New Jersey-2018-S1348-Introduced

An Act concerning medication assisted treatment and amending P.L.1991, c.378 and P.L.1991, c.377.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. Section 7 of P.L.1991, c.378 (C.45:9-27.16) is amended to read as follows:

7. a. A physician assistant may perform the following procedures:

(1) Approaching a patient to elicit a detailed and accurate history, perform an appropriate physical examination, identify problems, record information, and interpret and present information to the supervising physician;

(2) Suturing and caring for wounds including removing sutures and clips and changing dressings, except for facial wounds, traumatic wounds requiring suturing in layers, and infected wounds;

(3) Providing patient counseling services and patient education consistent with directions of the supervising physician;

(4) Assisting a physician in an inpatient setting by conducting patient rounds, recording patient progress notes, determining and implementing therapeutic plans jointly with the supervising physician, and compiling and recording pertinent narrative case summaries;

(5) Assisting a physician in the delivery of services to patients requiring continuing care in a private home, nursing home, extended care facility, or other setting, including the review and monitoring of treatment and therapy plans; [and]

(6) Referring patients to, and promoting their awareness of, health care facilities and other appropriate agencies and resources in the community[.] ; and

(7) (Deleted by amendment, P.L.2015, c.224)

(8) Dispensing narcotic drugs for maintenance treatment or detoxification treatment, provided that the physician assistant is otherwise authorized to order, prescribe, and dispense controlled dangerous substances pursuant to P.L.1991, c.378 (C.45:9-27.10 et seq.) and has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823. A physician assistant who is authorized to dispense such drugs may dispense the drugs regardless of whether the supervising physician has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823, and regardless of whether the authority to dispense the drugs has been expressly delegated to the physician assistant by the supervising physician.

b. A physician assistant may perform the following procedures only when directed, ordered, or prescribed by the supervising physician, or when performance of the procedure is delegated to the physician assistant by the supervising physician as authorized under subsection d. of this section:

(1) Performing non-invasive laboratory procedures and related studies or assisting duly licensed personnel in the performance of invasive laboratory procedures and related studies;

(2) Giving injections, administering medications, and requesting diagnostic studies;

(3) Suturing and caring for facial wounds, traumatic wounds requiring suturing in layers, and infected wounds;

(4) Writing prescriptions or ordering medications in an inpatient or outpatient setting in accordance with section 10 of P.L.1991, c.378 (C.45:9-27.19), except that the supervising physician's direction, order, or prescription shall not be required for the physician assistant to dispense narcotic drugs for maintenance treatment or detoxification treatment if authorized to do so pursuant to paragraph (8) of subsection a. of this section; and

(5) Prescribing the use of patient restraints.

c. A physician assistant may assist a supervising surgeon in the operating room when a qualified assistant physician is not required by the board and a second assistant is deemed necessary by the supervising surgeon.

d. A physician assistant may perform medical services beyond those explicitly authorized in this section, when such services are delegated by a supervising physician with whom the physician assistant has signed a delegation agreement pursuant to section 8 of P.L.1991, c.378 (C.45:9-27.17). The procedures delegated to a physician assistant shall be limited to those customary to the supervising physician's specialty and within the supervising physician's and the physician assistant's competence and training.

e. Notwithstanding subsection d. of this section, a physician assistant shall not be authorized to measure the powers or range of human vision, determine the accommodation and refractive states of the human eye, or fit, prescribe, or adapt lenses, prisms, or frames for the aid thereof. Nothing in this subsection shall be construed to prohibit a physician assistant from performing a routine visual screening.

(cf: P.L.2015, c.224, s.7)

2. Section 8 of P.L.1991, c.378 (C.45:9-27.17) is amended to read as follows:

8. a. (Deleted by amendment, P.L.2015, c.224)

b. Any physician who permits a physician assistant under the physician's supervision to practice contrary to the provisions of P.L.1991, c.378 (C.45:9-27.10 et seq.) shall be deemed to have engaged in professional misconduct in violation of subsection e. of section 8 of P.L.1978, c.73 (C.45:1-21) and shall be subject to disciplinary action by the board pursuant to P.L.1978, c.73 (C.45:1-14 et seq.);

c. In the performance of all practice-related activities, including, but not limited to, the ordering of diagnostic, therapeutic, and other medical services, a physician assistant shall be conclusively presumed to be the agent of the physician under whose supervision the physician assistant is practicing.

d. A physician who supervises a physician assistant may maintain a written delegation agreement with the physician assistant. A physician assistant shall sign a separate written agreement with each physician who delegates medical services in accordance with the provisions of subsection d. of section 7 of P.L.1991, c.378 (C.45:9-27.16). However, a written delegation agreement may be executed by a single-specialty physician practice, provided it is signed by all of the delegating physicians supervising the physician assistant. In the case of a multi-specialty physician practice, a written delegation agreement may be executed for each physician specialty within the practice, provided it is signed by all of the delegating physicians supervising the physician assistant in that specialty area. Nothing in this section shall authorize the execution of a global written delegation agreement between a physician assistant and a multi-specialty physician practice. The agreement shall:

