arizona STATE BOARD OF NURSING 70-t/O2 +6/& REGULATORY JOURNAL Experience0DJQHW <-&92&,3*9p 2*&3894:8ð …it’s the pride we feel because DOOğYH+RQRU+HDOWKPHGLFDO FHQWHUVKDYHHDUQHG0DJQHW UHFRJQLWLRQ ĽLWłVWKHYRLFHZHKDYHZLWKVKDUHG JRYHUQDQFHRXU8QLW%DVHG3DWLHQW&DUH &RXQFLOVWUXO\DOORZXVWRGULYHRXUSUDFWLFH ĽLWłVKDYLQJVXSSRUWWRGRZKDWłVEHVWIRU WKHSDWLHQWEHVWIRUHDFKRWKHUDQGEHVW IRURXUFDUHHUV Nursing excellence is central to everything we do and everything we are. HonorHealth is the only multihospital health system in Arizona to achieve elite Magnet recognition. This is an achievement shared with only 21 other multihospital health systems in the U.S. <-&9>4:2*&394:8 `œ˜i UÊÊ"ÝÞVœ`œ˜iÊ­ÃÕV Ê>ÃÊ"ÝÞ œ˜Ìˆ˜Á® UÊÊÞ`ÀœVœ`œ˜iÊ­ÃÕV Ê>ÃÊ6ˆVœ`ˆ˜Á®­3® Overdose Deaths Among those who died from prescription opioid overdose between 1999 and 2014: UÊ "ÛiÀ`œÃiÊÀ>ÌiÃÊÜiÀiÊ ˆ} iÃÌÊ>“œ˜}Ê«iœ«iÊ>}i`ÊÓxÊ 4 arizona STATE BOARD OF NURSING REGULATORY JOURNAL ̜Êx{ÊÞi>Àð UÊ i˜ÊÜiÀiʓœÀiʏˆŽiÞÊ̜Ê`ˆiÊvÀœ“ÊœÛiÀ`œÃi]ÊLÕÌÊÌ iʓœÀÌ>ˆÌÞÊ }>«ÊLiÌÜii˜Ê“i˜Ê>˜`Êܜ“i˜ÊˆÃÊVœÃˆ˜}°­4) OPIOID-RELATED SUBSTANCE ABUSE: While opioid-related deaths are increasing and alarming, opioid abuse is also at a critical level. More than 2.1 million in the US are struggling with substance abuse related to opioid pain medicine, thousands of Americans have lost their lives to prescription drug abuse, and nurses are currently participating in Board of Nursing non discipline and discipline programs related to opioid addiction. Opioid Abuse "ÛiÀ`œÃiʈÃʘœÌÊÌ iʜ˜ÞÊÀˆÃŽÊÀi>Ìi`Ê̜ʫÀiÃVÀˆ«Ìˆœ˜Êœ«ˆœˆ`ðʈÃÕÃi]Ê >LÕÃi]Ê>˜`ʜ«ˆœˆ`ÊÕÃiÊ`ˆÃœÀ`iÀÊ­>``ˆV̈œ˜®Ê>ÀiÊ>ÃœÊ«œÌi˜Ìˆ>Ê`>˜}iÀð UÊ ˜ÊÓä£{]Ê>“œÃÌÊÓʓˆˆœ˜Ê“iÀˆV>˜ÃÊ>LÕÃi`ʜÀÊÜiÀiÊ`i«i˜`i˜ÌÊ œ˜Ê«ÀiÃVÀˆ«Ìˆœ˜Êœ«ˆœˆ`ð UÊ Ãʓ>˜ÞÊ>Ãʣʈ˜Ê{Ê«iœ«iÊÜ œÊÀiViˆÛiÊ«ÀiÃVÀˆ«Ìˆœ˜Êœ«ˆœˆ`Ãʏœ˜}Ê ÌiÀ“ÊvœÀʘœ˜V>˜ViÀÊ«>ˆ˜Êˆ˜Ê«Àˆ“>ÀÞÊV>ÀiÊÃiÌ̈˜}ÃÊÃÌÀÕ}}iÊÜˆÌ Ê >``ˆV̈œ˜°­x® UÊ ÛiÀÞÊ`>Þ]ʜÛiÀÊ£]äääÊ«iœ«iÊ>ÀiÊÌÀi>Ìi`ʈ˜Êi“iÀ}i˜VÞÊ `i«>À̓i˜ÌÃÊvœÀʓˆÃÕȘ}Ê«ÀiÃVÀˆ«Ìˆœ˜Êœ«ˆœˆ`ð­6® CALL TO ACTION: The current public health crisis also demands an educational commitment and aggressive action by nursing regulators as we all need to answer the call. The current crisis demands aggressive Continued on page 6 >>> Nurses! Now Earn More at MMC Memorial Medical Center in Las Cruces ŚĂƐŵĂĚĞĂƐŝŐŶŝĮĐĂŶƚƐĂůĂƌLJŝŶĐƌĞĂƐĞĨŽƌ our Nursing Team! We are looking for nurses to work in our OR, ER, Perinatal Services, NICU, ICU, Cath Lab, Tele/Med/Surg. ŽŵĞũŽŝŶƵƐŝŶƚŚĞďĞĂƵƟĨƵůĐŝƚLJŽĨ>ĂƐƌƵĐĞƐĂƐǁĞĐŽŶƟŶƵĞƚŽŐƌŽǁ͘ƉƉůLJ ƚŽĚĂLJƚŽǁŽƌŬǁŚĞƌĞLJŽƵǁŝůůďĞŚŽŶŽƌĞĚĂŶĚǀĂůƵĞĚ͘ KŶͲƐŝƚĞŝŶƚĞƌǀŝĞǁĞdžƉĞŶƐĞƐ XZĞůŽĐĂƟŽŶƐƐŝƐƚĂŶĐĞ XWƌŽĨĞƐƐŝŽŶĂůĞǀĞůŽƉŵĞŶƚŝŶĐĞŶƟǀĞƐ X ĨŽƌEĂƟŽŶĂůĞƌƟĮĐĂƟŽŶƐ dƵŝƟŽŶZĞŝŵďƵƌƐĞŵĞŶƚ XŵƉůŽLJĞƌƐƉŽŶƐŽƌĞĚƐ XChildcare Reimbursement XReferral Bonus X sŝƐŝƚƵƐĂƚDD>͘ŽƌŐĂŶĚĂƉƉůLJŽŶůŝŶĞ͘ &ŽƌŵŽƌĞŝŶĨŽƌŵĂƟŽŶĐĂůůŽƌĞŵĂŝůŽƵƌ Nurse Recruiter, Ernest Perez, RN 575-635-7101 Ernest.Perez@LPNT.net X MMCLC.org 2450 S. Telshor Blvd, Las Cruces, NM 88011 arizonaX STATE BOARD OF NURSING REGULATORY JOURNAL 5 action by all stakeholders in nursing, medicine, and pharmacy. The educational commitment has been made by the leading nursing organizations, including American Association of Nurse Practitioners (AANP), the American Association of Colleges of Nursing (AACN), the American Association of Nurse Anesthetists, the American College of Nurse-Midwives, the American Nurses Association, the National Association of Clinical Nurse Specialists, and the National Organization of Nurse Practitioner Faculties. Safe Prescribing Saves Lives. References 1. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov. 2. Frenk SM, Porter KS, Palazzi LJ. Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS data brief, no 189. Hyattsville, MD: National Center for Health Statistics. 2015. 3. Ossiander EM. Using textual cause-of-death data to study drug poisoning Islander EM Am J Epidemiology. 2014 Apr 1; 179(7):884-94. doi: 10.1093/aje/kwt333. Epub 2014 Feb 1112.) 4. Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2014 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html. 5. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010; 105:1776–82. http://dx.doi. org/10.1111/j.1360-0443.2010.03052.x 6. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www.samhsa.gov/data/2k13/ DAWN127/sr127-DAWN-highlights.htm Summit Healthcare Regional Medical Center Trusted to Deliver Exceptional, Compassionate care close to home Come to Arizona’s cool, beautiful White Mountains where the quality of life soars as high as the tall pines! Sign on bonus / Relocation Assistance / Excellent Benefits / 403(b) Retirement / Tuition Reimbursement RN opportunities in: f Emergency Dept. f Med Surg f Surgery f ICU f Float f Labor & Delivery / Post Partum f Cath Lab To learn more about our Career opportunities visit www.summithealthcare.net or call to speak with the Nurse Recruiter, Stevie Burnside at 928-537-6367 email sburnside@summithealthcare.net Show Low Arizona has four beautiful, mild seasons — a perfect place for outdoor adventures year-round! 6 arizona STATE BOARD OF NURSING REGULATORY JOURNAL Summit Healthcare Regional Medical Center ÓÓääÊ °Ê- œÜÊœÜÊ>ŽiÊ,`°ÊUÊShow Low, AZ 85901 Th CE m Nurse.c o ink T hi nkN m CRUISE u r s e.c o Tenth April 21-29, 2017 NURSING CONTINUING EDUCATION Day Sat Sun Mon Tue Wed Thu Fri Sat Cruise Port Galveston, TX Fun Day At Sea Fun Day At Sea Montego Bay, Jamaica Grand Cayman, Cayman Islands Cozumel, Mexico Fun Day At Sea Galveston, TX Arrive Depart 4:00 PM 9:00 AM 7:00 AM 10:00 AM The moment I made a 6:00 PM 4:00 PM 6:00 PM 8:00 AM Who says Continuing Education can’t be fun? Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system comprised of eight hospitals, a medical group, and health plan. We are currently seeking registered nurses (RNs) for inpatient and outpatient opportunities in New Mexico, including: Join ThinkNurse and Poe Travel for our 10th CE Cruise. Cruise the Caribbean on Carnival’s Freedom while you earn your annual CE credits and write the trip off on your taxes! Prices for this cruise and conference are based on double occupancy (bring your spouse, significant other, or friend) and start at $945.00p/p based on double occupancy, includes – 1 night stay in Galvestion, 7 night cruise, port charges, government fees and taxes. A $250 nonrefundable per-person deposit is required to secure your reservations. Please ask about our Cruise LayAway Plan! UÊ >ÃiÊ>˜>}i“i˜Ì UÊ >À`ˆœÛ>ÃVՏ>ÀÊ"«iÀ>̈˜}Ê,œœ“ UÊ “iÀ}i˜VÞÊ i«>À̓i˜Ì UÊi˜iÀ>Êi`ˆV>Ê1˜ˆÌ UÊœ“iÊi>Ì V>ÀiÊ>˜`ʜëˆVi UʘÌiÀ˜>Ê}i˜VÞÊ­i`É-ÕÀ}É/iiÊ>˜`Ê ÀˆÌˆV>Ê >Ài® UÊ"«iÀ>̈˜}Ê,œœ“ UÊ"ÕÌ«>̈i˜ÌÊ >ÀiÊ>˜>}iÀà UÊ*Àœ}ÀiÃÈÛiÊ >Ài UÊ,iVœÛiÀÞÊ,œœ“ UÊ,i}ˆœ˜>ÊÀi>Ê"««œÀÌ՘ˆÌˆiÃ\Ê Ã«>˜œ>]Ê-œVœÀÀœ]Ê œÛˆÃ]Ê,Ո`œÃœ]Ê>˜`Ê/ÕVՓV>Àˆ We offer competitive salaries, day-one benefits packages, and wellness programs. Relocation and sign-on bonuses may also apply. To learn more about career opportunities at Presbyterian, visit phs.org/careers. Make every moment of your life count for more here. AA/EOE/VET/DISABLED This activity has been submitted to the Midwest Multistate Division for approval to award nursing contact hours. The Midwest Multistate Division is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. For more information about the cruise and the curriculum please log on to our Web site at ThinkNurse.com or call Teresa Grace at Poe Travel Toll-free at 800.727.1960. arizona STATE BOARD OF NURSING REGULATORY JOURNAL 7 Janeen Dahn PhD, FNP-C Associate Director, Complaints & Investigations Arizona Prescribers and the Opioid Epidemic Primer Since 1999, opiate overdose deaths have increased 265% among men and 400% among women (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). Opioids are substances chemically similar to alkaloids found in opium poppies that activate dopamine neurotransmitter receptors in the brain, mimicking that of a natural neurotransmitter. One of the transmitters activated by opioids is the mesolimbic (midbrain) reward system responsible for feelings of pleasure. Overstimulation of the reward system by opioids results in euphoric feelings that may lead to misuse and abuse of these drugs. Arizona prescribers can help to reduce the incidence of opioid overdose and opioid use disorder by identifying the problem of prescription abuse, the recognition of “red flags” indicating inappropriate use, and implementing universal precautions for all controlled substances. The Problem According to the Substance Abuse and Mental Health Services Administration (SAMHSA) prescription drugs are misused and abused more often than any other drug, except marijuana & alcohol (2015). The Center for Disease Control and Prevention reported that approximately 15,000 people die every year from overdoses involving prescription painkillers, more than those who die from heroin and cocaine combined (2013). Opioids reduce the perception of pain but can also produce drowsiness, mental confusion, euphoria, and respiratory depression. Some people who misuse opioids do so by trying to intensify their euphoric response by snorting 8 or injecting the substance (SAMHSA, 2015). Chronic opioid abuse may result in opioid tolerance, dependence, and addiction because of manifestations of brain changes. Prescription drug tolerance (an individual’s diminished response to a drug), dependence (the need to keep taking the drug to avoid a withdrawal syndrome), and addiction (intense drug craving and compulsive use) are all indications of changes in the brain resulting from chronic drug abuse. Diagnostic codes related to substance use disorders changed in 2013. According to the Diagnostic and Statistical Manual (DSM) opioid use disorder is coded as 304.00 for opioid dependence and 305.50 for opioid abuse and the International Statistical Classification of Diseases codes opioid use disorder as F-11.20. The