wa-26-20-095: Health, Department of — WSR 26-20-095

WSR 26-20-095 (26-20)WSR 26-20-095PROPOSED RULESDEPARTMENT OF HEALTH(Board of Nursing)[Filed October 6, 2026, 11:12 a.m.]Original Notice.Preproposal statement of inquiry was filed as WSR 25-15-033.Title of Rule and Other Identifying Information: Advanced practice and pain management rules. The Washington state board of nursing (board) is proposing amendments to WAC 246-840-010 and 246-840-300 through 246-840-4990 to clarify advanced practice licensure requirements, align standards with national best practices, integrate prescriptive authority into initial advanced registered nurse practitioner (ARNP) licensure, standardize supervised advanced clinical practice requirements, update continuing education and licensure requirements, modernize pain management standards, and address other related objectives. This rule making is phase 2 of four phases of the board's review of chapter 246-840 WAC conducted in accordance with RCW 43.70.041, which requires the board to formally review its rules at least every five years.Hearing Location(s): On November 13, 2026, at 1:15 p.m., at the Department of Health, Town Center 2, Room 153, 111 Israel Road S.E., Tumwater, WA 98501; or follow this Zoom link to register for the virtual hearing, which will give you instructions to either join the meeting on a device, or to call in to the meeting on the phone: https://us02web.zoom.us/meeting/register/AbNzQQ7TRTGYYDdUz4XpWA. After registering, you will receive a confirmation email containing information.Date of Intended Adoption: November 13, 2026.Submit Written Comments to: Jessilyn Dagum, P.O. Box 47864, Olympia, WA 98504-7864, email WABONRules@doh.wa.gov, fax 360-236-4738, web https://fortress.wa.gov/doh/policyreview, beginning the date and time of this filing, by October 23, 2026, at 11:59 p.m.Assistance for Persons with Disabilities: Contact Jessilyn Dagum, phone 360-236-3538, fax 360-236-4738, TTY 711, email WABONRules@doh.wa.gov, by October 23, 2026.Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The board is proposing amendments to WAC 246-840-010 and 246-840-300 through 246-840-4990 as part of phase 2 of the board's formal review of chapter 246-840 WAC.The proposed rules:•Clarify ARNP licensure, renewal, inactive status, and expired license requirements;•Integrate prescriptive authority into initial ARNP licensure;•Establish requirements for ARNPs adding prescriptive authority to an existing license;•Standardize supervised advanced clinical practice requirements for initial ARNP applicants and applicants educated outside United States jurisdictions;•Establish an optional ARNP interim permit pathway for applicants returning an expired license to active status;•Clarify continuing education requirements related to pharmacotherapeutics;•Update terminology and restructure rules for clarity and consistency;•Modernize opioid prescribing and pain management standards;•Clarify patient evaluation, treatment planning, periodic review, consultation, and prescription monitoring program requirements;•Incorporate current best practices related to individualized patient care, biological specimen testing, and risk assessment; and•Align rules with current national standards and applicable state law.The proposed rules are intended to improve clarity, usability, consistency, and patient safety while reducing unnecessary ambiguity and outdated language in rule.Reasons Supporting Proposal: RCW 43.70.041 requires the board to formally review its rules at least once every five years to simplify, streamline, and improve regulations. This proposal is phase 2 of the board's comprehensive review of chapter 246-840 WAC. WAC 246-840-010 and 246-840-300 through 246-840-4990 have been amended incrementally over many years, resulting in outdated terminology, inconsistencies, duplication, and structural gaps within the rules.The board conducted extensive collaborative rule making with interested parties, including the board's advanced practice subcommittee, nursing professionals, health care organizations, nursing associations, educators, and community members. Feedback received during workshops and rule review identified the need to modernize advanced practice licensure requirements and pain management standards to better reflect current practice, improve clarity, and align with national best practices. Following additional interested-party feedback regarding supervised advanced clinical practice requirements, the board held two focused rule workshops on August 7 and 11, 2026. Based on that feedback, the board revised the proposal to extend the period during which an initial ARNP applicant may qualify for licensure without supervised practice from one year to two years; standardize supervised advanced clinical practice requirements for initial applicants and applicants educated outside United States jurisdictions by establishing 250- and 500-hour tiers based on the length of time since graduation or advanced clinical practice; reduce the maximum supervised practice requirement from 1,000 hours to 500 hours; and establish an optional one-year interim permit pathway for applicants returning an expired ARNP license to active status. The proposed amendments also align with recent legislative changes related to advanced practice licensure and applicant documentation requirements, including SHB 2339 (chapter 139, Laws of 2026).The proposed amendments support the board's statutory authority and responsibility to regulate nursing practice, protect public health and safety, and conduct periodic rule review.Statutory Authority for Adoption: RCW 18.79.110, 18.79.800, and 43.70.041.Statute Being Implemented: RCW 18.79.110, 18.79.800, 18.130.040, 43.70.041, and SHB 2339 (chapter 139, Laws of 2026). Rule is not necessitated by federal law, federal or state court decision.Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: The board anticipates the proposed rules will improve clarity and consistency for applicants, licensees, employers, educators, and the public. The proposed amendments are not anticipated to create significant implementation or enforcement issues.Name of Proponent: Washington state board of nursing, governmental.Name of Agency Personnel Responsible for Drafting: Jessilyn Dagum, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-3538; Implementation: Mary Sue Gorski, 111 Israel Road S.E., Tumwater, WA 98501, 360-915-3334; and Enforcement: Catherine Woodard, 111 Israel Road S.E., Tumwater, WA 98501, 360-628-0786.A school district fiscal impact statement is not required under RCW 28A.305.135.A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jessilyn Dagum, P.O. Box 47864, Olympia, WA 98504-7864, phone 360-236-3538, fax 360-236-4738, TTY 711, email WABONRules@doh.wa.gov.This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal: Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect.Explanation of exemptions: Although many licensees practice within small businesses, the proposed rules regulate only individual professional standards and do not impose requirements on business operations, staffing, equipment, or reporting. Portions of the proposed rule amendments are exempt because they clarify, reorganize, modernize, or correct language without changing the effect of the rule under RCW 34.05.310 (4)(d). These include WAC 246-840-010, 246-840-300, 246-840-310, 246-840-311, 246-840-400, 246-840-420, 246-840-450, 246-840-451, 246-840-460, 246-840-465, 246-840-4653, 246-840-4655, 246-840-4657, 246-840-4659, 246-840-4661, 246-840-4667, 246-840-470, 246-840-487, 246-840-490, 246-840-493, 246-840-4935, 246-840-4940, 246-840-4950, 246-840-4955, 246-840-4960, 246-840-4970, and 246-840-4980.Scope of exemption for rule proposal:Is fully exempt.October 6, 2026Alison Bradywood DNP, MN/MPH, RN, NEA-BCExecutive DirectorWashington State Board of Nursing RDS-7251.6AMENDATORY SECTION(Amending WSR 25-02-080, filed 12/26/24, effective 1/26/25)WAC 246-840-010Definitions.The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.(1) "Advanced clinical practice" means practicing at an advanced level of nursing in a clinical setting performing direct patient care.(2) "Advanced nursing practice" means the delivery of nursing care at an advanced level of independent nursing practice that maximizes the use of graduate educational preparation, and in-depth nursing knowledge and expertise in such roles as autonomous clinical practitioner, professional and clinical leader, expert practitioner, and researcher.(3) "Advanced registered nurse practitioner (ARNP)" ((is a registered nurse (RN) as defined in RCW 18.79.050, 18.79.240, 18.79.250, and 18.79.400))means a nurse licensed under chapter 18.79 RCW and this chapter, who has obtained formal graduate education and national specialty certification through a board-approved certifying body in one or more of the ((designations))roles described in WAC 246-840-302, and who is licensed as an ARNP as described in WAC 246-840-300. The ((designations))roles include the following:(a) Certified nurse practitioner (CNP);(b) Certified registered nurse anesthetist (CRNA);(c) Certified nurse midwife (CNM); and(((c) Certified registered nurse anesthetist (CRNA); and))(d) Certified clinical nurse specialist (CCNS).(4) "Associate degree registered nursing ((education)) program" means a nursing ((education)) program ((which, upon successful completion of course work,)) that includes general education and core nursing courses that provide a sound theoretical base combining clinical experiences with theory, nursing principles, critical thinking, and interactive skills, and which upon successful completion of course work awards an associate degree in nursing (ADN) to prepare its graduates for initial licensure and entry level practice as an RN.(5) "Bachelor of science degree registered nursing ((education)) program" means a nursing ((education)) program which, upon successful completion of course work taught in an associate degree nursing ((education)) program, as defined in subsection (((29)))(4) of this section, plus additional courses such as physical and social sciences, nursing research, public and community health, nursing management, care coordination, and the humanities, awards a bachelor of science in nursing (BSN) degree, to prepare its graduates for a broader scope of practice, enhances professional development, and provides the nurse with an understanding of the cultural, political, economic, and social issues that affect patients and influence health care delivery.(6) "Board" means the Washington state board of nursing.(7) "Certifying body" means a nongovernmental ((agency using))organization recognized by the board that uses predetermined standards of nursing practice to validate an individual nurse's qualifications, knowledge, and practice in a defined functional or clinical area of nursing.(8) "Client advocate" means a ((licensed nurse))person licensed under chapter 18.79 RCW and this chapter who actively supports a client's rights and choices, including the client's right to receive safe, high quality care, and who facilitates the client's ability to exercise those rights and choices by providing the client with adequate information about their care and options.(9) "Competency" means demonstrated knowledge, skill and ability in the practice of nursing.(10) "Conditional approval" ((is))means the approval given a nursing ((education)) program that has not met the requirements of the law and the rules of the board. Conditions are specified that must be met within a designated time to rectify the deficiency.(11) "Dedicated education unit" means a clinical learning experience within a health care facility, as part of the curriculum of a nursing ((education)) program.(12) "Delegation" means ((the))a licensed ((nurse))RN transfers the performance of selected nursing tasks to competent individuals in selected situations. The nurse delegating the task is responsible and accountable for the nursing care of the client. The nurse delegating the task supervises the performance of the unlicensed person. Nurses must follow the delegation process ((following the))in accordance with RCW 18.79.260. Delegation in community and in-home care settings is defined by WAC 246-840-910 through 246-840-970.(13) "Distance education" or "distance learning" means instruction offered by any means where the student and faculty are in separate physical locations. Teaching methods may be synchronous, where the teacher and student communicate at the same time, or asynchronous, where the student and teacher communicate at different times, and shall facilitate and evaluate learning in compliance with nursing education rules.(14) "Full approval" ((of a nursing education program is))means the approval signifying that a nursing program meets the requirements of the law and the rules of the board.(15) "Good cause" as used in WAC 246-840-860 for extension of a nurse technician registration means that the nurse technician has had undue hardship such as difficulty scheduling the examination through no fault of their own; receipt of the examination results after 30 days after the nurse technician's date of graduation; or an unexpected family crisis which caused ((him or her))them to delay sitting for the examination. Failure of the examination is not "good cause."(16) "Good standing" ((as applied to a nursing technician,)) means the nursing technician is enrolled in a registered nursing program or licensed practical nursing program approved by the board and is successfully meeting all program requirements.