled substance analgesic;

(e) receiving opioids totaling more than 90 morphine milligram equivalents per day;

(f) exhibiting potential for misuse of opioids and other controlled substances, such as any of the following indicators:

(g) over-utilization;

(h) requests to fill early;

(i) requests for a controlled substance or specific opioid by specific name, street name; color, or identifying marks;

(j) requests to pay cash when insurance is available;

(k) receiving opioids from multiple pharmacies; or

(l) appearing overly sedated or intoxicated upon presentation.

(m) receiving a new prescription for any long-acting controlled substance analgesic formulation, including oral or transdermal dosage forms or methadone.

(3) Upon recognizing any of the above conditions described in Subparagraph (j) of Paragraph (2) of Subsection C of 16.11.2.11 NMAC, the practitioner, using professional judgement based on prevailing standards of practice, shall take action as appropriate to prevent, mitigate, or resolve any potential problems or risks that may result in opioid misuse or overdose. These steps may involve counseling the client on known risks and realistic benefits of opioid therapy, prescription and training for naloxone, consultation with or referral to a pain management specialist, or offering or arranging treatment for opioid or substance use disorder. The practitioner shall document actions taken to prevent, mitigate, or resolve the potential problems or risks.

(4) Practitioners licensed to practice in an opioid treatment program, as defined in 7.32.8 NMAC, shall review a prescription monitoring report upon a client's initial enrollment into the Opioid Treatment Program and every three months thereafter while prescribing, ordering, administering, or dispensing opioid treatment medications in Schedule II-V for the purpose of treating opioid use disorder. The practitioner shall document the receipt and review of a report in the client's medical record.

E.Immediate reporting: A CNM must report within 48 hours to the division any neonatal or maternal mortality in clients for whom the provider has cared in the perinatal period in a setting other than a licensed health facility; this includes stillbirths. These will be reviewed by the division on a case-by-case basis for compliance with these CNM regulations.

F.Other rules: a CNM shall fulfill the requirements of all relevant department rules including:

(1) "bureau of vital records and health statistics," 7.2.2 NMAC;

(2) "control of disease and conditions of public health significance," 7.4.3 NMAC;

(3) "newborn genetic screening," 7.30.6 NMAC;

(4) "prevention of infant blindness," 7.30.7 NMAC;

(5) "requirement for freestanding birth centers," 7.10.2 NMAC; and

(6) "birthing workforce retention fund," 7.30.9 NMAC.

N.M. Admin. Code § 16.11.2.11

16.11.2.11 NMAC - Rp, 16.11.2.11 NMAC, 8/30/13, Adopted by New Mexico Register, Volume XXX, Issue 12, June 25, 2019, eff. 6/25/2019, Adopted by New Mexico Register, Volume XXXI, Issue 22, November 24, 2020, eff. 11/24/2020, Adopted by New Mexico Register, Volume XXXV, Issue 09, May 7, 2024, eff. 5/7/2024