financial implications of substance abuse must also be considered as street prices reflect the IV-morphineequivalence of a dose of an opioid, and thereby its “desirability” for misuse by an individual with opioid use disorder (Hosea, 2015). According to the United States Department of Health and Human Services (2013), an estimated 24.6 million Americans, aged 12 or older, used illicit drugs in the past 30 days prior to the survey interview (Figure 1). The estimate represents 9.4% of the population aged 12 or older. In Arizona, approximately 10 million Class II-IV prescriptions were written and 524 million pills are dispensed each year and account for over half of the drugs dispensed in the state (Arizona Department of Health Services [ADHS], 2014). Opioid overdoses Continued on page 11 >>> Figure 1. Past Month Illicit Drug Use among Persons aged 12 or Older in 2013 (U.S. Department of Health Services, 2013). arizona STATE BOARD OF NURSING REGULATORY JOURNAL Your next healthcare journey starts here. CHOOSE YOUR PATH. EXCEPTIONAL CAREERS THROUGHOUT THE WEST FULL SPECTRUM OF HOSPITAL SETTINGS NURSING EXCELLENCE 7 STATES 29 HOSPITALS Our growing health system, one of the nation’s largest, features 29 hospitals in 7 western states and employs over 47,000 people. We feature every practice setting imaginable - from rural community hospitals to metropolitan teaching and research medical centers. Our locations also offer an unequaled variety of lifestyle options. Nurses are the heartbeat of a hospital, and we do our best to keep them beating happily and well. Part of this is the breadth of career options for RNs at Banner Health. We have opportunities for nurses of any skill set. CAREERS FOR NURSES ON THE MOVE AWARD-WINNING CARE Help define the future of healthcare. Learn more at http://tinyurl.com/h4v8vfj We are one of the most respected health systems in the nation, receiving accolades from Becker’s Hosptial Review, Truven Health Analytics, U.S. News & World Report and more - as a system, for individual locations and leadership. Banner Staffing Services has excellent travel and registry opportunities throughout our system, offering your career a welcome change of place. EEO/AA. We support a tobacco-free and drug-free workplace. STAFF DIRECTORY EDUCATION ADMINISTRATION Joey Ridenour, MN, RN, FAAN Executive Director 602.771.7801 jridenour@azbn.gov Janeen Dahn, PhD, RN, FNP-C Associate Director Complaints & Investigations 602.771.7814 jdahn@azbn.gov Judy Bontrager, MN, RN Associate Director, Operations & Licensing 602.771.7802 jbontrager@azbn.gov Pamela Randolph, MS, RN, FRE Associate Director Education & Evidenced Based Regulation 602.771.7803 prandolph@azbn.gov Valerie Smith, MS, RN, FRE Associate Director Hearings 602.771.7804 vsmith@azbn.gov Dolores Hurtado, Senior Investigator to the Associate Director of Complaints/Investigations - Intake Triage Coordinator 602.771.7845 dhurtado@azbn.gov Susie Flores Administrative Assistant to the Executive Director 602.771.7806 sflores@azbn.gov Becky Melton Administrative Assistant to Associate Director Operations/RN-LPN Exams 602.771.7805 bmelton@azbn.gov Lila Wiemann Administrative Assistant 602.771.7890 lwiemann@azbn.gov CANDO Janet (Jan) Kerrigan, BSN, RN Nurse Practice Consultant 602.771.7864 jkerrigan@azbn.gov Olga Zuniga Administrative Secretary 602.771.7865 ozuniga@azbn.gov Ronda Doolen, MSN, BSN, RN Education Program Administrator 602.771.7877 rdoolen@azbn.gov LICENSING Bonnie Richter, MSW Senior Investigator 602.771.7828 brichter@azbn.gov Claudia Deines Verifications 602.771.7833 cdeines@azbn.gov Cindy George, BSN, RN Nurse Practice Consultant 602.771.7857 cgeorge@azbn.gov Daniel Phelan, M. Adm., B.S. Senior Investigator 602.771.7813 dphelan@azbn.gov Lyn Ledbetter Administrative Assistant 602.771.7856 lledbetter@azbn.gov David Elson, III Senior Investigator 602.771.7851 delson@azbn.gov FISCAL SERVICES Tracy Kreck Fiscal Services Manager 602.771.7809 tkreck@azbn.gov Frank Curatola Senior Investigator 602.771.7822 fcuratola@azbn.gov Traci O’Connor Accounting Tech 602.771.7810 toconnor@azbn.gov HEARINGS Trina Smith Legal Assistant 602.771.7852 tsmith@azbn.gov Jennifer Ingram Senior Investigator 602.771.7835 jingram@azbn.gov Katrina Alberty Senior Investigator 602.771.7817 kalberty@azbn.gov INVESTIGATIONS Kirk Olson Senior Investigator 602.771.7824 kolson@azbn.gov Kristi Hunter, MSN, FNP-C Advanced Practice Nurse Consultant 602.771.7854 khunter@azbn.gov Linda Monas Senior Investigator 602.771.7826 lmonas@azbn.gov Kathleen Harrington, BA, ADN, RN Nurse Practice Consultant 602.771.7811 kharrington@azbn.gov Max Barker Senior Investigator 602.771.7812 mbarker@azbn.gov Donna Frye RN/LPN Renewals/Advance Practice Certifications dfrye@azbn.gov Gail Maloney LPN/RN & CNA Renewals 602.771.7836 gmaloney@azbn.gov Helen Tay CNA Exam/Endorsements 602.771.7832 htay@azbn.gov Idalyne Eskava RN/LPN Endorsements 602.771.7840 ieskava@azbn.gov Monica Ortiz RN/LPN Endorsements 602.771.7831 mortiz@azbn.gov Naira Kutnerian Administrative Assistant to Associate Director of Operations & Licensing/Advance Practice Certifications 602.771.7834 nkutnerian@azbn.gov MAILROOM Karen Johnson 602.771.7876 kjohnson@azbn.gov MONITORING Michelle Morton Senior Investigator 602.771.7850 mmorton@azbn.gov Tamara Greabell, MA, BSN, RN Nurse Practice Consultant 602.771.7862 tgreabell@azbn.gov Susan Bushong, B.A. Senior Investigator 602.771.7821 sbushong@azbn.gov Brent Sutter Legal Assistant 602.771.7860 bsutter@azbn.gov LEGAL SECRETARIES RECEPTIONISTS Ruth Kish, MN, RN Nurse Practice Consultant 602.771.7823 rkish@azbn.gov Lynette Drafton Senior Investigator 602.772.7827 ldrafton@azbn.gov Jamie Fivecoat 602.771.7871 jfivecoat@azbn.gov Stephanie Chambers, MN, RN Nurse Practice Consultant 602.771.7818 schambers@azbn.gov Gari Carrol Legal Secretary 602.771.7841 gcarrol@azbn.gov Cindy Mand, MSN, RN Nurse Practice Consultant 602.771.7815 cmand@azbn.gov Michael Pilder, MSN, PHCNS-BN APHN-BC Nurse Practice Consultant 602.771.7816 mpilder@azbn.gov COMPLAINTS-INTAKE Dolores Hurtado, Senior Investigator Complaints-Intake Triage Coordinator 602.771.7845 dhurtado@azbn.gov Lynette Drafton Senior Investigator Applicant Triage 602.771.7827 ldrafton@azbn.gov 10 SENIOR INVESTIGATORS arizona STATE BOARD OF NURSING REGULATORY JOURNAL Richard Carr Legal Secretary 602.771.7852 rcarr@azbn.gov INFORMATION TECHNOLOGY Adam Henriksen 602.771.7807 ahenriksen@azbn.gov Cory Davitt 602.771.7808 cdavitt@azbn.gov Nancy Davis 602.771.7872 ndavis@azbn.gov Susan Kingsland 602.771.7873 skingsland@azbn.gov RECORDS Anne Parlin 602.771.7875 aparlin@azbn.gov involve both men and women of all ages, ethnicities, demographic and economic characteristics, and involves both illicit opioids such as heroin and, prescription opioid analgesics such as oxycodone, hydrocodone, fentanyl, and methadone (Painkillers fuel growth in drug addiction, 2011). In 2010, Arizona ranked 6th highest in the nation for drug overdose deaths and 5th highest opioid prescribing rate in the U.S. (ADHS, 2014). Recognizing Signs of Misuse and Abuse - Red Flags Since 2006, death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, while the death rate associated with opioid pain medication has increased markedly. Opioid Southwest Region Indian Health Service The Southwest Region Indian Health Service is seeking Registered Nurses in multiple specialties including Medical/Surgical, ER, OB/L&D and Leadership Roles. Bring your innovative spirit to improve the health status of our Native American population. Why Nurses Choose IHS: s Loan Repayment Program – Up to $20,000 annually s #OMPETITIVE 3ALARIES s  EVENINGNIGHT DIFFERENTIAL s  WEEKEND DIFFERENTIAL s  VACATION DAYS s  SICK DAYS  &EDERAL HOLIDAYS s .UMEROUS HEALTH PLANS TO CHOOSE CONTINUE in retirement s /UTSTANDING &EDERAL 2ETIREMENT 0LAN AND much more s 4RANSFER OPPORTUNITIESn LICENSE STATES Our nursing career opportunities are available in rural and urban locations throughout the states of Arizona, Nevada and Utah. The Southwest Region also has the largest Medical Center in the Indian Health Service located in central Phoenix. Nurses interested in a rewarding career, please contact Kevin Long at 602-364-5178, or email Kevin at Kevin.long@ihs.gov. I hope we’ll talk soon. Your Southwest adventure awaits you. painkillers like OxyContin, Percocet, and Vicodin have become the most widely prescribed drugs in the country, with sales of nearly $2 billion a year (Upp Technology, 2015). Opioids are abused or misused for a variety of reasons but healthcare providers can reduce the incidence by recognizing the red flags that are signs of aberrant behavior. While not all users of opioids are seeking a prescription with an intention to misuse or abuse the drug, several behaviors are common in those who do. Prescriber Shopping Prescriber shopping, also known as “doctor shopping,” is characterized by an individual seeking out providers who will prescribe the requested medications without adhering to the safety guidelines. Individuals who use opioids illicitly will seek out prescribers who are known to not check the Controlled Substance Prescription Monitoring Program CSPMP, or who will prescribe without valid documentation or objective information supporting a complaint of pain. The CSPMP is a program developed to promote the public health and welfare by detecting diversion, abuse, and misuse of prescription medications classified as controlled substances under the Arizona Uniform Controlled Substances Act (Arizona State Board of Pharmacy, 2016). Drug monitoring programs collect, monitor, and analyze electronically transmitted controlled drug prescribing and dispensing data submitted by pharmacies and