(17) "Graduate degree" means a master's or doctoral degree.(18) "Health care professional" means the same as "health care provider" as defined in RCW 70.02.010(((18))).(19) "Home state" ((is defined as))means where the nursing ((education)) program has legal domicile.(20) (("Host state" is defined as the ((state)) jurisdiction outside the home state where a student participates in clinical experiences or didactic courses.(21))) "Immediately available" as applied to nursing technicians((,)) means that an RN who has agreed to act as supervisor is on the premises and is within audible range and available for immediate response as needed which may include the use of two-way communication devices which allow conversation between the nursing technician and an RN who has agreed to act as supervisor.(a) In a hospital setting, the RN who has agreed to act as supervisor is on the same patient care unit as the nursing technician and the patient has been assessed by the RN prior to the delegation of duties to the nursing technician.(b) In a nursing home or clinic setting, an RN who has agreed to act as supervisor is in the same building and on the same floor as the nursing technician and the patient has been assessed by the RN prior to the delegation of duties to the nursing technician.(((22)))(21) "Initial approval" of a nursing ((education)) program ((is))means the approval status conferred by the board to a new nursing program based on its proposal prior to the graduation of its first class.(((23)))(22) "Licensed practical nurse (LPN)" ((is))means a nurse licensed ((as defined in RCW 18.79.030(3)))under chapter 18.79 RCW and this chapter, with a scope of practice defined in RCW 18.79.020 and 18.79.060.(((24)))(23) "Limited educational authorization" ((is))means an authorization to perform clinical training when enrolled as a student through a board-approved refresher course. This authorization does not permit practice for employment.(((25)))(24) "Minimum standards of competency" means the knowledge, skills, and abilities that are expected of the beginning practitioner.(((26)))(25) "National nursing education accreditation body" means an independent nonprofit entity, approved by the United States Department of Education as a body that evaluates and approves the quality of nursing ((education)) programs within the United States and territories.(((27)))(26) "Nontraditional program of nursing" means a school that has a curriculum which does not include a faculty supervised teaching and learning component in clinical settings.(((28)))(27) "Nursing ((education)) program administrator" ((is))means an individual who has the authority and responsibility for the administration of the nursing ((education)) program.(((29)))(28) "Nursing ((education)) program" means a division or department within a state supported educational institution or other institution of higher learning, charged with the responsibility of preparing nursing students and nurses to qualify for initial licensing or higher levels of nursing practice.(((30)))(29) "Nursing faculty" means an individual employed by a nursing ((education)) program who is responsible for developing, implementing, evaluating, updating, and teaching nursing ((education)) program curricula.(((31)))(30) "Nursing technician" means a nursing student in a board-approved nursing program preparing for RN or LPN licensure who meets the qualifications for registration under RCW 18.79.340, who is employed in a hospital licensed under chapter 70.41 RCW ((or)), a nursing home licensed under chapter 18.51 RCW, or clinic. ((Approved))Board-approved nursing ((education)) programs do not include nontraditional ((schools))programs of nursing as defined in subsection (((27)))(26) of this section.(((32)))(31) "Philosophy" means the beliefs and principles upon which a nursing ((education)) program curriculum is based.(((33)))(32) "Practical nursing ((education)) program" means a nursing ((education)) program which, upon successful completion of course work that includes core nursing courses((to))that provide a sound theoretical base combining clinical experiences with nursing principles, critical thinking, and interactive skills for entry level practical nursing, awards a certificate or degree that the graduate is prepared for interdependent practice ((to prepare a practical nurse for interdependent practice)) as an LPN.(((34)))(33) "Registered nurse (RN)" ((or "RN" is a licensed nurse as defined in RCW 18.79.030(1), 18.79.040, 18.79.240, and 18.79.260))means a nurse licensed under chapter 18.79 RCW and this chapter.(((35)))(34) "Supervision" ((of))means a licensed RN who provides guidance and evaluation to licensed or unlicensed nursing personnel ((means the provision of guidance and evaluation)) for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.(a) "Direct supervision" means ((the))a licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is quickly and easily available, and has assessed the patient prior to the delegation of the duties.(b) "Immediate supervision" means ((the))a licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is on the premises, is within audible and visual range of the patient, and has assessed the patient prior to the delegation of duties.(c) "Indirect supervision" means ((the))a licensed RN who provides guidance to nursing personnel and evaluation of nursing tasks is not on the premises but has given either written or oral instructions for the care and treatment of the patient and the patient has been assessed by the registered nurse prior to the delegation of duties.(((36)))(35) "Traditional nursing ((education)) program" means a nursing program that has a curriculum which includes a faculty supervised teaching and learning component in clinical settings.AMENDATORY SECTION(Amending WSR 22-23-130, filed 11/21/22, effective 12/22/22)WAC 246-840-300ARNP scope of practice.The scope of practice of a licensed advanced registered nurse practitioner (ARNP) is ((as)) provided in RCW 18.79.250 and this section.(1) The ARNP ((is))shall be prepared and qualified to assume primary responsibility and accountability for the care of patients within their roles of ARNP licensure:(a) Certified nurse practitioner (CNP)((,));(b) Certified registered nurse anesthetist (CRNA)((,));(c) Certified nurse midwife (CNM)((,)); and(d) Certified clinical nurse specialist (CCNS).(2) As a licensed independent practitioner, an ARNP provides a wide range of health care services including the diagnosis and management of acute, chronic, and complex health conditions, health promotion, disease prevention, health education, and counseling to individuals, families, groups, and communities. Performing within the scope of the ARNP's education, training, and experience, the licensed ARNP may perform the following:(a) Examine patients and establish diagnoses by patient history, physical examination, and other methods of assessment;(b) Admit, manage, and discharge patients to and from health care facilities;(c) Order, collect, perform, and interpret diagnostic tests;(d) Manage health care by identifying, developing, implementing, and evaluating a plan of care and treatment for patients;(e) Prescribe therapies and medical equipment;(f) Prescribe medications when ((granted))the licensed ARNP has prescriptive authority under this chapter;(g) Refer patients to other health care practitioners, services, or facilities; and(h) Perform procedures or provide care services that are within the ARNP's scope of practice according to a ((commission))board-approved certifying body ((as defined))for ARNPs as described in WAC 246-840-302.(3) ((As leaders in health care))In addition to the health care services in subsection (2) of this section, an ARNP may serve in a variety of capacities including, but not limited to, mentors, educators, coaches, advocates, researchers, interprofessional consultants, and administrators.(4) ARNP practice is grounded in nursing process and incorporates the use of independent judgment. ARNP practice also includes interprofessional interaction with other health care professionals in the assessment and management of wellness and health conditions.(5) Health care is a dynamic field requiring the scope of the ARNP to continually evolve. The ARNP ((is))shall be responsible for possessing a clear understanding of, and functioning within, the scope of practice of the role for which a license has been issued following the standards of care defined by the applicable ((certifying body as defined))national certifying body approved by the board as described in WAC 246-840-302.(6) An ARNP may choose to specialize and perform those acts for which the individual is qualified and has appropriate education and competence.AMENDATORY SECTION(Amending WSR 17-12-113, filed 6/7/17, effective 7/8/17)WAC 246-840-302ARNP ((designations))roles, certification, and approved certification examinations.(1) ((ARNP designations))Advanced registered nurse practitioner (ARNP) roles recognized by the ((commission))board include:(a) Certified nurse practitioner (CNP);(b) Certified registered nurse anesthetist (CRNA);(c) Certified nurse-midwife (CNM); and(((c) Certified registered nurse anesthetist (CRNA); and))(d) Certified clinical nurse specialist (CCNS).(2) An ARNP ((must))shall maintain current ((certification within his or her designation(s) by a commission approved certifying body as identified in subsection (3) of this section. An ARNP license becomes invalid when the certification expires))national board certification within each ARNP role by a board-approved certifying body to maintain a valid license. An ARNP shall provide evidence of current certification to the board upon renewal of certification or when requested by the board. Failure to provide evidence of current certification may result in the license being considered invalid until verification is received.(3) To be eligible for licensure as an ARNP, an applicant ((must))shall pass an examination from ((one of the following certifying bodies))a board-approved certifying body within the ARNP's specialty designation((:(a) For NP designation:(i) The American Academy of Nurse Practitioners;(ii) The American Nurses Credentialing Center;(iii) The National Certification Corporation;(iv) The Pediatric Nursing Certification Board;(v) The American Association of Critical Care Nurses; or(vi) The Oncology Nursing Certification Corporation.(b) For CNM designation, the American Midwifery Certification Board.(c) For CRNA designation, the National Board of Certification and Recertification for Nurse Anesthetists.(d) For CNS designation:(i) The American Nurses Credentialing Center;(ii) The American Association of Critical Care Nurses; or(iii) The Oncology Nursing Certification Corporation)).(4) The board shall maintain a list of board-approved certifying bodies on its website.(5) An ARNP ((recognized))certified in more than one ((designation must))role shall obtain and maintain education, training, and ((practice))certification in each area.AMENDATORY SECTION(Amending WSR 25-02-080, filed 12/26/24, effective 1/26/25)WAC 246-840-340Initial ((ARNP requirements))licensure by examination for ARNPs.(((1) An applicant for licensure as an ARNP shall have the following qualifications:(a) An active Washington state RN license, without sanctions or restrictions;(b) A graduate degree from an advanced nursing education program accredited by a national nursing accreditation body recognized by the United States Department of Education;(c) Certification from a certifying body as identified in WAC 246-840-302;(d) Completion of advanced clinical practice hours, as defined in WAC 246-840-010(1) and in the role of an advanced practice nurse as defined in WAC 246-840-010(2), when applicable, in situations under subsection (3) of this section.(2) An applicant for ARNP licensure shall submit:(a) A completed ARNP application for licensure to the board;(b) The license fee as specified in WAC 246-840-990;(c) A request to the certifying body, as identified in WAC 246-840-302, to send official documentation of certification directly to the board;(d) A request to the advanced nursing educational program to send an official transcript directly to the board showing courses, grades, degree or certificate granted, official seal, and appropriate registrar; and(e) Program objectives and course descriptions when requested by the board.(3) To be granted a license without meeting the advanced clinical practice requirements identified in subsection (4) of this section, the ARNP shall initiate the application process within one year of earning a graduate degree from an advanced nursing education program.(4) An ARNP applicant who does not apply within one year of earning a graduate degree from an advanced nursing education program may be eligible to receive an ARNP interim permit for the purpose of completing 125 hours of advanced clinical practice for every additional year following graduation, not to exceed 1,000 hours. The ARNP interim permit expires one year after the submission of the application.(a) An ARNP applicant's clinical practice must be supervised by an ARNP under chapter 18.79 RCW, a physician licensed under chapter 18.71 RCW, an osteopathic physician licensed under chapter 18.57 RCW, or equivalent licensure in another state or United States jurisdiction. The ARNP interim permit holder must complete supervised advanced clinical practice as defined in subsections (4) and (5) of this section.