(1) state that the physician will exercise supervision over the physician assistant in accordance with the provisions of P.L.1991, c.378 (C.45:9-27.10 et seq.) and any rules adopted by the board;

(2) be signed and dated annually by the physician and the physician assistant, and updated as necessary to reflect any changes in the practice or the physician assistant's role in the practice; and

(3) be kept on file at the practice site, be provided to the Physician Assistant Advisory Committee, and be kept on file by the committee.

e. The delegation agreement shall include, but need not be limited to, the following provisions:

(1) The physician assistant's role in the practice, including any specific aspects of care that require prior consultation with the supervising physician;

(2) A determination of whether the supervising physician requires personal review of all charts and records of patients and countersignature by the supervising physician of all medical services performed under the delegation agreement, including prescribing and administering medication as authorized under section 10 of P.L.1991, c.378 (C.45:9-27.19), but not including dispensing narcotic drugs for maintenance treatment or detoxification treatment, if the physician assistant is authorized to dispense such drugs pursuant to paragraph (8) of subsection a. of section 7 of P.L.1991, c.378 (C.45:9-27.16). This provision shall state the specified time period in which a review and countersignature shall be completed by the supervising physician. If no review and countersignature is necessary, the agreement must specifically state such provision; and

(3) The locations of practice where the physician assistant may practice under the delegation agreement, including licensed facilities in which the physician authorizes the physician assistant to provide medical services.

(cf: P.L.2015, c.224, s.5)

3. Section 10 of P.L.1991, c.378 (C.45:9-27.19) is amended to read as follows:

10. A physician assistant may dispense narcotic drugs for maintenance treatment or detoxification treatment if the physician assistant is authorized to do so pursuant to paragraph (8) of subsection a. of section 7 of P.L.1991, c.378 (C.45:9-27.16), and may order, prescribe, dispense, and administer other medications and medical devices to the extent delegated by a supervising physician.

a. [Controlled] Except in the case of narcotic drugs for maintenance treatment or detoxification treatment, which an authorized physician assistant may dispense as provided in paragraph (8) of subsection a. of section 7 of P.L.1991, c.378 (C.45:9-27.16), controlled dangerous substances may only be ordered or prescribed if:

(1) a supervising physician has authorized a physician assistant to order or prescribe Schedule II, III, IV, or V controlled dangerous substances in order to:

(a) continue or reissue an order or prescription for a controlled dangerous substance issued by the supervising physician;

(b) otherwise adjust the dosage of an order or prescription for a controlled dangerous substance originally ordered or prescribed by the supervising physician, provided there is prior consultation with the supervising physician;

(c) initiate an order or prescription for a controlled dangerous substance for a patient, provided there is prior consultation with the supervising physician if the order or prescription is not pursuant to subparagraph (d) of this paragraph; or

(d) initiate an order or prescription for a controlled dangerous substance as part of a treatment plan for a patient with a terminal illness, which for the purposes of this subparagraph means a medical condition that results in a patient's life expectancy being 12 months or less as determined by the supervising physician;

(2) the physician assistant has registered with, and obtained authorization to order or prescribe controlled dangerous substances from, the federal Drug Enforcement Administration and any other appropriate State and federal agencies; and

(3) the physician assistant complies with all requirements which the board shall establish by regulation for the ordering, prescription, or administration of controlled dangerous substances, all applicable educational program requirements, and continuing professional education programs approved pursuant to section 16 of P.L.1991, c.378 (C.45:9-27.25).

b. (Deleted by amendment, P.L.2015, c.224)

c. (Deleted by amendment, P.L.2015, c.224)

d. In the case of an order or prescription for a controlled dangerous substance, the physician assistant shall print on the order or prescription the physician assistant's Drug Enforcement Administration registration number.

e. The dispensing of medication or a medical device by a physician assistant shall comply with relevant federal and State regulations, and shall occur only if: (1) pharmacy services are not reasonably available; (2) it is in the best interest of the patient; or (3) the physician assistant is rendering emergency medical assistance.

f. A physician assistant may request, receive, and sign for prescription drug samples and may distribute those samples to patients.

(cf: P.L.2015, c.224, s.7)

4. Section 10 of P.L.1991, c.377 (C.45:11-49) is amended to read as follows:

10. a. In addition to all other tasks which a registered professional nurse may, by law, perform, an advanced practice nurse may manage preventive care services and diagnose and manage deviations from wellness and long-term illnesses, consistent with the needs of the patient and within the scope of practice of the advanced practice nurse, by:

(1) initiating laboratory and other diagnostic tests;

(2) prescribing or ordering medications and devices, as authorized by subsections b. [and] , c., and g. of this section; and

(3) prescribing or ordering treatments, including referrals to other licensed health care professionals, and performing specific procedures in accordance with the provisions of this subsection.

b. An advanced practice nurse may order medications and devices in the inpatient setting, subject to the following conditions:

(1) the collaborating physician and advanced practice nurse shall address in the joint protocols whether prior consultation with the collaborating physician is required to initiate an order for a controlled dangerous substance;

(2) the order is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the advanced practice nurse, or pursuant to the specific direction of a physician;

(3) the advanced practice nurse authorizes the order by signing the nurse's own name, printing the name and certification number, and printing the collaborating physician's name;

(4) the physician is present or readily available through electronic communications;

(5) the charts and records of the patients treated by the advanced practice nurse are reviewed by the collaborating physician and the advanced practice nurse within the period of time specified by rule adopted by the Commissioner of Health pursuant to section 13 of P.L.1991, c.377 (C.45:11-52);

(6) the joint protocols developed by the collaborating physician and the advanced practice nurse are reviewed, updated, and signed at least annually by both parties; and

(7) the advanced practice nurse has completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion, in accordance with regulations adopted by the New Jersey Board of Nursing. The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an advanced practice nurse as set forth in N.J.A.C.13:37-7.2.

c. An advanced practice nurse may prescribe medications and devices in all other medically appropriate settings, subject to the following conditions:

(2) the prescription is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the advanced practice nurse, or pursuant to the specific direction of a physician;

(3) the advanced practice nurse writes the prescription on a New Jersey Prescription Blank pursuant to P.L.2003, c.280 (C.45:14-40 et seq.), signs the nurse's own name to the prescription and prints the nurse's name and certification number;

(4) the prescription is dated and includes the name of the patient and the name, address, and telephone number of the collaborating physician;

(5) the physician is present or readily available through electronic communications;

(6) the charts and records of the patients treated by the advanced practice nurse are periodically reviewed by the collaborating physician and the advanced practice nurse;

(7) the joint protocols developed by the collaborating physician and the advanced practice nurse are reviewed, updated, and signed at least annually by both parties; and

(8) the advanced practice nurse has completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion, in accordance with regulations adopted by the New Jersey Board of Nursing. The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an advanced practice nurse as set forth in N.J.A.C.13:37-7.2.

d. The joint protocols employed pursuant to subsections b. and c. of this section shall conform with standards adopted by the Director of the Division of Consumer Affairs pursuant to section 12 of P.L.1991, c.377 (C.45:11-51) or section 10 of P.L.1999, c.85 (C.45:11-49.2), as applicable.

e. (Deleted by amendment, P.L.2004, c.122.)

f. An attending advanced practice nurse may determine and certify the cause of death of the nurse's patient and execute the death certification pursuant to R.S.26:6-8 if no collaborating physician is available to do so and the nurse is the patient's primary caregiver.

g. (1) An advanced practice nurse may dispense narcotic drugs for maintenance treatment or detoxification treatment, provided the advanced practice nurse has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823.

(2) An advanced practice nurse who meets the requirements to dispense narcotic drugs for maintenance treatment or detoxification treatment as provided in paragraph (1) of this subsection shall be authorized to do so regardless of whether the collaborating physician has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823, and regardless of whether any joint protocols established between the advanced practice nurse and the collaborating physician expressly authorize the advanced practice nurse to dispense the drugs.

(cf: P.L.2017, c.28, s.15)

5. This act shall take effect immediately.

STATEMENT

This bill authorizes physician assistants and advanced practice nurses to dispense narcotic drugs for maintenance treatment or detoxification treatment for individuals with a substance use disorder. This type of treatment is known as "medication assisted treatment," and includes the use of drugs such as buprenorphine, naltrexone, methadone, and naloxone to treat drug cravings and reverse or block the effects of opioid intoxication. The use of medication assisted treatment can be a key element in treating and overcoming the powerful physical addiction resulting from an opioid use disorder.

The bill requires physician assistants and advanced practice nurses seeking to dispense narcotic drugs for medication assisted treatment to have completed all federal requirements to become registered to dispense the drugs, as provided in subsection (g) of 21 U.S.C. s.823. Additionally, physician assistants who wish to dispense the drugs will be required to have obtained authorization to order, prescribe, and administer controlled dangerous substances pursuant to the "Physician Assistant Licensing Act." A physician assistant or advanced practice nurse who meets these requirements will be authorized to dispense narcotic drugs for maintenance treatment or detoxification treatment, regardless of whether the physician assistant's supervising physician or the advanced practice nurse's collaborating physician has completed the federal requirements to dispense such drugs, and regardless of whether the authority to dispense the drugs has been expressly delegated to the physician assistant by the supervising physician or is expressly included in the joint protocols established between the advanced practice nurse and the collaborating physician.

Subsection (g) of 21 U.S.C. s.823 formerly only authorized certain physicians to dispense narcotic drugs for maintenance treatment or detoxification treatment. However, in 2016, the section was amended to allow physician assistants and nurse practitioners to dispense the drugs, subject to any state laws limiting the scope of practice for physician assistants and nurse practitioners. This bill is intended to remove these scope-of-practice limitations, so as to make certain forms of medication assisted treatment more widely available to residents of New Jersey struggling to overcome an opioid use disorder.