dispensing practitioners. This pattern is evidenced by multiple providers noted on the CSPMP, often in different geographical regions, and sometimes across state lines. Individuals with substance use disorders may state they are unable to provide past medical records because the provider is no longer in business, or the office burned down, had a computer failure, or a variety of other reasons. Instead of relying on patient reports of previous care provided, Continued on next page >>> arizona STATE BOARD OF NURSING REGULATORY JOURNAL 11 prescribers should consider starting from the beginning in the treatment plan by obtaining the appropriate test, examinations, and supportive evidence for the need of opioid treatment. Standard of care frequently recommends patients participate in physical therapy for many acute and chronic pain conditions and evidence of this therapy should be obtained from the treatment facility, not from patient report. Multiple Pharmacies Drug seeking individuals may also have prescriptions filled at multiple pharmacies in different locations, ranging from corporate pharmacies such as Wal-Mart®, Walgreen®, or CVS®, to the smaller privately owned establishments and typically, the locations are several miles apart. Individuals who obtain prescriptions from multiple providers tend to pay cash for the prescriptions in an attempt to circumvent the insurance company from tracking the use of controlled substances, to persuade the small business owner from asking questions, or because of lack of coverage. Frequent Visits, Escalating Dosages, and High Quantities When an individual has frequent office visits and consistently asks for higher dosages and larger quantities of pain medication, a mental red flag should be raised in the prescriber’s mind, to evaluate the appropriateness of the drug, dose, and quantity prescribed. The prescriber should determine if the opioid is absolutely necessary and if the dose and quantity are appropriate given the objective supportive information available. For example, “back pain,” or lumbago is a symptom, not a pain generator. The clinician must first determine what is causing the pain using objective information such as a comprehensive musculoskeletal examination, diagnostic imaging, review of previous medical records, etc. Once a diagnosis is determined, the clinician should choose the best treatment, pharmacological and/or nonpharmacological, for the individual patient. Clinicians may see frequent canceled appointments for diagnostic imaging for a number of reasons. For example, patients may cite financial stressors, family emergencies, work schedules, out of state commitments, personal crises, etc. as reasons for not obtaining the imaging. Additionally, those individuals with substance use disorders, or those who are diverting medications commonly refuse diagnostic imaging and are not interested in a diagnosis or alternative treatments. Morphine Equivalency Dosing (MED) The Morphine Equivalency Dosing (MED) number is provided on the CSPMP when opioids are reported to the databank. The MED number was developed by the Center for Disease Control, and is a conversion chart designed to equate different opiates and strengths into a standard morphine equivalent value. Each active opioid prescription (those that the patient is currently taking based on how the prescription is written) will have a MED value on the conversion chart, and then combined into one daily MED value. It is important to note that the MED value is a snapshot of the day that the report is run and may have up to a two-week lag time for prescriptions not yet entered. The MED value is intended to trigger the prescriber to pause and take into account a number of clinical considerations (Dahn, 2015). A study published in the Journal of the American Medical Association identifies an increased incidence of accidental overdose in patients taking opioids at doses greater than 100mg of morphine equivalents each day. Early Refills, Lost or Stolen Prescriptions Requests for early refills are common in 12 arizona STATE BOARD OF NURSING REGULATORY JOURNAL individuals who have an active opioid use disorder.. A few days early every month quickly adds up to a full prescription in a short period of time and often a variety of excuses are provided for why an early refill is necessary. If an early refill is provided, prescribers should consider a lesser quantity on the next refill to reduce the incidence of over prescribing. Lost or stolen prescriptions are another common tactic for those with aberrant behaviors. A police report is only evidence that a report was filed, not that the individual actually had a prescription or that it was stolen, it is merely a record of a report. Abnormal Drug Screen/Test Drug screens conducted in the office or tests in the lab are another method for monitoring compliance with a medication plan. An unexpected test result may be a red flag that the individual is not taking the medication (as evidenced by a negative test), or that the individual is taking medications “COME JOIN ME AT TMC! BE A PART OF A GROWING TEAM AND A PROUD NURSING ORGANIZATION.” Marty Enriquez, TMC Chief Nursing Officer email us at: JoinMarty@tmcaz.com or check out all available positions at: jobs.tmcaz.com cost only $50 as it turns into a gel when crushed and consequently not easily converted into an intravenous formulation (Figure 2 and 3). Figure 2. New and Old OxyContin Pills. 80-milligram tablets of the current OxyContin OROS REMS abuse prevention formula (left) and the previous OxyContin formula (right). not prescribed or illicit drugs. Unexpected lab results should always raise a flag of aberrant behavior. Social Issues and Street Value Another common red flag are individuals who do not have a job or legitimate source of income but frequently pay cash for office visits or prescription drugs. According to the National Association of Drug Diversion Investigators (2007) and StreetRx (2015), oxycodone in any formulation cost about $1.00 a milligram almost anywhere in the United States. A 30mg instant release oxycodone tablet has a street value as much as $60.00. The higher doses of 80mg extended release formula, sold as OxyContin, with Osmotic ControlledRelease Oral Delivery System (OROS) Risk Evaluation and Mitigation Strategies (REMS) “abuse” prevention Clinicians should be aware that Percocet 10/325, written for a quantity of 90 tablets may only cost a $10 copay at the pharmacy, but sell for $900, or more, on “the street.” Patterns of behaviors relating to missed appointments, termination by other providers and reports of deterioration of work/ social function or disability are all signs of possible substance use disorder. Combined Controlled Substances Cocktail The “Trio” or “Trinity” is a popular drug regimen that contains hydrocodone, a benzodiazepine, and carisoprodol (Soma). When hydrocodone is replaced by oxycodone, the popular name is the “Holy Trinity” (Figure 4 and 5). Opioids, benzodiazepines, and carisoprodol have some side effects that include drowsiness, respiratory depression, confusion, tremor, and seizures risk. In combination, these three drugs are synergistic in causing respiratory depression and may consequently result in death (Fudin, 2014). Sharing of Medications and Fraudulent Demographics Other potential red flags include patients whose family members are taking the same type of opioid. Sharing of medications is common among persons with substance use disorders and frequently found in those whose intention it is to sell the prescription drug as Continued on next page >>> 5301 E. Grant Road, Tucson, Arizona 85712 EOE tobacco-free workplace Figure 3. New Verses Old OxyContin. The newer formula OROS REMS abuse prevention formula is more difficult to break up (right) while the pre-2010 OxyContin pill crushes into grains (left). arizona STATE BOARD OF NURSING REGULATORY JOURNAL 13 Figure 4. Trio or Trinity. Benzodiazepine, Muscle Relaxant, and Hydrocodone. infected to which a reasonable approach was to apply a minimum level of precaution to all patients reducing the risk of infection. Opioid precautions in pain management began in the mid 2000’s with the rise in opioid abuse. The application of “universal precautions” in the initial assessment and treatment of a patient may reduce the risk of accidental overdose, abuse, and misuse. Gourlay and Heit (2005) identified 10 recommended steps in universal precautions for all pain patients. 