(b) The supervisor must be in the same practice specialty in which the applicant is seeking licensure. The supervising ARNP or physician:(i) Shall have an active ARNP or physician license, for two or more years, without sanctions or restrictions;(ii) Must not be a member of the applicant's immediate family, as defined in RCW 42.17A.005(27); or have a financial, business, or professional relationship that is in conflict with the proper discharge of the supervisor's duties to impartially supervise and evaluate the nurse;(iii) Must not have current disciplinary action on their license;(iv) Shall submit documented evidence to the board verifying the applicant's successful completion of the required supervised clinical practice hours in an ARNP role.(5) An ARNP applicant needing to complete supervised advanced clinical practice:(a) Shall meet the requirements of subsection (1)(a) and (b) of this section;(b) Shall indicate on the ARNP application the need for an interim permit; and(c) Must obtain:(i) Board approval of the supervising ARNP or physician; and(ii) The interim permit.(6) The nurse must use the designation interim ARNP at all times and on all documentation of the supervised clinical practice hours.(7) An applicant holding an active RN license, without sanctions or restrictions; and current national certification as a CNS; and is practicing in Washington state in an advanced nursing role, will be exempt from the supervised practice requirement if they can provide evidence of 250 hours of advanced clinical practice within the last two years.))Beginning on the effective date of this section, prescriptive authority is included as part of advanced registered nurse practitioner (ARNP) licensure. An ARNP licensed prior to the effective date of this section may continue to practice without prescriptive authority or may apply to add prescriptive authority to their existing ARNP license in accordance with WAC 246-840-410.An applicant for initial ARNP licensure by examination shall meet the following requirements:(1) Have an active, unencumbered Washington state registered nurse (RN) license or an active RN multistate license issued by another state, without sanctions or restrictions;(2) Have a graduate degree from an advanced nursing program accredited by a national nursing accreditation body that is recognized by the United States (U.S.) Secretary of Education or the Council for Higher Education Accreditation (CHEA);(3) Provide verification of advanced nursing program completion:(a) For applicants who graduated from Washington advanced nursing programs, the postsecondary educational institution shall submit verification to the board that the applicant for licensure has met the nursing program and graduation requirements to facilitate timely licensing.(b) For applicants who graduated from out-of-state advanced nursing programs, the applicant shall request that their nursing program send an official transcript directly to the board. The transcripts must:(i) Include the applicant's dates of enrollment, course names, earned credits, date of graduation, and the credential conferred, if applicable; and(ii) Identify any other programs from which the applicant has received credits.(4) Provide program objectives and course descriptions when requested by the board.(5) Provide evidence of current national board certification from a board-approved certifying body for each ARNP role as described in WAC 246-840-302. The applicant shall request the certifying body send official documentation of certification directly to the board.(6) Provide evidence of having completed an advanced pharmacology course, of at least 30 contact hours which includes didactic and clinical application, and consisting of pharmacodynamics, pharmacokinetics, pharmacotherapeutics, and pharmacological management of individual patients related to the applicant's scope of practice.(a) The pharmacology education must be completed within a two-year time period immediately prior to the date of application unless the applicant has graduated within the past two years from an advanced nursing program meeting requirements identified in WAC 246-840-543.(i) If an applicant does not apply for licensure within two years of graduation from an advanced nursing program, the applicant shall complete 30 contact hours of advanced pharmacology education prior to being approved for licensure.(ii) The 30 contact hours of advanced pharmacology education must be obtained from the following:(A) Study within an advanced nursing program; or(B) Continuing education programs accepted by a national credentialing body.(b) An applicant who applies for a new or additional ARNP role shall provide evidence of advanced pharmacology education appropriate to each role or certification.(7) To be granted a license without meeting the supervised advanced clinical practice requirements in subsection (8) of this section, the applicant shall submit an application for ARNP licensure within two years of graduation from an advanced nursing program.(8) An applicant who applies more than two years after graduation from an advanced nursing program or whose program does not meet the advanced clinical practice requirements in WAC 246-840-543, may be eligible to receive an ARNP interim permit for the purpose of completing supervised advanced clinical practice. The ARNP interim permit expires one year after submission of the application.(a) The applicant shall complete 250 hours if the applicant applies more than two years but less than three years after graduation or 500 hours if the applicant applies three years or more after graduation.(b) An ARNP applicant's clinical practice must be supervised by an ARNP under chapter 18.79 RCW, a physician licensed under chapter 18.71 RCW, an osteopathic physician licensed under chapter 18.57 RCW, or equivalent licensure in another state or United States jurisdiction. The ARNP interim permit holder must complete supervised advanced clinical practice as defined in this subsection and subsection (9) of this section.(c) The supervisor must be in the same practice specialty in which the applicant is seeking licensure. The supervising ARNP or physician:(i) Shall have an active ARNP or physician license, for two or more years, without sanctions or restrictions;(ii) Must not be a member of the applicant's immediate family, as defined in RCW 29B.10.280; or have a financial, business, or professional relationship that is in conflict with the proper discharge of the supervisor's duties to impartially supervise and evaluate the nurse;(iii) Must not have current disciplinary action on their license;(iv) Shall submit documented evidence to the board verifying the applicant's successful completion of the required supervised clinical practice hours in an ARNP role.(9) An ARNP applicant needing to complete supervised advanced clinical practice:(a) Shall meet the requirements of subsections (1) and (2) of this section;(b) Shall indicate on the ARNP application the need for an interim permit; and(c) Must obtain:(i) Board approval of the supervising ARNP or physician; and(ii) The interim permit.(10) The nurse must use the designation interim ARNP at all times and on all documentation of the supervised clinical practice hours.(11) An applicant holding an active RN license, without sanctions or restrictions; and current national certification as a certified clinical nurse specialist (CCNS); and is practicing in Washington state in an advanced nursing role, will be exempt from the supervised practice requirement if they can provide evidence of 250 hours of advanced clinical practice within the last two years.(12) Submit a completed ARNP licensure application with the required fee as specified in WAC 246-840-990.AMENDATORY SECTION(Amending WSR 25-02-080, filed 12/26/24, effective 1/26/25)WAC 246-840-342Licensure by interstate endorsement for ((ARNP applicants by interstate endorsement))ARNPs.(((1))) An applicant for advanced registered nurse practitioner (ARNP) licensure by interstate endorsement ((for Washington state licensure as an ARNP shall meet the following requirements))shall:(((a)))(1) Have an active ((RN and ARNP license, or recognition in another state or jurisdiction, as practicing in an advanced practice role, without sanctions or restrictions)), unencumbered Washington state registered nurse (RN) license or hold an active RN multistate license issued by another state, without sanctions or restrictions;(2) Hold an active, unencumbered ARNP license or other authorization issued by another U.S. jurisdiction that authorizes practice in an advanced practice role;(((b)))(3) Have a graduate degree from an advanced nursing ((education)) program ((as identified in WAC 246-840-340 (1)(b), unless the applicant has been practicing in another state, U.S. territory, or the District of Columbia (D.C.) as an ARNP and demonstrates that the following criteria have been met:(i) Current advanced nursing practice, as defined in WAC 246-840-010(2), in the advanced role and population focus area;(ii) National certification or recertification, in the advanced role and population focus area;(iii) Compliance with the ARNP educational requirements of the board that were in effect at the time the ARNP completed their ARNP education program; and(iv) Compliance with all other criteria for licensure set forth by the board; and(c) Hold certification from a certifying body as identified in WAC 246-840-302(3).(2) An applicant for an ARNP license through interstate endorsement shall:(a) Apply for and be granted a Washington state RN license as identified in WAC 246-840-090;(b) Submit a completed ARNP application for licensure to the board;(c) Submit the license fee as specified in WAC 246-840-990;(d) Request the certifying body, as identified in WAC 246-840-302, to send official documentation of certification directly to the board;(e) Request the advanced nursing educational program to send an official transcript directly to the board showing courses, grades, degree or certificate granted, official seal and appropriate registrar; and(f) Submit nursing education program objectives and course descriptions when requested by the board.))accredited by a nursing accrediting body that is recognized by the United States (U.S.) Secretary of Education or the Council for Higher Education Accreditation (CHEA). The applicant shall request that their advanced nursing program send an official transcript directly to the board. The transcript must:(a) Include the applicant's dates of enrollment, course names, earned credits, date of graduation, and the credential conferred, if applicable; and(b) Identify any other programs from which the applicant has received credits;(4) Provide program objectives and course descriptions when requested by the board;(5) Provide evidence of current national board certification from a board-approved certifying body for each ARNP role. The applicant shall request the certifying body to send official documentation of certification directly to the board;(6) Provide verification of meeting the pharmacology education requirements in WAC 246-840-340 or evidence of current independent prescriptive authority in another U.S. jurisdiction with authority equivalent to Washington state practice. Evidence must include a current Drug Enforcement Administration (DEA) registration authorizing schedules II through V;(7) Submit a completed ARNP licensure application with the required fee as specified in WAC 246-840-990.AMENDATORY SECTION(Amending WSR 19-08-031, filed 3/27/19, effective 4/27/19)WAC 246-840-344Licensure for ARNP applicants educated ((and licensed)) outside ((the United States))U.S. jurisdictions.(((1))) An applicant for ARNP licensure in Washington state, educated ((and licensed)) outside ((the United States))U.S. jurisdictions, shall:(((a)))(1) Apply for and be granted an active, unencumbered Washington state RN license((, or recognition in another state or jurisdiction, without sanctions or restrictions, issued by a regulatory entity outside the United States, and have been practicing at an advanced practice level;(b)))or hold an active RN multistate license issued by another state, without sanctions or restrictions;(2) Submit a course-by-course evaluation of education from a ((commission))board-approved credential evaluating service verifying the advanced nursing ((educational)) program completed by the applicant is equivalent to the ARNP education identified in WAC ((246-840-455))246-840-543;(((c) Hold certification from a certifying body as identified in WAC 246-840-302(3); and(d) Have been performing advanced clinical practice in his or her country for at least two hundred fifty hours within the two years prior to the date of application for ARNP licensure.(2) An applicant educated and licensed outside of the United States shall:(a) Apply for and be granted a Washington state RN license, without sanctions or restrictions, as identified in WAC 246-840-045;(b) Submit a completed ARNP application to the commission;(c) Submit the license fee as specified in WAC 246-840-990;(d) Submit a course-by-course evaluation of education completed from a commission approved credential evaluating service;(e) Request the certifying body, as identified in WAC 246-840-302(3), to send official documentation of certification directly to the commission; and(f) Submit evidence of at least two hundred fifty hours of advanced clinical practice as an ARNP, or in an advanced practice role, within the two years prior to the date of application. The two hundred fifty hours may include teaching advanced nursing practice if providing direct patient care as a faculty member or serving as a preceptor in a clinical setting.(3) Internationally educated ARNP applicants who do not meet advanced clinical practice requirements shall complete two hundred fifty hours of supervised advanced clinical practice for every two years the applicant may have been out of practice, not to exceed one thousand hours.(4) An ARNP applicant needing to complete supervised advanced clinical practice shall obtain an ARNP interim permit consistent with the requirements for supervised practice defined in WAC 246-840-340 (4) and (5).))(3) Hold current national board certification from a board-approved certifying body for each ARNP role as described in WAC 246-840-302. The applicant shall request the board-approved certifying body send official documentation of certification directly to the board;(4) Provide verification of meeting the pharmacology education requirements in WAC 246-840-340 or evidence of current independent prescriptive authority in another U.S. jurisdiction with authority equivalent to Washington state practice. Evidence must include a current Drug Enforcement Administration (DEA) registration authorizing schedules II through V;(5) Submit evidence of at least 250 hours of advanced clinical practice as an ARNP, or in an advanced practice role, within the two years immediately preceding the application. The practice hours may include teaching advanced nursing practice when the applicant provides direct patient care as a faculty member or serves as a preceptor in a clinical setting;(6) An applicant who does not meet the advanced clinical practice requirement in subsection (5) of this section shall complete supervised advanced clinical practice as follows:(a) 250 hours if less than three years have elapsed since the applicant last engaged in advanced clinical practice; or(b) 500 hours if three years or more have elapsed since the applicant last engaged in advanced clinical practice;(7) An applicant required to complete supervised advanced clinical practice shall obtain an ARNP interim permit and comply with the applicable requirements in WAC 246-840-340; and(8) Submit a completed ARNP licensure application with the required fee as specified in WAC 246-840-990.AMENDATORY SECTION(Amending WSR 20-10-015, filed 4/24/20, effective 4/24/20)WAC 246-840-360Renewal of ARNP licensure.(((1) An applicant applying for ARNP license renewal, shall have:(a) An active Washington state RN license, without sanctions or restrictions;(b) Current certification from a certifying body as identified in WAC 246-840-302; and(c) Thirty contact hours of continuing education obtained during the renewal period in each ARNP designation. An ARNP who has certification in more than one area of practice may count the continuing education hours for more than one certification when applicable to each area of practice.(2) An applicant for ARNP licensure renewal shall comply with the requirements of chapter 246-12 WAC, Part 2 and submit:(a) The renewal license fee as specified in WAC 246-840-990;(b) Evidence of current certification by the commission approved certifying body for each designation;(c) A written declaration, on forms provided by the commission attesting to: Completion of thirty contact hours of continuing education during the renewal period for each ARNP designation; and(d) Evidence of completion of continuing education contact hours and advanced clinical practice hours when requested by the commission.))(1) A licensed advanced registered nurse practitioner (ARNP) shall renew their license every two years in compliance with WAC 246-12-030.(2) An ARNP applying for license renewal shall meet the following requirements:(a) Hold an active, unencumbered Washington state registered nurse (RN) license or RN multistate license issued by another state, without sanctions or restrictions;(b) Hold current national certification from a board-approved certifying body for each ARNP role. The ARNP must provide evidence of current certification when requested by the board;(c) Meet continuing education requirements as follows:(i) Complete 30 contact hours of continuing education obtained during the renewal period for each ARNP role;(ii) Complete an additional 15 contact hours of continuing education in pharmacotherapeutics related to the ARNP's scope of practice if the ARNP has prescriptive authority;(d) An ARNP who holds certification in more than one role may apply continuing education hours to more than one role when applicable;(e) Submit the license renewal fee as specified in WAC 246-840-990; and(f) Submit evidence of completion of continuing education contact hours when requested by the board.AMENDATORY SECTION(Amending WSR 16-08-042, filed 3/30/16, effective 4/30/16)WAC 246-840-361Continuing education for ARNP license renewal.((The thirty contact hours of continuing education required for the two-year renewal of ARNP licensure must:(1) Be acceptable to the certifying body identified in WAC 246-840-302(3);(2) Be obtained from courses in which the contact hour is at least fifty minutes;(3) Not include the fifteen hours of continuing education required for an ARNP with prescriptive authority as identified in WAC 246-840-450 (1)(b); and(4) Not include the same course taken more than once during the renewal cycle.))The continuing education required for the two-year renewal of an advanced registered nurse practitioner (ARNP) license under WAC 246-840-360 must meet the following requirements:(1) Thirty contact hours of continuing education obtained during the renewal period for each ARNP role. An ARNP who holds certification in more than one role may apply continuing education hours to more than one role when applicable;(2) An additional 15 contact hours of continuing education in pharmacotherapeutics related to the ARNP's scope of practice if the ARNP has prescriptive authority.(3) Continuing education must be obtained through programs recognized by a board-approved certifying body.(4) One contact hour must consist of at least 60 minutes of instruction.(5) Continuing education hours completed to meet the ARNP license renewal requirements under this section may also be applied toward the RN continuing competency requirements identified in WAC 246-840-200 through 246-840-260, when applicable.(6) The same continuing education course may not be counted more than once during a renewal cycle.AMENDATORY SECTION(Amending WSR 23-08-069, filed 4/4/23, effective 5/7/23)WAC 246-840-365Inactive and reactivating an ARNP license.((To apply for an inactive ARNP license, an ARNP shall comply with WAC 246-12-090 or 246-12-540, if military related.))(1) An advanced registered nurse practitioner (ARNP) may apply for an inactive license if ((he or she holds))they hold an active Washington state ARNP license without sanctions or restrictions.(2) To apply for an inactive ARNP license, an ARNP shall comply with WAC 246-12-090 or 246-12-540, if military related.(3) To return an inactive ARNP license to active status, the ARNP shall:(a) ((Shall))Meet the requirements for an inactive credential for nonmilitary practitioners identified under WAC 246-12-090 through 246-12-110;(b) ((Must))Hold an active, unencumbered Washington state registered nurse (RN) license issued under chapter 18.79 RCW or a RN multistate license issued by another state without sanctions or restrictions;(c) ((Shall))Submit the applicable fee as identified ((under))in WAC 246-840-990;(d) ((Shall))Submit evidence of current national board certification by ((the commission))a board-approved certifying body ((identified))as described in WAC 246-840-302(((1); and));(e) ((Shall))Submit evidence of 30 contact hours of continuing education for each ((designation))role within the past two years; and(f) Submit evidence of an additional 15 contact hours of continuing education in pharmacotherapeutics related to the ARNP's scope of practice if the ARNP previously held prescriptive authority.(((3) To regain prescriptive authority after inactive status, the applicant must meet the prescriptive authority requirements identified in WAC 246-840-410.))AMENDATORY SECTION(Amending WSR 23-08-069, filed 4/4/23, effective 5/7/23)WAC 246-840-367Expired license.When an advanced registered nurse practitioner (ARNP) license is not renewed, it is placed in expired status and the nurse must not practice as an ARNP.(1) To return to active status when the license has been expired for less than ((two))five years, the ((nurse shall))applicant shall:(a) Meet the requirements for ((initial and renewal credentialing of practitioners as identified under WAC 246-12-020 through 246-12-051))renewing an expired credential under WAC 246-12-040; and(b) Meet ARNP license renewal requirements identified in WAC 246-840-360((; and(c) Meet the prescriptive authority requirements identified in WAC 246-840-450, if renewing prescriptive authority)).(2) If the ARNP license has expired for ((two))five years or more, the applicant shall:(a) Meet the requirements for ((initial and renewal credentialing of practitioners as identified under WAC 246-12-020 through 246-12-051))renewing an expired credential under WAC 246-12-040;(b) Submit evidence of current national board certification by the ((commission))board-approved certifying body ((identified))as described in WAC 246-840-302(((3)));(c) Submit evidence of 30 contact hours of continuing education for each ((designation))ARNP role within the prior two years; and(d) ((Meet the prescriptive authority requirements identified in WAC 246-840-410 if requesting prescriptive authority, which may be granted once the ARNP license is returned to active status))Submit evidence of an additional 15 contact hours of continuing education in pharmacotherapeutics related to the ARNP's scope of practice if the ARNP previously held prescriptive authority.(3) An applicant seeking to return an expired ARNP license to active status may choose to apply for an ARNP interim permit to obtain additional supervised advanced clinical practice experience. An applicant issued an interim permit under this subsection shall comply with WAC 246-840-340 (8)(b) and (c), (9), and (10). The interim permit expires one year after issuance.AMENDATORY SECTION(Amending WSR 16-08-042, filed 3/30/16, effective 4/30/16)WAC 246-840-400ARNP prescriptive authority.Beginning on the effective date of this section, prescriptive authority is included as part of advanced registered nurse practitioner (ARNP) licensure. An ARNP licensed prior to the effective date of this section may continue to practice without prescriptive authority or may apply to add prescriptive authority to their existing ARNP license in accordance with WAC 246-840-410.(1) An ARNP licensed under chapter 18.79 RCW when authorized by the ((nursing commission))board may prescribe drugs and medical devices pursuant to applicable state and federal laws.(2) The ARNP when exercising prescriptive authority ((is))shall be accountable for competency in:(a) Problem identification through appropriate assessment;(b) Medication and device selection;(c) Patient education for use of therapeutics;(d) Knowledge of interactions of therapeutics;(e) Evaluation of outcome; and(f) Recognition and management of side effects, adverse reactions, and complications.AMENDATORY SECTION(Amending WSR 16-08-042, filed 3/30/16, effective 4/30/16)WAC 246-840-410Application requirements for ARNPs adding prescriptive authority to an existing license.Beginning on the effective date of this section, prescriptive authority is included as part of advanced registered nurse practitioner (ARNP) licensure.(1) An ARNP licensed before the effective date of this section who does not hold prescriptive authority may apply to add prescriptive authority to an existing ARNP license by meeting the requirements of this section.(2) An ARNP ((who applies))applying for prescriptive authority ((must))shall:(a) Hold an active Washington state ARNP license, without sanctions or restrictions, issued by the ((commission))board;(b) Provide evidence of ((thirty))30 contact hours of education in advanced pharmacology, including didactic and clinical application, and consisting of pharmacodynamics, pharmacokinetics, pharmacotherapeutics, and pharmacological management of individual patients related to the applicant's scope of practice.(((2) Pharmacology education must be completed within a two-year time period immediately prior to the date of application for prescriptive authority unless the applicant has graduated within the past two years from an advanced nursing education program meeting requirements identified in WAC 246-840-455 (11)(e).(3) If an ARNP applicant does not have advanced pharmacology education, the applicant must complete:(a) Advanced pharmacology education of at least thirty contact hours, including pharmacodynamics, pharmacokinetics, pharmacotherapeutics and pharmacological management of individual patients, differential diagnosis, and applied pharmacological management of patients consistent with the applicant's area of certification.(b) Supervised advanced clinical practice of no less than one hundred fifty hours that meets the requirements of WAC 246-840-340 (4) and (5). The clinical practice hours shall occur after completion of the thirty hours of advanced pharmacology education under the direct supervision of an ARNP with prescriptive authority, a physician as identified in chapter 18.71 RCW, an osteopathic physician as identified in chapter 18.57 RCW, or equivalent in other states or jurisdictions. The thirty contact hours of advanced pharmacology education is obtained from the following:(i) Study within the advanced nursing education program; or(ii) Continuing education programs accepted by a national credentialing body.))