10 Recommended Steps in Universal Precautions Figure 5. Holy Trinity. Benzodiazepine, Muscle Relaxant, and Oxycodone. multiple sources are of value when trying to pass “pill counts” (counting of pills as a strategy to determine if patients are taking pills as prescribed). Patients at risk for opioid addiction may use the strategy of providing multiple addresses or similar birthdates in an attempt to divert identity on the CSPMP. According to the National Institute on Drug Abuse, as of 2014, prescription drug misuse or abuse is increasing among young men and women in their 20s and people in their 50s. Universal Precautions Universal precautions are strategies intended to minimize the risk of opioid misuse and abuse while maintaining compassionate care. The term ““universal precautions,” in terms of infectious diseases, evolved out of the realization that it was impossible for providers to reliably assess risk of infectivity during an initial assessment of a patient and therefore, all patients were considered potentially 14 Step 1. Diagnosis. Identify the pathophysiology for the pain. Identify the pain generator through appropriate diagnostic imaging and other testing. Step 2. Psychological assessment. Psychological screening including risk of addictive disorders, depression, and anxiety; positive findings may require referral to specialist. Step 3. Informed consent. Discuss the risks and benefits of opiate therapy, including side effects and risk of addiction. Step 4. Treatment agreement. This agreement details the conditions under which the opioid will be continued or discontinued. Both the provider and patient should agree on the contents prior to entering into a long-term opioid treatment plan. Step 5. Step 6. Pre and post intervention assessment of pain level and function. Pain scores and level of functionality should be recorded in the medical record to support continuation of therapy. Appropriate trial of opioid therapy with or without adjunctive medication. If no improvement, the arizona STATE BOARD OF NURSING REGULATORY JOURNAL Step 7. Step 8. treatment should be titrated down and discontinued. Reassessment of pain score and level of function. Reassessment should be completed at each visit and support the need for continued treatment. Regularly assess the “A’s” of pain medicine. Routine assessment of analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors support the need for continued therapy. “Adherence” (urine toxicology) and “affect” (observed mood) might also be added. Step 9. Periodically review pain diagnosis and comorbid conditions, including addictive disorders. Refer to specialist if underlying addiction disorder or aberrant behaviors are present. Step 10. Documentation. Complete and accurate documentation of the initial and each follow up visit. Documentation of a physical assessment should be completed with each dosage adjustment. State and National Guidelines Other strategies identified as universal precautions are evident in state and national guidelines. In 2004, the Arizona State Board of Nursing developed an advisory opinion addressing The Use of Controlled Substances for the Treatment of Chronic Pain that was later revised in 2009, 2012 and is in the process of updating in 2016. In 2014, the Arizona Department of Health Services published a voluntary consensus set of guidelines that promotes promising practices for prescribing opioids for acute and chronic pain. Additionally, in March of 2016, the Centers for Disease Control and Prevention released CDC Guideline for Prescribing Opioids for Chronic Pain in an effort to improve the way opioids are prescribed. Common themes found in state and national guidelines include: UÊ ÊVœ“«Ài i˜ÃˆÛiʓi`ˆV>Ê>˜`Ê«>ˆ˜Ê related evaluation determining if opioids are appropriate or if other non-opioid pharmacological or nonpharmacological therapies are preferred. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Clinicians treating patients with opioids for chronic pain should obtain and review past records or communicate with former treatment providers. Caution should be used when patients provide their own medical record instead of obtaining of records directly from the provider. UÊ Ê}œ>Ê`ˆÀiVÌi`ÊÌÀˆ>Êœvʜ«ˆœˆ`ÊÌ iÀ>«ÞÊ and the establishment of treatment goals. Opioids should only be continued if there is meaningful clinical improvement. UÊ ivœÀiÊÃÌ>À̈˜}Ê>˜`Ê«iÀˆœ`ˆV>ÞÊ`ÕÀˆ˜}Ê opioid therapy, the clinician should assess for risk of misuse, addiction, or adverse effects, and perform a risk stratification before initiating opioid treatment and discuss patient and clinician responsibilities for managing therapy in an “Opioid Agreement” signed by both the clinician and patient. In patients with a history of substance abuse, strong consideration should be given for a referral to an addictionologist or a physician with specialty training in this area. UÊ 7 i˜ÊÃÌ>À̈˜}ʜ«ˆœˆ`ÊÌ iÀ>«ÞÊvœÀÊ chronic pain, clinicians should prescribe immediate-release (IR) opioids instead of extended-release/long-acting (ER/LA) opioids. Clinical evidence reveals a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids (Miller, Barber, Leatherman, 2015). UÊ 7 i˜Êœ«ˆœˆ`ÃÊ>ÀiÊÕÃi`ÊvœÀÊ>VÕÌiÊ«>ˆ˜]Ê clinicians should prescribe the lowest UÊ UÊ UÊ UÊ effective dose of immediate-release opioids and no greater quantity than needed for the expected duration of pain severe enough to require opioids. Opioid related adverse events increase with doses >50 -100 mg of morphine equivalent dose per day (MED) and reaching these doses should trigger a re-evaluation of therapy. ivœÀiÊÃÌ>À̈˜}Ê>˜`Ê«iÀˆœ`ˆV>ÞÊ during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. ,iۈiÜʜvÊÌ iÊ -**Ê̜Ê`iÌiÀ“ˆ˜iÊ whether the patient is receiving opioid dosages or dangerous combinations that put the individual at high risk for overdose. ÀÕ}ÊÌiÃ̈˜}Ê>˜`Ê*ˆÊVœÕ˜ÌðÊÊ ÀÕ}Ê testing before starting opioid therapy and periodically thereafter (at least annually). Drug testing should access for the presence of prescribed drugs, as well as other drugs, to ensure the patient is taking the drugs prescribed and not taking illicit or other substances. A common strategy in practicing universal precautions is a random system determining who will submit to a pill count or drug test during medical visits. The use of a “testing die” (small throwable object with multiple resting positions, used for generating a random number) and a predetermined number for the day. For example, anyone rolling a four (4) that day will submit to a pill count or drug test. Consistent with universal precautions, this practice should be applied to all patients receiving controlled substances. Drug testing or pill counts should also be performed when the healthcare provider suspects aberrant behaviors. ۜˆ`Ê«ÀiÃVÀˆLˆ˜}ʜ«ˆœˆ`Ê«>ˆ˜Ê“i`ˆV>̈œ˜Ê and benzodiazepines concurrently whenever possible as this practice significantly increases the incidence of overdose and respiratory depression. UÊ ,iviÀÊvœÀÊÌÀi>̓i˜Ìʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Êœ«ˆœˆ`Ê use disorder. Clinicians should consider consultation for patients with complex pain conditions, serious co-morbidities including mental illness, a history or evidence of current drug addiction or abuse, patients who are pregnant or breastfeeding, or when the provider would benefit from help managing the patient. UÊ ` iÀi˜ViÊ̜ÊVˆ˜ˆV>Ê}Ո`iˆ˜iÃÊ>Àiʜ˜iÊ strategy to optimize care and improve patient safety based on evidence-based practice and for improving prescribing practices and health outcomes in Arizona, as well as reverse the cycle of opioid pain medication misuse that contributes to the opioid overdose epidemic. State and national guidelines provide recommendations that are based on the best available evidence that is interpreted and informed by expert opinion. UÊ / iÊ -**Ê >ÃÊi“iÀ}i`Ê>ÃÊ>ʎiÞÊ strategy nationally for addressing the misuse of prescription opioids and thus preventing opioid overdoses and deaths. Twenty-nine (29) states have mandatory access provisions mandating, by statute, rule, or board that a prescriber query the prescription monitoring program for information regarding a patient when prescribing controlled substances. Universal precautions recommend accessing the CSPMP whenever prescribing any opioid substance to any patient. UÊ ˜œÜÊÌ iÊÀˆÃŽÃÊ>˜`ÊiÃÌ>LˆÃ ÊÌÀi>̓i˜ÌÊ goals: If the benefits of opioids do not outweigh the risks of the drug, clinicians should consider discontinuing the opioid. UÊ *ÀiÃVÀˆLiʈ˜ÊÌiÀ“ÃʜvÊ`ÕÀ>̈œ˜\Ê*ÀiÃVÀˆLˆ˜}Ê the lowest effective dose of immediaterelease medications over long-term release medications. Avoid prescribing immediate-release opioids in combination with long-acting opioids. UÊ ,iۈiÜÊ*>̈i˜ÌʈÃ̜ÀÞ\Ê ˆ˜ˆVˆ>˜ÃÊà œÕ`Ê Continued on next page >>> arizona STATE BOARD OF NURSING REGULATORY JOURNAL 15 check for a history of controlled substance abuse or if a patient may be taking another drug that could have a negative interaction with the prescribed opioid. (ADHS, 2014, Arizona State Board of Nursing, 2012, Center for Disease control and Prevention, 2016, Upp Technology, 2016). Arizona Legislation Enacted in 2015 & 2016 Arizona Revised Statute (A.R.S.) 36-2606. A.R.S. 36-2606, effective December 31, 2015, requires every Arizona medical practitioner, including Nurse Practitioners & Nurse Midwives who intend to obtain a Drug Enforcement Administration (DEA) number or who hold one or more DEA registration number to also hold a Controlled Substances Prescription Monitoring Program (CSPMP) registration issued by the Arizona State Board of Pharmacy. Senate Bill 1283. Governor Ducey signed Senate Bill (SB) 1283 into law on May 12, 2016. The mandate would become effective October 1, 2017, and 60 days after the Arizona Health-e Connection has integrated the PDMP data into the state health information exchange, states that a medical practitioner, before prescribing an opioid analgesic or benzodiazepine controlled substance shall obtain a patient utilization report (CSPMP) regarding the patient for the preceding 12 months from the CSPMP central database tracking system at the beginning of each new course of treatment and at least quarterly while that prescription remains a part of the treatment. Prescribers would not be required to check the CSPMP if any of the following apply (please refer to the statute for a full description of the exceptions): UÊ *>̈i˜ÌʈÃÊÀiViˆÛˆ˜}Ê œÃ«ˆViʜÀÊ«>ˆ>̈ÛiÊ care serious or chronic illnesses. UÊ *>̈i˜ÌʈÃÊÀiViˆÛˆ˜}ÊV>ÀiÊvœÀÊV>˜ViÀʜÀÊ>Ê cancer-related illness or dialysis treatment. UÊ *ÀiÃVÀˆLiÀʈÃÊ>`“ˆ˜ˆÃÌiÀˆ˜}ÊÌ iÊ 16 controlled substance. UÊ / iÊ«>̈i˜ÌʈÃÊÀiViˆÛˆ˜}ÊÌ iÊVœ˜ÌÀœi`Ê substance during the course of inpatient or residential treatment in a hospital, nursing care facility, assisted living facility, mental health facility or a correctional facility. UÊ *ÀiÃVÀˆLiÀʈÃÊ«ÀiÃVÀˆLˆ˜}ÊÌ iÊVœ˜ÌÀœi`Ê substance to the patient for no more than ten days for invasive medical procedure or medical