(3) Advanced pharmacology education must be completed within a two-year time period immediately prior to the date of application for prescriptive authority unless the applicant has graduated within the past two years from an advanced nursing program meeting requirements identified in WAC 246-840-543.(a) If an ARNP applies to add prescriptive authority to an existing license more than two years after graduation from an advanced nursing program, the ARNP must complete 30 contact hours of advanced pharmacology education.(b) The 30 contact hours of advanced pharmacology education must be obtained from:(i) Study within an advanced nursing program; or(ii) Continuing education programs accepted by a national credentialing body.(c) An ARNP who applies for a new or additional ARNP role must provide evidence of advanced pharmacology education appropriate to each role or certification.(4) The ARNP applying for prescriptive authority must submit:(a) A completed application on a ((commission))board-approved form;(b) The fee as specified in WAC 246-840-990; and(c) Evidence of completion of required advanced pharmacology education hours ((and supervised advanced clinical practice hours)) identified in subsection (3) (((a) and (b))) of this section.(5) (((If an ARNP does not apply for prescriptive authority within two years of graduation from an advanced practice program, an additional thirty contact hours of advanced pharmacology education shall be required.(6) An ARNP who applies for a new or additional ARNP designation must send proof of advanced pharmacology educational content appropriate to each designation.(7))) Applicants who hold current independent prescriptive authority from another ((state))U.S. jurisdiction equivalent to Washington state practice at the time of application may request an exemption ((to))from subsection (3) (((a) and (b))) of this section ((if he or she provides evidence of at least two hundred fifty hours of advanced clinical practice in an ARNP role with prescriptive authority in his or her scope of practice within the two years prior to application for prescriptive authority))by providing a current copy of their Drug Enforcement Administration (DEA) registration authorizing schedules II through V.AMENDATORY SECTION(Amending WSR 16-08-042, filed 3/30/16, effective 4/30/16)WAC 246-840-420Authorized prescriptions by an ARNP with prescriptive authority.Prescriptions for drugs and medical devices must comply with all applicable state and federal laws and be within the ((ARNP's))advanced registered nurse practitioner's (ARNP) scope of practice.(1) An ARNP ((must))shall sign prescriptions and include the ((initials ARNP or NP))appropriate credential or role designation recognized under chapter 18.79 RCW.(2) An ARNP may not, under RCW 18.79.240(1) and chapter 69.50 RCW, prescribe controlled substances in Schedule I.(3) An ARNP with prescriptive authority who prescribes controlled substances must be registered with the Drug Enforcement Administration (DEA).AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-460Pain management—Intent.WAC 246-840-460 through 246-840-4990 govern the use of opioids in the treatment of pain in the acute, perioperative, subacute, and chronic phases. Treatment modalities including opioid use can serve to improve the quality of life for ((those)) patients who suffer from pain, as well as reduce the morbidity and costs associated with ((undertreatment or)) inappropriate treatment of pain. For the purpose of these rules, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments. In addition to these rules, the nursing ((commission recommends practitioners adhere to))board encourages advanced registered nurse practitioners to consider applicable state agency medical directors' group (AMDG) and federal Centers for Disease Control and Prevention (CDC) guidelines for the treatment of pain in all phases.AMENDATORY SECTION(Amending WSR 23-14-082, filed 6/29/23, effective 7/30/23)WAC 246-840-463Exclusions.WAC 246-840-460 through 246-840-4990 do not apply to:(1) The treatment of patients with cancer-related pain;(2) The treatment of patients with sickle cell disease;(3) The provision of palliative, hospice, or other end-of-life care;(((3)))(4) The treatment of inpatient hospital patients; or(((4)))(5) Procedural premedications.(((5)))(6) The treatment of patients in nursing homes licensed under chapter 18.51 RCW or 388-97 WAC, ((nursing homes and))or long-term acute care hospitals (LTACs) licensed under chapter 70.41 RCW.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-465Definitions.The following definitions apply in WAC 246-840-460 through 246-840-4990, unless the context clearly requires otherwise.(1) "Aberrant behavior" means behavior that indicates misuse, diversion, or substance use disorder. This includes, but is not limited to, multiple early refills or renewals, as well as requesting or obtaining prescriptions for the same or similar drugs from more than one ((practitioner or other)) health care provider.(2) "Acute pain" means the normal, predicted physiological response to a noxious chemical, thermal, or mechanical stimulus, and typically is associated with invasive procedures, trauma, and disease. Acute pain is considered to be six weeks or less in duration.(3) "At-risk" means a category of patients at increased risk of morbidity or mortality, such as from comorbidities, polypharmacy, history of substance use disorder or abuse, aberrant behavior, high dose opioid prescription, or the use of any central nervous system depressant.(4) "Biological specimen test" or "biological specimen testing" means testing of bodily fluids or other biological samples including, but not limited to, urine or hair for the presence of various drugs and metabolites.(((4)))(5) "Chronic pain" means a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process, that causes continuous or intermittent pain more than ((twelve))12 weeks in duration, lasting months or years. Chronic pain includes pain resulting from cancer or treatment in a patient who is two years post completion of curative anti-cancer treatment with no current evidence of disease.(((5)))(6) "Comorbidities" means a preexisting or coexisting physical or psychiatric disease or condition.(((6)))(7) "Episodic care" means medical care provided by an ((advanced registered nurse practitioner))ARNP other than the designated primary care practitioner in the acute care setting, ((for example,))such as urgent care or an emergency department.(((7)))(8) "High dose" means ((ninety))90 milligram morphine equivalent dose (MED), or more, per day.(((8) "High-risk" means a category of patient at increased risk of morbidity or mortality, such as from comorbidities, polypharmacy, history of substance use disorder or abuse, aberrant behavior, high dose opioid prescription, or the use of any central nervous system depressant.))(9) "Hospice" means a model of care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less.(10) "Hospital" means any institution, place, building, or agency licensed by the department under chapter 70.41 or 71.12 RCW or designated as a state hospital under chapter 72.23 RCW, to provide accommodations, facilities, and services over a continuous period of ((twenty-four))24 hours or more, for observation, diagnosis, or care of two or more individuals not related to the operator who are suffering from illness, injury, deformity, or abnormality, or from any other condition for which obstetrical, medical, or surgical services would be appropriate for care or diagnosis.(11) "Inpatient" means a person who has been admitted to a hospital for more than ((twenty-four))24 hours.(12) "Medication assisted treatment (MAT)" means the use of pharmacologic therapy, often in combination with counseling and behavioral therapies, for the treatment of substance use disorders.(13) "Morphine equivalent dose (MED)" means a conversion of various opioids to a morphine equivalent dose by the use of accepted conversion tables or calculators.(14) "Multidisciplinary pain clinic" means a facility that provides comprehensive pain management and includes care provided by multiple available disciplines, practitioners, or treatment modalities.(15) "Nonoperative pain" means pain which does not occur as a result of surgery.(16) "Opioid analgesic" or "opioid" means a drug that is either an opiate derived from the opium poppy, or opiate-like semi-synthetic or synthetic drugs. Examples include morphine, codeine, hydrocodone, oxycodone, fentanyl, meperidine, and methadone.(17) "Palliative care" means care that maintains or improves the quality of life of patients and their families facing serious, advanced, or life-threatening ((illness))illnesses. With palliative care, particular attention is given to the prevention, assessment, and treatment of pain and other symptoms, and to the provision of psychological, spiritual, and emotional support.(18) "Pain" means an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.(19) "Pain management clinic" means a publicly or privately owned facility for which a majority of patients are receiving chronic pain treatment.(20) "Perioperative pain" means acute pain that occurs ((as the result))surrounding the performance of surgery.(21) "Prescription monitoring program" or "PMP" means the Washington state prescription monitoring program authorized under chapter 70.225 RCW.(22) "Practitioner" means an advanced registered nurse practitioner (ARNP) licensed under chapter 18.79 RCW, a dentist licensed under chapter 18.32 RCW, a physician licensed under chapter 18.71, 18.71B, or 18.57 RCW, a physician assistant licensed under chapter 18.71A or ((18.57A))18.71C RCW, or a podiatric physician licensed under chapter 18.22 RCW.(23) "Risk assessment tools" means validated tools or questionnaires appropriate for identifying a patient's level of risk for substance use or misuse.(24) "Subacute pain" means a continuation of pain, of six to ((twelve))12 weeks in duration.(25) "Substance use disorder (SUD)" means a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. ((Substance use disorder))SUD is not the same as physical dependence or tolerance that are normal physiological consequences of extended opioid therapy for pain. ((It))SUD is characterized by behaviors that include, but are not limited to, impaired control over drug use, craving, compulsive use, or continued use despite harm.AMENDATORY SECTION(Amending WSR 20-02-026, filed 12/19/19, effective 1/19/20)WAC 246-840-4651Patient notification, secure storage, and disposal.(1) The ((practitioner shall provide information to the patient educating them of))requirements in this section do not apply to the administration of an opioid including, but not limited to, the following situations as documented in the patient record:(a) Emergent care;(b) Where patient pain represents a significant health risk;(c) Procedures involving the administration of anesthesia;(d) When the patient is unable to grant or revoke consent; or(e) MAT for substance use disorders.(2) The advanced registered nurse practitioner (ARNP), except as noted in subsection (1) of this section, shall educate the patient regarding the:(a) Risks associated with the use of opioids ((as)), including the risk of dependence and overdose, and the availability of overdose reversal medication when appropriate and related to the medical condition, the type of patient, and the phase of treatment;(b) ((The))Safe and secure storage of opioid prescriptions;(c) ((The))Proper disposal of unused opioid medications including, but not limited to, the availability of recognized drug take-back programs; and(d) ((The))Patient's right to refuse an opioid ((prescription or order))medication for any reason.(((2) The practitioner))(3) The ARNP shall document such notification in the patient record. ((If the patient refuses an opioid prescription or order, the practitioner must document the patient's request and avoid prescribing or ordering opioids, unless the request is revoked by the patient.(3)))(4) Patient notification must occur, at a minimum, at the following points of treatment:(a) The first issuance of a prescription for an opioid; and(b) The transition between phases of treatment, as follows:(i) Acute nonoperative pain or acute perioperative pain to subacute pain; and(ii) Subacute pain to chronic pain.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4653Use of alternative modalities for pain treatment.The advanced registered nurse practitioner (ARNP) shall consider multimodal pharmacologic and nonpharmacologic therapy for pain rather than defaulting to the use of opioid therapy alone whenever reasonable as evidence-based, clinically appropriate alternatives exist. ((A practitioner))An ARNP may combine opioids with other medications and treatments including, but not limited to, acetaminophen, acupuncture, chiropractic care, cognitive behavior therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), osteopathic manipulative treatment, physical therapy, massage, or sleep hygiene.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4655Continuing education requirements for opioid prescribing.