procedure, which results in severe acute pain to the patient. UÊ *ÀiÃVÀˆLiÀʈÃÊ«ÀiÃVÀˆLˆ˜}ÊÌ iÊVœ˜ÌÀœi`Ê substance to the patient for no more than a ten-day period for an invasive medical or dental procedure or a medical or dental procedure that results in acute pain to the patient. UÊ *ÀiÃVÀˆLiÀʈÃÊ«ÀiÃVÀˆLˆ˜}ʘœÊ“œÀiÊÌ >˜Ê>Ê five-day prescription and has reviewed the CSPMP patient data within the last thirty days and no other medical practitioner has prescribed to the patient in the preceding 30-day period. UÊ / iÊ«ÀiÃVÀˆ«Ìˆœ˜ÊˆÃÊ>ÊÃÕLÃ̈ÌÕÌiÊvœÀÊ>˜Ê initial prescription to which the patient had an adverse reaction. UÊ vÊÌ iÊ -**ʈÃʘœÌʜ«iÀ>̈œ˜>ÊœÀÊ available in a timely manner or the medical practitioner is experiencing equipment or technological problems (date and time must be documented). Conclusion With an increasing number of opioid overdose deaths, Arizona can participate in combating the epidemic of opioid overdoses by arizona STATE BOARD OF NURSING REGULATORY JOURNAL changing the current practices of prescribing opioids for acute and chronic pain. Before starting opioid therapy, clinicians should be mindful of red flags that may indicate abuse or misuse. Clinicians should follow state and national guidelines for the treatment of acute and chronic pain. Additionally, prescribers should adopt universal precautions by treating every patient who receives opioids with the same precaution. Every patient should be screened for appropriateness of the drug and clinicians should be mindful of aberrant behaviors. Every patient should have established treatment goals, including realistic goals for pain and function. Prescribers should consider how opioid therapy will be discontinued if benefits do not outweigh risks and should continue opioid therapy only if there is meaningful clinical improvement in pain and function that outweighs risks to patient safety. The risk of opioid overdose can be minimized through adherence to universal precautions whenever prescribing any opioid substance to any patient. Opioid medication have a clear role in the treatment of acute and chronic pain, but by applying these strategies into practice the risk of opioid use and abuse is significantly lessened. References Arizona Department of Health Services [ADHS]. (2014). Arizona opioid prescribing guidelines. Retrieved from http://azdhs.gov/ documents/audiences/clinicians/clinicalguidelines-recommendations/prescribingguidelines/az-opiod-prescribing-guidelines.pdf Arizona State Board of Pharmacy. (2016). Latest News. Retrieved from https:// pharmacypmp.az.gov/ Center for Disease control and Prevention. (2016). CDC guideline for prescribing opioids for chronic pain – United States, 2016. Retrieved from http://www.cdc.gov/mmwr/ volumes/65/rr/rr6501e1.htm Center for Disease Control and Prevention. (2013). Prescription Painkiller Overdoses in the U.S. Retrieved from http://www.cdc.gov/ Features/VitalSigns/PainkillerOverdoses/index. html Dahn, J. (2015). Controlled substance prescription monitoring program. Retrieved from http://www.digitaleditionsonline.com/ article/Controlled+Substance+Prescription+ Monitoring+Program/2261463/271503/article. html Fudin, J. (2014). The perfect storm: Opioid risk and ‘The Holy Trinity’. Retrieved from http://www.pharmacytimes.com/contributor/ jeffrey-fudin/2014/09/the-perfect-storm-opioidrisks-and-the-holy-trinity Gourlay D., Heit H. (2005). Universal precautions in pain medicine: the treatment of chronic pain with or without the disease of addiction. Medscape Neurol Neurosurg. 7(1). Retrieved from http://www.medscape.org/ viewarticle/503596 Miller M., Barber C.W., Leatherman S., Fonda, J., Hermos, J.A., Cho, K, Gagnon, D.R. (2015). Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med 175:608–15 Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/25686208 National Association of Drug Diversion Investigators. (2007). Street prices. Retrieved from: http://www.naddi.org/aws/NADDI/ asset_manager/get_file/3145 National Alliance for Model State Drug Laws. (2015). 2015 annual review of prescription monitoring programs. Retrieved from: http://www.namsdl.org/library/1810E284A0D7-D440-C3A9A0560A1115D7/ Painkillers fuel growth in drug addiction. (2011). Harvard Health Publications. The >ÀÛ>À`Êi˜Ì>Êi>Ì ÊiÌÌiÀ, Retrieved from http://search.proquest.com/docview/1370198247 ?accountid=35812 ResearchGate. (2015). What is the predictive value of STREET PRICES in determining potential for misuse of substances? Retrieved from https://www.researchgate. net/post/What_is_the_predictive_value_ of_STREET_PRICES_in_determining_ potential_for_misuse_of_substances Substance Abuse and Mental Health Services Administration [SAMHSA]. (2015). Substance Use Disorders. Retrieved from http://www.samhsa.gov/disorders/ substance-use StreetRx (2015). Latest prices. Retrieved from: http://streetrx.com/index.php Upp Technology. (2015). America’s opioid Epidemic. Retrieved from: http:// www.upp.com/news/special_report_ america%E2%80%99s_opioid_epidemic Upp Technology. (2016). CDC releases new painkiller prescriptions guidelines. Retrieved from http://www.smarthealthclaims. com/blog_post/cdc_releases_new_painkiller_ prescriptions_guidelines Nearly 79% of employers prefer a BSN graduate* In as little as 16 months**, earn your RN to BSN, with our 100% online, CCNE-accredited program. Or save time and money earning two degrees with our RN-to-BSN to MSN Fast Track Option. Visit gcu.edu/aznurses RN to BSN | MSN | DNP **16 month completion date is based on transferring 84 credits *http://www.aacn.nche.edu/news/articles/2013/employment13 For more information about our graduation rates, the median debt of students who completed the program, and other important information, please visit our website at gcu.edu/disclosures. Please note, not all GCU programs are available in all states and in all learning modalities. Program availability is contingent on student enrollment. Grand Canyon University is regionally accredited by the Higher Learning Commission. (800-621-7440; http://hlcommission.org/) The baccalaureate degree in nursing and master’s degree in nursing at Grand Canyon University are accredited by the Commission on Collegiate Nursing Education (http://www.aacn.nche.edu/ccne-accreditation). 16CONE0031 arizona STATE BOARD OF NURSING REGULATORY JOURNAL 17 WHAT SHOULD I CONSIDER WHEN PRESCRIBING OPIOIDS? High Dosage Talk to your patient about the risks for respiratory depression and overdose. Consider offering to taper opioids as well as prescribing naloxone for patients taking 50 MME/day or more. Multiple Providers Counsel your patient and coordinate care with their other prescribers to improve safety and discuss the need to obtain opioids from a single provider. Check the PDMP regularly and consider tapering or discontinuation of opioids if pattern continues. Drug Interactions Whenever possible, avoid prescribing opioids and benzodiazepines concurrently. Communicate with other prescribers to prioritize patient goals and weigh risks of concurrent opioid and benzodiazepine use. WHAT SHOULD I DO IF I FIND INFORMATION ABOUT A PATIENT IN THE PDMP THAT CONCERNS ME? Patients should not be dismissed from care based on PDMP information. Use the opportunity to provide potentially life-saving information and interventions. 1 Confirm that the information in the PDMP is correct. 2 Assess for possible misuse or abuse. 3 Discuss any areas of concern with your patient and emphasize your interest in their safety. Check for potential data entry errors, use of a nickname or maiden name, or possible identity theft to obtain prescriptions. Offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients who meet criteria for opioid use disorder. If you suspect diversion, urine drug testing can assist in determining whether opioids can be discontinued without causing withdrawal. HOW CAN I REGISTER AND USE THE PDMP IN MY STATE? Processes for registering and using PDMPs vary from state to state. For information on your state’s requirements, check The National Alliance for Model State Drug Laws online: www.namsdl.org/prescription-monitoring-programs.cfm L E A R N M O R E | www.cdc.gov/drugoverdose/prescribing/guideline.html Checklist for prescribing opioids for chronic pain For primary care providers treating adults (18+) with chronic pain ≥ 3 months, excluding cancer, palliative, and end-of-life care CHECKLIST REFERENCE EVIDENCE ABOUT OPIOID THERAPY When CONSIDERING long-term opioid therapy C Benefits of long-term opioid therapy for chronic pain not well supported by evidence. Set realistic goals for pain and function based on diagnosis (eg, walk around the block). C Short-term benefits small to moderate for pain; inconsistent for function. Check that non-opioid therapies tried and optimized. C Insufficient evidence for long-term benefits in low back pain, headache, and fibromyalgia. Discuss benefits and risks (eg, addiction, overdose) with patient. Evaluate risk of harm or misuse. C Discuss risk factors with patient. C Check prescription drug monitoring program (PDMP) data. C Check urine drug screen. NON-OPIOID THERAPIES Use alone or combined with opioids, as indicated: C Non-opioid medications (eg, NSAIDs, TCAs, SNRIs, anti-convulsants). C Physical treatments (eg, exercise therapy, weight loss). C Behavioral treatment (eg, CBT). C Procedures (eg, intra-articular corticosteroids). Set criteria for stopping or continuing opioids. Assess baseline pain and function (eg, PEG scale). Schedule initial reassessment within 1– 4 weeks. Prescribe short-acting opioids using lowest dosage on product labeling; match duration to scheduled reassessment. If RENEWING without patient visit Check that return visit is scheduled ≤ 3 months from last visit. When REASSESSING at return visit Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm. EVALUATING RISK OF HARM OR MISUSE Known risk factors include: C Illegal drug use; prescription drug use for nonmedical reasons. C History of substance use disorder or overdose. C Mental health conditions (eg, depression, anxiety). C Sleep-disordered breathing. C Concurrent benzodiazepine use. Urine drug testing: Check to confirm presence of prescribed substances and for undisclosed prescription drug or illicit substance use. Assess pain and function (eg, PEG); compare results to baseline. Evaluate risk of harm or misuse: C Observe patient for signs of over-sedation or overdose risk. – If yes: Taper dose. C Check PDMP. C Check for opioid use disorder if indicated (eg, difficulty controlling use). – If yes: Refer for treatment. Check that non-opioid therapies optimized. Determine whether to continue, adjust, taper, or stop opioids. PEG score = average 3 individual question scores (30% improvement from baseline is clinically meaningful) Q1: What number from 0 –10 best describes your pain in the past week? Q2: What number from 0 –10 describes how, during the past week, pain has interfered with your enjoyment of life? C If ≥ 50 MME /day total (≥ 50 mg hydrocodone; ≥ 33 mg oxycodone), increase frequency of follow-up; consider offering naloxone. 