(1) In order to prescribe an opioid in Washington state, an advanced registered nurse practitioner (ARNP) licensed to prescribe opioids shall complete a one-time continuing education requirement regarding best practices in the prescribing of opioids. ((Additionally,))(2) A chronic pain management specialist ((must))shall meet the continuing education requirements in WAC 246-840-493. The continuing education must be at least four hours in length.(((2) The advanced registered nurse practitioner))(3) The ARNP shall complete the one-time continuing education requirement described in subsection (1) of this section by the end of the ((advanced registered nurse practitioner's))ARNP's first full continuing education reporting period ((after January 1, 2019, or during the first full continuing education reporting period)) after initial licensure((, whichever is later)). The four-hour course may count toward any ((NCQAC))board required continuing education.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4657Diagnosis identified on prescriptions.The advanced registered nurse practitioner (ARNP) shall include the diagnosis or the International Classification of Diseases (ICD) code on all opioid prescriptions.AMENDATORY SECTION(Amending WSR 23-14-082, filed 6/29/23, effective 7/30/23)WAC 246-840-4659Patient evaluation and patient record—Acute.Prior to prescribing an opioid for acute nonoperative pain or acute perioperative pain, the advanced registered nurse practitioner (ARNP) shall:(1) Conduct and document an appropriate history and physical examination including screening for risk factors for overdose and severe postoperative pain; or(2) Consider the discharge facility's history and physical examination an appropriate history and physical examination to allow timely prescribing of needed medications for acute nonoperative pain or acute perioperative pain in nursing homes licensed under chapter 18.51 RCW or 388-97 WAC, nursing homes and long-term acute care hospitals (LTACs);(3) Evaluate the nature and intensity of the pain or anticipated pain following surgery; and(4) Inquire about any other medications the patient is prescribed or is taking including type, dosage, and quantity prescribed.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4661Treatment plan—Acute nonoperative pain.The advanced registered nurse practitioner (ARNP) shall comply with the requirements in this section when prescribing opioid analgesics for acute nonoperative pain and shall document completion of these requirements in the patient record.(1) The ((advanced registered nurse practitioner))ARNP shall consider recommending or prescribing nonopioid analgesics as the first line of pain control in patients under the provisions of WAC 246-840-4653, unless not clinically appropriate.(2) The ((advanced registered nurse practitioner))ARNP, or the practitioner's authorized designee as defined in WAC 246-470-050, shall conduct queries of the prescription monitoring program (PMP) in accordance with the provisions of WAC 246-840-4990 to identify any Schedule II-V medications or drugs of concern received by the patient, and document their review and any concerns.(3) If the ((advanced registered nurse practitioner))ARNP prescribes opioids for effective pain control, such prescription must not be in greater quantity than needed for the expected duration of pain severe enough to require opioids. A three-day supply or less will often be sufficient; more than a seven-day supply will rarely be needed. The ((advanced registered nurse practitioner))ARNP shall not prescribe beyond a seven-day supply without clinical documentation in the patient record to justify the need for such a quantity.(4) The ((advanced registered nurse practitioner))ARNP shall reevaluate the patient who does not follow the expected course of recovery. If ((significant and)) documented improvement in function or pain control has not occurred, the ((advanced registered nurse practitioner))ARNP shall reconsider the continued use of opioids, or whether tapering or discontinuing opioids is clinically indicated.(5) Follow-up visits for pain control must include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:(a) Change in pain level;(b) Change in physical function;(c) Change in psychosocial function; and(d) Additional planned diagnostic evaluations to investigate causes of continued acute nonoperative pain or other treatments.(6) Long-acting or extended release opioids are not typically indicated for acute nonoperative pain. Should an ((advanced registered nurse practitioner))ARNP need to prescribe a long-acting opioid for acute pain, that reason must be documented in the patient record.(7) Medication assisted treatment (MAT) medications shall not be discontinued when treating acute pain, except ((as consistent))in accordance with the provisions of WAC 246-840-4970.(8) If the ((advanced registered nurse practitioner))ARNP elects to treat a patient with opioids beyond the six-week time period of acute nonoperative pain, the ((advanced registered nurse practitioner))ARNP shall document in the patient record that the patient is transitioning from acute pain to subacute pain. Rules governing the treatment of subacute pain, WAC 246-840-4665 and 246-840-4667, shall apply.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4663Treatment plan—Acute perioperative pain.The advanced registered nurse practitioner (ARNP) shall comply with the requirements in this section when prescribing opioid analgesics for perioperative pain and shall document completion of these requirements in the patient's record.(1) The ((advanced registered nurse practitioner))ARNP shall consider prescribing nonopioid analgesics as the first line of pain control in patients under the provisions of WAC 246-840-4653, unless not clinically appropriate.(2) The ((advanced registered nurse practitioner))ARNP, or practitioner's authorized designee as defined in WAC 246-470-050, shall conduct queries of the prescription monitoring program (PMP) in accordance with the provisions of WAC 246-840-4990 to identify any Schedule II-V medications ((or drugs of concern)) received by the patient, including patterns that may indicate potential misuse or receipt of prescriptions from multiple prescribers or pharmacies, and document ((in the patient record)) their review and any concerns in the patient record.(3) If the ((advanced registered nurse practitioner))ARNP prescribes opioids for effective pain control, such prescription shall be in no greater quantity than needed for the expected duration of pain severe enough to require opioids. A three-day supply or less will often be sufficient; more than a ((fourteen))14-day supply will rarely be needed for perioperative pain. The ((advanced registered nurse practitioner))ARNP shall not prescribe beyond a ((fourteen))14-day supply from the time of discharge without clinical documentation in the patient record to justify the need for such a quantity. For ((more specific best practices, the advanced registered nurse practitioner))additional clinical guidance, the ARNP may refer to clinical practice guidelines including, but not limited to, those produced by the agency medical directors' group (AMDG), the Centers for Disease Control and Prevention (CDC), or the Bree Collaborative.(4) The ((advanced registered nurse practitioner))ARNP shall reevaluate a patient who does not follow the expected course of recovery. If ((significant and)) documented improvement in function or pain control has not occurred, the ((advanced registered nurse practitioner))ARNP shall reconsider the continued use of opioids, or whether tapering or discontinuing opioids is clinically indicated.(5) Follow-up visits for pain control should include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:(a) Change in pain level;(b) Change in physical function;(c) Change in psychosocial function; and(d) Additional planned diagnostic evaluations or other treatments.(6) If the ((advanced registered nurse practitioner))ARNP elects to prescribe a combination of opioids with a medication listed in WAC 246-840-4960 or to a patient known to be receiving a medication listed in WAC 246-840-4960 from another practitioner, such prescribing must be in accordance with WAC 246-840-4960.(7) If the ((advanced registered nurse practitioner))ARNP elects to treat a patient with opioids beyond the six-week time period of acute perioperative pain, the ((advanced registered nurse practitioner))ARNP shall document in the patient record that the patient is transitioning from acute pain to subacute pain. Rules governing the treatment of subacute pain, WAC 246-840-4665 and 246-840-4667, shall apply unless there is documented improvement in function or pain control, and there is a documented plan and timing for discontinuation of all opioid medications.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4665Patient evaluation and patient record—Subacute pain.The advanced registered nurse practitioner (ARNP) shall comply with the requirements in this section when prescribing opioid analgesics for subacute pain and shall document completion of these requirements in the patient record.(1) Prior to prescribing an opioid for subacute pain, the ((advanced registered nurse practitioner))ARNP shall:(a) Conduct an appropriate history and physical examination or review and update the patient's existing history and examination taken during the acute nonoperative or acute perioperative phase;(b) Evaluate the nature and intensity of the pain;(c) Inquire about other medications the patient is prescribed or taking including type, dosage, and quantity prescribed;(d) Conduct, or cause the practitioner's authorized designee as defined in WAC 246-470-050 to conduct, a query of the prescription monitoring program (PMP) in accordance with the provisions of WAC 246-840-4990, to identify any Schedule II-V medications ((or drugs of concern)) received by the patient, including patterns that may indicate potential misuse or receipt of prescriptions from multiple prescribers or pharmacies, and document their review and any concerns in the patient record;(e) Screen and document the patient's potential for ((high-risk))at-risk behavior and adverse events related to opioid therapy. If the ((advanced registered nurse practitioner))ARNP determines the patient is ((high-risk))at-risk, consider lower dose therapy, shorter intervals between prescriptions, more frequent visits, increased biological specimen testing, and prescribing rescue naloxone;(f) Obtain a biological specimen test if the patient's function is deteriorating or if pain is escalating; and(g) Screen or refer the patient for further consultation for psychosocial factors that may be impairing recovery including, but not limited to, depression or anxiety.(2) The ((advanced registered nurse practitioner))ARNP treating a patient for subacute pain with opioids shall ensure that, at a minimum, the following are documented in the patient record:(a) The presence of one or more recognized diagnoses or indications for the use of opioid pain medication;(b) The observed ((significant and)) documented improvement in function or pain control forming the basis to continue prescribing opioid analgesics beyond the acute pain episode;(c) The result of any queries of the PMP;(d) All medications the patient is known to be prescribed or taking;(e) An appropriate pain treatment plan, including the consideration of, or attempts to use, nonpharmacological modalities and nonopioid therapy;(f) Results of any aberrant biological specimen testing ((results)) and the risk-benefit analysis if opioids are to be continued;(g) Results of screening or referral for further consultation for psychosocial factors that may be impairing recovery including, but not limited to, depression or anxiety;(h) Results of screening for the patient's level of risk for aberrant behavior and adverse events related to opioid therapy;(i) The risk-benefit analysis of any combination of prescribed opioid and benzodiazepines or sedative-hypnotics, if applicable; and(j) All other required components of the patient record, as established in statute or rule.(3) Follow-up visits for pain control must include objectives or metrics to be used to determine treatment success if opioids are to be continued. This includes, at a minimum:(a) Change in pain level;(b) Change in physical function;(c) Change in psychosocial function; and(d) Additional planned diagnostic evaluations or other treatments.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4667Treatment plan—Subacute pain.(1) The advanced registered nurse practitioner (ARNP) shall recognize the progression of a patient from the acute nonoperative or acute perioperative phase to the subacute phase and take into consideration the risks and benefits of continued opioid prescribing for the patient.(2) If tapering has not begun prior to the six- to ((twelve))12-week subacute phase, the ((advanced registered nurse practitioner))ARNP shall reevaluate the patient who does not follow the expected course of recovery. If ((significant and)) documented improvement in function or pain control has not occurred, the ((advanced registered nurse practitioner))ARNP shall reconsider the continued use of opioids, or whether tapering or discontinuing opioids is clinically indicated. The ((advanced registered nurse practitioner))ARNP shall make reasonable attempts to discontinue the use of opioids prescribed for the acute pain event by no later than the ((twelve))12-week conclusion of the subacute phase.