0 = “not at all”, 10 = “complete interference” C Avoid ≥ 90 MME /day total (≥ 90 mg hydrocodone; ≥ 60 mg oxycodone), Schedule reassessment at regular intervals (≤ 3 months). ASSESSING PAIN & FUNCTION USING PEG SCALE 0 = “no pain”, 10 = “worst you can imagine” Calculate opioid dosage morphine milligram equivalent (MME). or carefully justify; consider specialist referral. Prescription drug monitoring program (PDMP): Check for opioids or benzodiazepines from other sources. Q3: What number from 0 –10 describes how, during the past week, pain has interfered with your general activity? 0 = “not at all”, 10 = “complete interference” U.S. Department of Health and Human Services Centers for Disease Control and Prevention TO LEARN MORE ZZZFGFJRYGUXJRYHUGRVHSUHVFULELQJJXLGHOLQHKWPO arizona STATE BOARD OF NURSING REGULATORY JOURNAL 19 March 2016 Valerie Smith MS, RN, FRE Associate Director Hearing Department Substance Use Disorders Recognizing and Speaking Up Can Save Lives Addiction, also referred to as substance use disorder, is a chronic and complex disease with physical, cognitive, emotional, spiritual, financial and legal consequences not uncommon. It is a brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual and to those around him or her. The course of the disease follows a predictable and progressive course and may result in death if left untreated. Substance use disorder is characterized by a maladaptive pattern of substance use manifested by at least two of the following: UÊ UÊ UÊ UÊ UÊ UÊ UÊ *iÀÈÃÌi˜ÌÊ`iÈÀiʜÀÊ՘ÃÕVViÃÃvՏÊ>ÌÌi“«ÌÃÊ to “cut down” or control one’s use 1Ș}ÊÌ iÊÃÕLÃÌ>˜Vi­Ã®Êˆ˜Ê>ʏ>À}iÀÊ>“œÕ˜ÌÊ or longer than intended ÝViÃÈÛiÊ̈“iÊëi˜ÌÊÃiiŽˆ˜}Ê>˜`ɜÀÊÕȘ}Ê alcohol and/or drugs ,i`ÕV̈œ˜Êœvʈ“«œÀÌ>˜ÌÊ>V̈ۈ̈iÃÊ>ÃÊÌ iÊ substance use becomes more pervasive >˜}iÃʈ˜Ê̜iÀ>˜Vi œ˜Ìˆ˜Õi`ÊÕÃiÊ`iëˆÌiÊ>`ÛiÀÃiÊ consequences or high potential for adverse consequences 7ˆÌ `À>Ü> While individuals may have initially chosen to use or misuse substances, the disease of addiction is not intentional. Individuals who struggle with a substance use disorder do not set out to destroy themselves, everyone and everything in their path. These disastrous and often deadly consequences are the result of the vicious cycle of a defined medical condition. Second to alcohol, the most commonly used and abused drug by the general population 20 is marijuana. However, the abuse of opioids, prescribed and illicit, is on the rise. Other common drugs of abuse include cocaine, inhalants, LSD (acid), MDMA (ecstasy), methamphetamine, phencyclidine (PCP), steroids (anabolic), and other prescription and non-prescription drugs. Opioid Crisis In recent years, the opioid crisis and the resulting devastation in the United States has drawn the attention of healthcare providers, legislators, communities, families and the media. Opioids are a class of controlled drugs that include oxycodone, hydrocodone, codeine, morphine, fentanyl, heroin and others. The U.S. consumes more legal and illegal opioids than any other country. According to the Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, of the 21.5 million Americans 12 or older that had a substance use disorder in 2014, 1.9 million had a substance use disorder involving prescription pain relievers and 586,000 had a substance use disorder involving heroin. Unintentional drug overdoses are the leading cause of accidental death in the U.S., with 47,055 lethal drug overdoses in 2014. In 2014, 18,893 overdose deaths were related to prescription pain relievers, and 10,574 overdose deaths were related to heroin. Heroin use has been on the rise. Four in five new heroin users started out misusing prescription opioids. It is less expensive to obtain than prescription opioids and readily available for purchase on the streets. In more recent years, other potent and deadly drugs have joined heroin as being cheaper and readily available from the illicit market. In March 2015, the Drug Enforcement Agency (DEA) arizona STATE BOARD OF NURSING REGULATORY JOURNAL issued a nationwide alert on fentanyl as a threat to health and public safety after identifying an alarming rate of drug incidents and overdoses related to fentanyl. Fentanyl is a schedule II narcotic used as an anesthetic and analgesic. It is the most potent opioid available for use in medical treatment and is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin. According to the DEA, illicit fentanyl is being produced in clandestine labs and is being trafficked into the U.S. for sale and distribution. While it is often laced in heroin resulting in unpredictable but higher potency dose, fentanyl and fentanyl analogues are also being used by individuals unaware of the potency and lethal consequences, even when used at a low dose. In the media are multiple reports of many deaths due to unintentional fentanyl overdoses. While there is a common cause of death, the deaths span age, gender, ethnic and socioeconomic groups. Local Impact: Opioid Crisis Arizona has the tenth highest overdose rate in the nation. Information available from the Arizona Department of Health Services indicates that 1,052 people required emergency room treatment for prescription drug overdoses in 2014, up from 1,018 in the previous year. Approximately one Arizona resident dies per day due to prescription opiate poisoning. Heroin overdoses increased from 521 in 2013 to 605 in 2014 and the number of heroin related deaths has doubled between 2010 and 2014 with 180 deaths in 2014. More recently, media articles and reports describe the increasing availability and prevalence of illicit fentanyl being cut into heroin and other drugs, or being used independently, resulting in unintended fatal overdoses. Many of these overdoses and deaths impact our youth. Substance Use Disorders In Nursing Substance use disorders in nursing is not a modern day phenomenon and many experts believe the risk of prescription drug misuse is higher among nurses than the general population. Factors associated with nurses having a higher risk of misuse and abuse include the easy access of medications/drugs, belief that medications/drugs can and will alleviate unwanted feelings and the belief that with the nurse’s knowledge of pharmacology, they can control their use. Although the actual rate of addiction in nurses is unknown, estimates range from 6% to 20% of all nurses suffer from a substance use disorder. What is known is that allegations of substance misuse, abuse, dependence and including drug diversion from patients is one of the most common complaints received by boards of nursing and resulting licensure disciplinary action. Profile Of The Nurse With A Substance Use Disorder Despite the prevalence of substance use disorders both within society and the nursing profession and despite increased media attention, many co-workers, supervisors, employers and others have difficulty recognizing or assisting a nurse colleague with an obvious substance use disorder. This is disturbing considering the inherent responsibilities nurses have for patient care and safety and the fatal nature of the disease if left untreated. Nurses and other healthcare professionals take great effort to protect their professional reputation, identity and nursing license. It is not uncommon that the nurse with a substance use disorder continues to be perceived by colleagues and themselves as high functioning well into their disease. Thus, signs and symptoms of the disease in the workplace usually indicates a late stage disease process and is characteristic of the inability to control one’s use and the continued use despite potential for negative consequences including compromised patient care, patient harm, loss of job and licensure sanctions. Even late into their disease process, many nurses will continue to rationalize their use and want to believe they can control their substance use. Their denial, intense shame and fear of consequences should others learn of their “secret” prevents them from proactively seeking treatment. Managers and co-workers may unintentionally enable the disease to progress by ignoring or excusing poor performance, incomplete work, attendance issues and other symptoms of a substance use disorder. Another way in which the disease is enabled is when an employer recognizes symptoms consistent with a possible substance use disorder and opts to allow the nurse to