(3) If the ((advanced registered nurse practitioner))ARNP prescribes opioids for effective pain control, such prescription shall be in no greater quantity than needed for the expected duration of pain severe enough to require opioids. The ((advanced registered nurse practitioner))ARNP shall not prescribe beyond a ((fourteen))14-day supply of opioids without clinical documentation in the patient record to justify the need for such a quantity during the subacute phase.(4) If the ((advanced registered nurse practitioner))ARNP elects to prescribe a combination of opioids with a medication listed in WAC 246-840-4960 or prescribes opioids to a patient known to be receiving a medication listed in WAC 246-840-4960 from another practitioner, such prescribing must be in accordance with WAC 246-840-4960.(5) If the ((advanced registered nurse practitioner))ARNP elects to treat a patient with opioids beyond the six- to ((twelve))12-week subacute phase, the ((advanced registered nurse practitioner))ARNP shall document in the patient record that the patient is transitioning from subacute pain to chronic pain. Rules governing the treatment of chronic pain, WAC 246-840-467 through 246-840-4940, shall apply.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-467Patient evaluation and patient record—Chronic pain.((The advanced registered nurse practitioner shall evaluate and document the patient's health history and physical examination in the patient's health record prior to treating for chronic pain.(1) The patient's health history shall include:(a) The nature and intensity of the pain;(b) The effect of pain on physical and psychosocial function;(c) Current and past treatments for pain, including medications and their efficacy;(d) Review of any significant comorbidities;(e) Any current or historical substance use disorder;(f) Current medications and, as related to treatment of the pain, the efficacy of medications tried; and(g) Medication allergies.(2) The patient evaluation prior to opioid prescribing must include:(a) Appropriate physical examination;(b) Consideration of the risks and benefits of chronic pain treatment for the patient;(c) Medications the patient is taking including indication(s), type, dosage, quantity prescribed, and as related to treatment of the pain, efficacy of medications tried;(d) Review of the prescription monitoring program (PMP) to identify any Schedule II-V medications or drugs of concern received by the patient in accordance with the provisions of WAC 246-840-4990;(e) Any available diagnostic, therapeutic, and laboratory results;(f) Use of a risk assessment tool and assignment of the patient to a high, moderate, or low risk category. The advanced registered nurse practitioner should use caution and shall monitor a patient more frequently when prescribing opioid analgesics to a patient identified as high risk;(g) Any available consultations, particularly as related to the patient's pain;(h) Pain related diagnosis, including documentation of the presence of one or more recognized indications for the use of pain medication;(i) Written agreements, as described in WAC 246-840-475 for treatment between the patient and the advanced registered nurse practitioner;(j) Patient counseling concerning risks, benefits, and alternatives to chronic opioid therapy;(k) Treatment plan and objectives including:(i) Documentation of any medication prescribed;(ii) Biologic specimen testing ordered; and(iii) Any labs or imaging ordered.(3) The health record must be maintained in an accessible manner, readily available for review, and contain documentation of requirements in subsections (1) and (2) of this section, and all other required components of the patient record, as set out in statute or rule.))(1) Before initiating or continuing chronic opioid therapy, the advanced registered nurse practitioner (ARNP) shall complete and document an appropriate evaluation in the patient record. At a minimum, the evaluation must address:(a) A review of the prescription monitoring program (PMP) for Schedule II–V medications or drugs of concern, including patterns that may indicate potential misuse or receipt of prescriptions from multiple prescribers or pharmacies, in accordance with WAC 246-840-4990;(b) A pain-related diagnosis or other recognized clinical indication supporting the use of opioid therapy;(c) Relevant medical and behavioral health history, including any current or past substance use disorder; and(d) Completion and documentation of a risk assessment for opioid-related harm, including any increased monitoring or precautions for at-risk patients.(2) The patient record must be maintained in an accessible manner and must document the evaluation and risk assessment required in this section, along with the treatment plan, patient counseling, and any written agreement as required by WAC 246-840-470 and 246-840-475.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-470Treatment plan.(1) When the patient enters the chronic pain phase, the advanced registered nurse practitioner (ARNP) shall reevaluate the patient by treating the situation as a new disease.(2) The chronic pain treatment plan must state the objectives that will be used to determine treatment success and must include, at a minimum:(a) Any change in pain relief;(b) Any change in physical and psychosocial function; and(c) Additional diagnostic evaluations or other planned treatments.(3) After treatment begins, the ((advanced registered nurse practitioner))ARNP shall adjust drug therapy to the individual health needs of the patient.(4) The ((advanced registered nurse practitioners))ARNPs shall complete patient notification in accordance with the provisions of WAC 246-840-4651.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-475Written agreement for treatment.The advanced registered nurse practitioner (ARNP) shall use a written agreement for treatment with the patient who requires long-term opioid therapy for chronic pain that outlines the patient's responsibilities. This written agreement for treatment must include:(1) The patient's agreement to provide biological samples for biological specimen testing when requested by the ((advanced registered nurse practitioner))ARNP. Biological specimen testing shall not be used in a punitive manner, but should be used in the context of clinical information used to improve patient care. Patients should not be dismissed from care on the basis of a biological specimen test result alone;(2) The patient's agreement to take medications at the dose and frequency prescribed, with a specific protocol for lost prescriptions and early refills or renewals;(3) Reasons for which opioid therapy may be discontinued;(4) The requirement that all chronic opioid prescriptions are provided by a single prescriber, a single clinic, or a multidisciplinary pain clinic;(5) The requirement that all chronic opioid prescriptions are to be dispensed by a single pharmacy or pharmacy system whenever possible;(6) The patient's agreement to not abuse substances that can put the patient at risk for adverse outcomes;(7) A written authorization for:(a) The ((advanced registered nurse practitioner))ARNP to release the agreement for treatment to:(i) Local emergency departments;(ii) Urgent care facilities;(iii) Other practitioners caring for the patient who might prescribe pain medications; and(iv) Pharmacies.(b) Other practitioners to report violations of the agreement to the ((advanced registered nurse practitioner))ARNP treating the patient's chronic pain and to the prescription monitoring program (PMP).(8) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and(9) Acknowledgment that, if the patient violates the terms of the agreement, the violation and the ((advanced registered nurse practitioner's))ARNP's response to the violation will be documented, as well as the rationale for changes in the treatment plan.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-477Periodic review.(1) The advanced registered nurse practitioner (ARNP) shall periodically review the course of treatment for chronic pain. Periodic reviews must consider the patient's response to treatment, including adherence, stability, and functional status, and any changes to the treatment plan must be based on clinical indications and documented in the patient record.The frequency of visits, biological testing, and prescription monitoring program (PMP) queries are determined based on the patient's risk category:(a) For ((a high-risk))an at-risk patient, at least quarterly and for all other patients at least annually;(b) ((For a moderate-risk patient, at least semiannually;(c) For a low-risk patient, at least annually;(d))) Immediately upon indication of concerning aberrant behavior; and(((e)))(c) More frequently at the ((advanced registered nurse practitioner's))ARNP's discretion.(2) During the periodic review, the ((advanced registered nurse practitioner))ARNP shall determine:(a) Patient's compliance with any medication treatment plan;(b) If pain, function, or quality of life have improved, diminished, or are maintained using objective evidence; and(c) If continuation or modification of medications for pain management treatment is necessary based on the ((advanced registered nurse practitioner's))ARNP's evaluation of progress towards treatment objectives.(3) Periodic ((or patient)) evaluations must also include:(a) History and physical examination related to the pain;(b) Use of validated tools to document either maintenance of function and pain control or improvement in function and pain level; and(c) Review of the PMP to identify any Schedule II-V medications or drugs of concern received by the patient at a frequency determined by the patient's risk category, and otherwise in accordance with the provisions of WAC 246-840-4990 and subsection (1) of this section.(4) The ((advanced registered nurse practitioner))ARNP shall assess the appropriateness of continued use of the current treatment plan if the patient's progress or compliance with current treatment plan is unsatisfactory. The ((advanced registered nurse practitioner))ARNP shall consider tapering, changing, or discontinuing treatment in accordance with the provisions of WAC 246-840-4935.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-485Consultation—Recommendations and requirements.(1) The advanced registered nurse practitioner (ARNP) shall consider and document referring the patient for additional evaluation and treatment as needed to achieve treatment objectives. Special attention should be given to those chronic pain patients who are under ((eighteen))18 years of age or who are potential ((high-risk))at-risk patients. The management of pain in patients with a history of substance use or with comorbid psychiatric disorders may require extra care, monitoring, documentation, and consultation with, or referral to, an expert in the management of such patients.(2) The mandatory consultation threshold is ((one hundred twenty))120 milligrams morphine equivalent dose (MED). If an ((advanced registered nurse practitioner))ARNP prescribes a dosage amount that meets or exceeds the mandatory consultation threshold of ((one hundred twenty))120 milligrams MED per day, a consultation with a pain management specialist as described in WAC 246-840-493, 246-853-750, 246-854-330, 246-817-965, 246-918-880, 246-919-940, or 246-922-750 is required, unless the consultation is exempted under WAC 246-840-487 or 246-840-490. The mandatory consultation shall consist of at least one of the following:(a) An office visit with the patient and the pain management specialist;(b) A consultation between the pain management specialist and the ((advanced registered nurse practitioner))ARNP;(c) An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the ((advanced registered nurse practitioner))ARNP or with a licensed health care practitioner designated by the ((advanced registered nurse practitioner))ARNP or the pain management specialist; ((or))(d) Other chronic pain evaluation services as approved by the ((commission.))board; or(e) Participation in peer case presentations such as Project ECHO or similar. If the ARNP observes a case presentation that is substantially similar to the case of their specific patient, it may be documented as meeting the consultation requirement.(3) The ((advanced registered nurse practitioner))ARNP shall document each consultation with the pain management specialist. Any written record of a consultation by the pain management specialist shall be maintained as a patient record by the specialist. If the pain management specialist provides a written record of the consultation to the ((advanced registered nurse practitioner, the advanced registered nurse practitioner))ARNP, the ARNP shall maintain it as part of the patient record.(4) The ((advanced registered nurse practitioner))ARNP shall use great caution when prescribing opioids to children and adolescents with chronic pain; appropriate referral to a specialist is encouraged.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-487Consultation—Exemptions for exigent and special circumstances.An advanced registered nurse practitioner (ARNP) is not required to consult with a pain management specialist as defined in WAC 246-840-493 when the ((advanced registered nurse practitioner))ARNP has documented adherence to all standards of practice as defined in WAC 246-840-460 through 246-840-493, and when any one or more of the following conditions apply:(1) The patient is following a tapering schedule;(2) The patient requires treatment for acute pain, which may or may not include hospitalization, requiring a temporary escalation in opioid dosage with expected return to their baseline dosage level or below;(3) The ((advanced registered nurse practitioner))ARNP documents reasonable attempts to obtain a consultation with a pain management specialist and the circumstances justifying prescribing above ((one hundred twenty))120 milligrams morphine equivalency dosage (MED) per day without first obtaining a consultation; or(4) The ((advanced registered nurse practitioner))ARNP documents that the patient's pain and function ((is))are stable, and the patient is on a nonescalating dosage of opioids.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-490Consultation—Exemptions for the ((advanced registered nurse practitioner))ARNP.The advanced registered nurse practitioner (ARNP) is exempt from the consultation requirement in WAC 246-840-485 if one or more of the following qualifications are met:(1) The ((advanced registered nurse practitioner))ARNP is a pain management specialist under WAC 246-840-493;(2) The ((advanced registered nurse practitioner))ARNP has successfully completed, within the last two years, a minimum of ((twelve))12 continuing education hours on chronic pain management approved by a continuing education accrediting organization. At least two of these hours must be dedicated to substance use disorder;(3) The ((advanced registered nurse practitioner))ARNP is a pain management practitioner working in a multidisciplinary chronic pain clinic or a multidisciplinary academic research facility; or(4) The ((advanced registered nurse practitioner))ARNP has a minimum of three years of clinical experience in a chronic pain management clinic, and at least ((thirty))30 percent of the ((advanced registered nurse practitioners'))ARNP's current practice is the direct provision of pain management care.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-493Pain management specialist.An advanced registered nurse practitioner (ARNP) pain management specialist, functioning as a consultant for the prescribing of chronic opioid therapy, shall meet the following qualifications:(1) Credentialed in pain management by a Washington state ((nursing care quality assurance commission-approved))board-approved certifying or credentialing entity; or(2) Meet all of the following:(a) A minimum of three years of clinical experience in a chronic pain management care setting;(b) Successful completion of a minimum of ((at least eighteen))18 continuing education hours in pain management during the past two years; and(c) At least ((thirty))30 percent of the ((advanced registered nurse practitioner's))ARNP's current practice is the direct provision of pain management care or is in a multidisciplinary pain clinic. AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4935Assessment of treatment plan.The advanced registered nurse practitioner (ARNP) shall assess and document the appropriateness of continued use of the current treatment plan if the patient's response to, or compliance with, the current treatment plan is unsatisfactory. The ((advanced registered nurse practitioner))ARNP shall consider tapering, changing, discontinuing treatment, or referral for a substance use disorder evaluation when:(1) The patient requests;(2) The patient experiences a deterioration in function or pain;(3) The patient is noncompliant with the written agreement;(4) Other treatment modalities are indicated;(5) There is evidence of misuse, abuse, substance use disorder, or diversion;(6) The patient experiences a severe adverse event or overdose;(7) There is unauthorized escalation of doses; or(8) There is continued dose escalation with no improvement in pain, function, or quality of life.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4940Patients with chronic pain((, including those on high doses,)) establishing a relationship with a new practitioner.(1) When a patient receiving chronic opioid pain medication(s) changes to a new advanced registered nurse practitioner (ARNP), the ((advanced registered nurse practitioner))ARNP shall query the prescription monitoring program (PMP). It is normally appropriate for the new ((advanced registered nurse practitioner))ARNP to initially maintain the patient's current opioid doses. Over time, the ((advanced registered nurse practitioner))ARNP may evaluate if any tapering or other adjustments in the treatment plan can or should be done.(2) An ((advanced registered nurse practitioner's))ARNP's treatment of a new ((high dose)) chronic pain patient is exempt from the mandatory consultation requirements of WAC 246-840-485 and the tapering requirements of WAC 246-840-4935 if:(a) The patient was previously being treated with a dosage of opioids in excess of ((one hundred twenty milligram MED))120 milligrams morphine equivalent dose (MED) for chronic pain under an established written agreement for treatment of the same chronic condition or conditions;(b) The patient's dose is stable and nonescalating;(c) The patient has a demonstrated history ((in their record)) of compliance with treatment plans and written agreements ((as documented by medical records and PMP queries)); and(d) The patient has documented functional stability, pain control, or improvements in function or pain control, at ((the))a dose in excess to ((one hundred twenty))120 milligrams MED.(3) With respect to the treatment of a new patient under subsection (1) or (2) of this section, this exemption applies for the first three months of newly established care, after which the requirements of WAC 246-840-485 and 246-840-4935 shall apply unless the patient qualifies for exemption under WAC 246-840-463.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4950Special populations—Patients ((twenty-five))25 years of age or under, pregnant patients, and aging populations.(1) Patients ((twenty-five))25 years of age or under. In the treatment of pain for patients ((twenty-five))25 years of age or under, the advanced registered nurse practitioner (ARNP) shall treat pain in a manner equal to that of an adult but must account for the weight of the patient and adjust the dosage prescribed accordingly.(2) Pregnant patients. Use of medication assisted treatment (MAT) opioids, such as methadone or buprenorphine, by a pregnant patient shall not be discontinued without oversight by the MAT prescribing practitioner. The ((advanced registered nurse practitioner))ARNP shall weigh carefully the risks and benefits of opioid detoxification during pregnancy.(3) Aging populations. ((As people age, their tolerance and metabolizing of opioids may change. The advanced registered nurse practitioner))The ARNP shall consider the distinctive needs of patients who are ((sixty-five))65 years of age or older and who have been on chronic opioid therapy or who are initiating opioid treatment.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4955Episodic care of chronic opioid patients.(1) When providing episodic care for a patient who the advanced registered nurse practitioner (ARNP) knows is being treated with opioids for chronic pain, such as for emergency or urgent care, the ((advanced registered nurse practitioner))ARNP shall review the prescription monitoring program (PMP) to identify any Schedule II-V ((or drugs of concern))medications received by the patient and document in the patient record ((their review and))if there are any concerns.(2) An ((advanced registered nurse practitioner))ARNP providing episodic care to a patient who the ((advanced registered nurse practitioner))ARNP knows is being treated with opioids for chronic pain should provide additional opioids to be equal to the severity of the acute pain. If opioids are provided, the ((advanced registered nurse practitioner))ARNP shall limit the use of opioids to the minimum amount necessary to control the acute nonoperative pain, acute perioperative pain, or similar acute exacerbation of pain until the patient can receive care from the practitioner who is managing the patient's chronic pain treatment.(3) The ((episodic care advanced registered nurse practitioner))ARNP providing episodic care shall report known violations of the patient's written agreement to the patient's treatment practitioner who provided the agreement for treatment.(4) ((The episodic care advanced registered nurse practitioner))An ARNP providing episodic care shall coordinate care with the patient's chronic pain treatment practitioner if that person is known to the episodic care ((advanced registered nurse practitioner))ARNP, when practicable.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4960Coprescribing with certain medications.(1) The advanced registered nurse practitioner (ARNP) shall not knowingly prescribe opioids in combination with the following Schedule II-IV medications without documentation in the patient record of clinical judgment and discussion of risks with the patient:(a) Benzodiazepines;(b) Barbiturates;(c) Sedatives;(d) Carisoprodol; or(e) Nonbenzodiazepine hypnotics also known as Z drugs.(2) If a patient receiving an opioid prescription is known to be concurrently prescribed one or more of the medications listed in subsection (1) of this section, the ((advanced registered nurse practitioner))ARNP prescribing opioids shall consult with the other prescriber(s) to establish a patient care plan for the use of the medications concurrently or consider whether one of the medications should be tapered.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4970Coprescribing of opioids for patients receiving medication assisted treatment (MAT).(1) Where practicable, the advanced registered nurse practitioner (ARNP) providing acute nonoperative pain or acute perioperative pain treatment to a patient known to be receiving medication assisted treatment (MAT) shall prescribe opioids for pain relief either in consultation with the MAT prescribing practitioner or a pain specialist.(2) The ((advanced registered nurse practitioner))ARNP shall not discontinue MAT medications when treating acute nonoperative pain or acute perioperative pain without documentation of the reason for doing so, nor shall use of these medications be used to deny necessary operative intervention.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4980Coprescribing of naloxone.(1) The advanced registered nurse practitioner (ARNP) shall confirm or provide a current prescription for naloxone when ((fifty))50 milligrams MED or above is prescribed, or when ((prescribed to a high-risk))prescribing to an at-risk patient.(2) The ((advanced registered nurse practitioner))ARNP should counsel and provide an option for a current prescription for naloxone to patients being prescribed opioids as clinically indicated.AMENDATORY SECTION(Amending WSR 18-20-086, filed 10/1/18, effective 11/1/18)WAC 246-840-4990Prescription monitoring program—Required registration, queries, and documentation.(1) The advanced registered nurse practitioner (ARNP) shall register to access the prescription monitoring program (PMP) or demonstrate proof of having registered to access the PMP if they prescribe opioids in Washington state.(2) The ((advanced registered nurse practitioner))ARNP is permitted to delegate performance of a required PMP query to an authorized designee, as defined in WAC 246-470-050.(3) At a minimum, the ((advanced registered nurse practitioner))ARNP shall ensure a PMP query is performed prior to the prescription of an opioid at the following times:(a) First opioid prescription for acute pain unless clinical exception is documented; such exceptions should be rare, occurring in less than ((ten))10 percent of the first prescriptions;(b) First refill for acute pain if not checked with initial prescription due to documented clinical exception;(c) Time of transition from acute to subacute pain;(d) Time of transition from subacute to chronic pain; and(e) Time of preoperative assessment for any elective surgery or prior to discharge for nonelective surgery.(4) For chronic pain management, the ((advanced registered nurse practitioner))ARNP shall ensure a PMP query is performed at a minimum frequency determined by the patient's risk assessment, as follows: (((a))) For ((a high-risk))an at-risk patient, a PMP query shall be completed at least quarterly and at least annually for all other patients.(((b) For a moderate-risk patient, a PMP query shall be completed at least semiannually.(c) For a low-risk patient, a PMP query shall be completed at least annually.))(5) The ((advanced registered nurse practitioner))ARNP shall ensure a PMP query is performed for any chronic pain patient immediately upon identification of aberrant behavior.(6) The ((advanced registered nurse practitioner))ARNP shall ensure a PMP query is performed when providing episodic care to a patient who the ((advanced registered nurse practitioner))ARNP knows to be receiving opioids for chronic pain, in accordance with WAC 246-840-4955.(7) For the purposes of this section, the requirement to consult the PMP does not apply when the PMP or the electronic medical record (EMR) cannot be accessed by the ((advanced registered nurse practitioner))ARNP due to a temporary technological or electrical failure. The query shall be completed as soon as technically feasible.(8) Pertinent concerns discovered in the PMP shall be documented in the patient record.REPEALERThe following sections of the Washington Administrative Code are repealed:WAC 246-840-310Use and protection of professional titles.WAC 246-840-311ARNP previously adopted specialties.WAC 246-840-450Renewal of ARNP prescriptive authority.WAC 246-840-451Continuing education requirements for ARNP prescriptive authority.