resign or terminates the nurse without addressing the possible substance use disorder and/or reporting the nurse to the Board. When this happens, the nurse is allowed to continue with a potentially fatal disease and patient care with the next employer is potentially negatively impacted. Recognizing Workplace Indicators Of Substance Use Disorder As the substance use disorder progresses, signs and symptoms of the disease begin to manifest in the workplace. Workplace indicators of a substance use disorder may include and is not limited to the following: Attendance: As the disease progresses, the individual’s world get smaller as they select activities providing access and opportunity to use. If the substance of abuse is obtained outside of the workplace (alcohol, illegal drugs) the individual may begin to demonstrate progressive absences from work, difficulty adhering to their work schedule, unusual or implausible reasons for absences. When at work, they may also demonstrate on the job absences such as unexplained frequent or prolonged absences from the unit. When the workplace has become a source of supply of the drug and drugs are being diverted, it is not uncommon for the nurse to seek employment opportunities that provide access to the drug. This may be through work setting, patient selection, additional work hours including overtime and they may have unexplained presence in the workplace during scheduled times off. Interpersonal: Indicators of a substance use disorder may include complaints from coworkers, patients or others; increased isolation from others; unpredictability; changes in mood and/or energy level (alert to appearing sedated); increased conflict with others; legal problems; family or social problems. Job Performance: Substance use disorder indicators may include difficulty in organizing and prioritizing duties and responsibilities; difficulty meeting deadlines; deterioration in quality of work; poor judgment; forgetfulness; below standard of practice in care of patients; odor of alcohol; inappropriate, inadequate or missing documentation; discrepancies with controlled drugs or the amount removed as compared to co-workers without a corresponding change in the patient condition that would explain the need for additional medications; high volume of controlled drug “waste”, discrepancies in the accounting for controlled medications signed out; unauthorized removal of controlled substances or other medications of abuse; missing medications; selecting patients or assignments that provide them with access to drugs; altered provider orders for controlled substances and prescription fraud. Just as we are seeing with the general public, when controlled drugs are involved, the drugs are most commonly opioids and the nurse may also be obtaining from other non-work related sources. What Not To Do Whether it is a member of your family, a friend, or colleague, do not ignore your observations and intuitive concerns. Often by Continued on next page >>> arizona STATE BOARD OF NURSING REGULATORY JOURNAL 21 the time an individual begins to consider the possibility that their family member, friend, patient or colleague has a substance use disorder, there is merit to the concerns. Speaking up and proactively addressing your concerns can save lives. If it is a nurse colleague, do not allow the nurse who is demonstrating active signs and symptoms of impairment to continue to provide patient care or make decisions impacting patient care until further expert assessment can be completed and evidence of ability to safely practice is determined. Do not encourage the nurse to resign or be terminated without addressing identified concerns, providing resources for further evaluation and treatment and without notifying or causing the Board to be notified. Do not encourage the nurse to hide information from the Board. At times, and perhaps well meaning friends, colleagues, and others advising the nurse have encouraged the nurse to not disclose their substance use history or substance use disorder with the Board. Not disclosing can put patients at risk and can have deadly consequences for the nurse. It is a barrier to the nurse obtaining appropriate intervention and treatment. Addiction is a chronic progressive disease that may and often does result in death if left untreated. What To Do One of the first steps is to increase everyone’s knowledge and understanding of substance use disorder. It is an equal opportunity disease that is often misunderstood by those with or impacted by the disease, and frequently misunderstood by family members, healthcare providers, employers and colleagues. In caring for patients, nurses are in an important position to provide patient education related to safe medication use, including use while driving or engaged in other safety sensitive activities; appropriate disposal once the medication is no longer needed; and dangers of sharing medications with others, including family members. An unsafe but not uncommon practice is for individuals to 22 save and later use or share their unused pain medications with others. According the Center for Disease Control, most adolescents who misuse prescription opioids were initially given them by a friend or relative or took them from the family medicine cabinet. Education is critical to combating the current opioid crisis. If you suspect a patient you are providing care to has an underlying substance use disorder, speak up and advocate for the patient to receive appropriate referrals, assessments and treatment. Recognizing and speaking up saves lives. Nurses with an active substance use disorder have potential to not only harm patients but also cause harm or death to themselves. Colleagues who work closely with a nurse struggling with a substance use disorder often recognize that something is wrong before the manager, who may not have as frequent encounters with the nurse, recognize the indicators. Do not assume the manager is aware and openly address the concerns with the manager. Understand that simply asking the nurse whether or not they have a substance use disorder will not likely result in an admission. The barriers for those with a substance use disorder being truthful results from their intense shame and fear. Be prepared to present objective information and ask questions until you understand what did or did not happen. Do not accept implausible answers. Anytime that there is reasonable concern that a nurse, for whatever reason, is currently unable to safely practice, they should immediately be removed from patient care until further assessment can be completed. If employer policies permit, and there is reasonable suspicion that the nurse may be under the influence of a substance, a drug test should be obtained and the panel of drugs tested should include the drug(s) that are suspected. A nurse with a suspected substance use disorder should be referred for further evaluation for possible treatment and a report submitted to the Board for further review and investigation by the Board to determine safeness to practice. If the nurse acknowledges a substance use disorder, they may be eligible for CANDO, the Board’s non-public and non-disciplinary monitoring program for nurses arizona STATE BOARD OF NURSING REGULATORY JOURNAL with substance use disorders. Information about CANDO can be found on the Board’s website at www.azbn.gov. Although the Board’s mission is patient protection, patient protection can often be accomplished by nurses who have a recent or active substance use disorder entering into CANDO or entering into a Consent Agreement with the Board that mandates treatment, abstaining from unauthorized substance use, practice limitations and practice supervision. Summary As nurses, we have shared responsibilities for patient safety. When we recognize that one of our patients may be struggling with a substance use disorder, we have a responsibility to do the right thing and bring it to the attention of someone who can intervene on behalf of the patient. Likewise, when we recognize that one of our colleagues may be struggling with a substance use disorder, we have a responsibility to do the right thing and bring it to the attention of someone who can intervene on behalf of both the nurse and patients under their care. While there remains much to learn about substance use disorders, the evidence shows that a combination of treatment and involvement in 12-step meetings can have a positive impact on facilitating remission and preventing deaths. We need to see this disease and the current opioid crisis with eyes wide open. The increasing death rates are staggering and profoundly impacting families, communities and others. To be effective in identifying and appropriately responding to individuals with possible substance use disorders we need to shed the stereotype view of what a person with an addiction looks or acts like and timely respond with compassion, understanding, firmness and at times, persistence. It is not if but rather when you suspect a family member, friend, patient or colleague has a substance use disorder, dare to do the right thing and share your concerns. By speaking up and making your concerns known to those who have the ability to further assess and intervene if needed, lives can be saved. JOIN THE TEAM THAT TREATS YOU LIKE FAMILY At CVRMC we aim to serve the region with quality, efficiency and compassion. Our goal is to provide each patient with the same care you would expect for a family member or a friend. Our region, which is located just an hour outside the Phoenix area, is based around community and has a tight-knit, small-town feel. Our employees are our greatest assets. RN OPPORTUNITIES: ER s ICU s MED/ SURG s OR If you are a caring and hardworking individual looking for an employer that values these same traits, CVRMC wants you. JOIN OUR COMMUNITY OF BIG HEARTS! www.CVMRC.org Take advantage of this UNM limited time offer for Arizona Nurses! Call Now: 844.303.7224 Visit: rnbsnonline.unm.edu/arizona Receive $1,000 toward your online RN to BSN Degree Completion Option at UNM for a total tuition of just $8,950. Get started on your UNM RN to BSN program today! arizona STATE BOARD OF NURSING REGULATORY JOURNAL 23 *Not reported in previous Journal CNA DISCIPLINARY ACTION DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 12/30/2015 Alchesay, Lauren G. CNA1000022650 Revoked 12/14/2015 Alvey, Judah D. CNA Applicant Certificate Denied 2/8/2016 Arroyo, Jessica A. CNA999995403 Voluntary Surrender 3/24/2016 Battle, Sherrod T. CNA Applicant Certificate Denied 12/21/2015 Begay, Linda C. CNA480118353 Decree of Censure 3/10/2016 Bennett, Brett S. CNA1000041932 Revoked 2/1/2016 Bernot, Anthony J. CNA Applicant Certificate Denied 3/9/2016 Berryhill, Brittany A. CNA Applicant Certificate Denied 3/7/2016 Boarder, Carrie L. CNA1000007537 Voluntary Surrender 2/22/2016 Botta, Aleshia S. CNA1000026576 Voluntary Surrender 1/14/2016 Bouchard, Channel C. CNA1000037612 Revoked 3/9/2016 Bowers, Wesley J. CNA999998005 Revoked 1/21/2016 Carasco, Ghislaine CNA999996010 Stayed Revocation with Suspension 12/8/2015 Casey, Monica E. CNA999995295 Decree of Censure 2/24/2016 Chandler, Paul E. CNA1000043924 Voluntary Surrender 3/7/2016 Chavez, Angelica M. CNA Applicant Certificate Denied 3/7/2016 Chavez, Sabrina N. CNA Applicant Certificate Denied 12/14/2015 Chillis, Lashunda D. CNA Applicant Certificate Denied 1/29/2016 Clah, Christine R. CNA1000014051 Stayed Revocation 2/4/2016 Clements, Mariah CNA Applicant Certificate Denied 12/3/2015 Comer, Keith E. CNA Applicant Certificate Denied 12/16/2015 Davis, Kristy A. CNA Applicant Certificate Denied 12/30/2015 Davis, Natanya R. CNA Applicant Certificate Denied 3/9/2016 Dayway, Tina R. CNA1000014883 Revoked 12/24/2015 Delgado, Jose M. CNA Applicant Certificate Denied 3/23/2016 Dixon, Caroline L. CNA Applicant Certificate Denied 3/9/2016 Dow, Cheriena K. CNA1000024739 Revoked 2/10/2016 Downing, Tammy K. CNA Applicant Certificate Denied 12/30/2015 Driver, Crystal A. CNA1000028604 Revoked 3/15/2016 Durazo, Maria L. CNA Applicant Certificate Denied 12/28/2015 Dursma, Jennifer R. CNA1000045326 Revoked 3/29/2016 Ellsworth, Amanda M. CNA1000031012 Voluntary Surrender 12/30/2015 Esquer, Cynthia CNA457283333 Decree of Censure 3/24/2016 Fadok, Daniel S. CNA Applicant Certificate Denied 2/4/2016 Foos, Melissa A. CNA Applicant Certificate Denied 12/1/2015 Fraga, Jonelle L. CNA1000036629 Probation 3/28/2016 Giamei, Desiree R. CNA Applicant Certificate Denied 3/2/2016 Gomez, Julissa A. CNA1000022127 Decree of Censure 12/14/2015 Graham, Keith A. CNA1000049082 Civil Penalty 12/14/2015 Greer, John A. CNA Applicant Certificate Denied 24 arizona STATE BOARD OF NURSING REGULATORY JOURNAL *Not reported in previous Journal CNA DISCIPLINARY ACTION DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 12/30/2015 Greybull, Anita L. CNA1000019636 Revoked 12/30/2015 Gronewold, Holly A. CNA1000035109 Revoked 3/16/2016 Guerrero, Marlayna A. CNA Applicant Certificate Denied 3/23/2016 Gullett, Lance C. CNA Applicant Certificate Denied 3/25/2016 Hall, Jeffrey J. CNA1000035855 Stayed Revocation 3/23/2016 Harris, Ivey H. CNA1000035493 Voluntary Surrender 3/28/2016 Hewitt, Jeremy CNA Applicant Certificate Denied 1/6/2016 Hillo Contreras, Vania N. CNA1000007351 Decree of Censure 12/18/2015 Hinton, Colette E. CNA Applicant Certificate Denied 2/29/2016 Hunter, Gregory E. CNA Applicant Certificate Denied 2/10/2016 Jhinnu, Erica A. CNA1000049456 Suspension 9/10/2015* Johnson, Debra J. CNA Applicant Certificate Denied 3/24/2016 Johnson, Justin I. CNA Applicant Certificate Denied 3/7/2016 Johnson, Yolanda CNA Applicant Certificate Denied 1/15/2016 Jorstad, Jeri A. CNA Applicant Certificate Denied 3/9/2016 Kaylor, Wendy M. CNA873294641 Revoked 3/22/2016 Kelley, Ashley A. CNA Applicant Certificate Denied 2/11/2016 King, Louise E. CNA919401093 Decree of Censure 2/1/2016 Lapizco, Javier A. CNA Applicant Certificate Denied 1/29/2016 Leon, Vanessa M. CNA1000038133 Stayed Revocation 3/18/2016 Leon, Vanessa M. CNA1000038133 Revoked 2/10/2016 Lewis, Keishawna R. CNA Applicant Certificate Denied 3/29/2016 Loudermilk, Lasheika D. CNA Applicant Certificate Denied 3/2/2016 Loustaunau, Samuel D. CNA Applicant Certificate Denied 12/24/2015 Luna, Krystal M. CNA1000001930 Renewal Denied 12/2/2015 Lupkin, Elizabeth CNA643386803 Decree of Censure 12/30/2015 Maloney, Stella CNA854036803 Revoked 3/23/2016 Martin, Sheila CNA Applicant Certificate Denied 3/9/2016 Mattson, Carl W. CNA231441106 Revoked 12/30/2015 Mccollam, Lyle G. CNA1000009153 Revoked 12/30/2015 Mendoza, Elizabeth A. CNA1000022954 Revoked 3/8/2016 Merkle, Jessi D. CNA999993874 Decree of Censure 3/28/2016 Miller, Alexandria R. CNA Applicant Certificate Denied 2/10/2016 Miller, Stephenie C. CNA Applicant Certificate Denied 3/17/2016 Mims, Tamara L. CNA Applicant Certificate Denied 3/9/2016 Monterroso, Lucrecia M. CNA1000038279 Revoked 3/8/2016 Moreno, Christopher E. CNA999994803 Decree of Censure 3/3/2016 Morren, Nicole R. CNA1000028218 Decree of Censure 3/9/2016 Morris, Mellonee L. CNA174139237 Certificate Denied 1/4/2016 Munhall, Kadee R. CNA Applicant Certificate Denied arizona STATE BOARD OF NURSING REGULATORY JOURNAL 25 *Not reported in previous Journal CNA DISCIPLINARY ACTION DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 3/16/2016 Nachu, Sasha T. CNA Applicant Certificate Denied 12/2/2015 Nelson, Gail M. CNA1000048914 Decree of Censure 12/30/2015 Partridge, Pamila A. CNA999951646 Revoked 2/12/2016 Peters, Sharon L. CNA Applicant Certificate Denied 12/24/2015 Phelps, Andrea L. CNA1000021611 Civil Penalty 2/10/2016 Pleasant, Tony CNA Applicant Certificate Denied 3/1/2016 Ramierz Olvera, Amador CNA999992750 Voluntary Surrender 12/30/2015 Roberts Rodriquez, Enrique B. CNA1000035858 Decree of Censure 2/3/2016 Rojas Flores, Jaravith CNA999950975 Civil Penalty 12/29/2015 Rubio, Rachel A. CNA Applicant Certificate Denied 12/15/2015 Russell, Cheyenne B. CNA Applicant Certificate Denied 12/30/2015 Sailer, Galen B. CNA1000021612 Revoked 2/29/2016 Salcido, Catherine E. CNA Applicant Certificate Denied 3/8/2016 Sanchez, Alexis N. CNA1000024984 Decree of Censure 3/9/2016 Santillan, Michael S. CNA1000039987 Revoked 12/29/2015 Schwind, Michele M. CNA Applicant Certificate Denied 3/10/2016 Sharpe, Chaunci L. CNA1000030803 Revoked 3/16/2016 Sheridan, Gerard A. CNA Applicant Certificate Denied 12/29/2015 Skinner, Catherin M. CNA595830103 Renewal Denied 3/16/2016 Snodgrass, Michael A. CNA Applicant Certificate Denied 11/20/2015* Spangler, Pamela J. CNA1000000543 Stayed Revocation 3/24/2016 Springer, Pena C. CNA Applicant Certificate Denied 3/10/2016 Sturges, Angela M. CNA999999851 Revoked 3/8/2016 Tavara, Karen L. CNA1000032237 Decree of Censure 3/16/2016 Taylor, Sequone L. CNA Applicant Certificate Denied 3/25/2016 Thomas, Wilma T. CNA704099803 Revoked 3/24/2016 Van Kirk, Patricia D. CNA Applicant Certificate Denied 12/24/2015 Villalba, Jessica M. CNA1000021398 Decree of Censure 12/29/2015 Ward, Roxie M. CNA Applicant Certificate Denied 2/10/2016 Washington, Lasheena M. CNA Applicant Certificate Denied 2/11/2016 Weaver, Stephanie A. CNA Applicant Certificate Denied 3/15/2016 Wells, Tiffany L. CNA Applicant Certificate Denied 3/24/2016 Wersonick, Brittney M. CNA Applicant Certificate Denied 2/10/2016 Wienskovich, Rachel A. CNA Applicant Certificate Denied 2/10/2016 Willie, Karen CNA Applicant Certificate Denied 3/16/2016 Wilson, Justin R. CNA Applicant Certificate Denied 12/31/2015 Wise, Pamela E. CNA Applicant Certificate Denied 3/24/2016 Wright, Keosha Q. CNA Applicant Certificate Denied 2/10/2016 Zay Zay, Henry L. CNA Applicant Certificate Denied 3/16/2016 Zbasnik, Becky A. CNA Applicant Certificate Denied 26 arizona STATE BOARD OF NURSING REGULATORY JOURNAL *Not reported in previous Journal RN/LPN DISCIPLINARY ACTION DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 3/21/2016 Absalon, Michelle L. RN134359 Voluntary Surrender 1/29/2016 Anako, Imo J. RN107716 Probation 2/18/2016 Arguelles, Carmen RN082051/CRNA0354 Voluntary Surrender 1/28/2016 Atha IV, Frank P. LP047602 Decree of Censure 3/23/2016 Bader, Sarah A. LPN Endorsement License Denied 2/1/2016 Balka, Eric A. RN Endorsement License Denied 3/9/2016 Ballhorst, Chelsie R. RN162043/LP044594 Revocation 1/13/2016 Bays, Nichole L. RN137178 Voluntary Surrender 3/4/2016 Biggs, Jamey L. Compact, MO RN2003024481 Revocation of Nurse Multi-State Licensure Privilege` 2/29/2016 Bolton, Cecilia D. RN097867 Decree of Censure 2/1/2016 Borkowski, Annie C. RN Endorsement License Denied 2/22/2016 Botta, Aleshia S. RN196179 Voluntary Surrender 2/3/2016 Bowditch, Allison D. RN146622 Revocation 1/5/2016 Boyle, Dale R. RN167405 Voluntary Surrender 12/21/2015 Bresil, Lorie RN170756 Suspension 2/2/2016 Bush, Jeremy F. RN191903 Voluntary Surrender 3/23/2016 Bustillos, Ryan E. LPN Reissuance Reissuance Denied 12/9/2015 Butler, Jeremy S. RN140180/AP8337 Civil Penalty 3/14/2016 Calabro, Elizabeth J. RN078191 Voluntary Surrender 12/8/2015 Callaghan, Kristina D. RN113300 Voluntary Surrender 1/4/2016 Coleman, Samuel L. RN135736 Revocation 2/12/2016 Davison, Sarah K. RN134577 Stayed Revocation with Suspension 3/10/2016 Devillier, Jamie P. RN168377 Voluntary Surrender 12/3/2015 Diaz, Richard M. RN138054 Civil Penalty 3/21/2016 Downey, Jeffrey L. LP026343 Decree of Censure 3/16/2016 Droit, Jennifer C. RN162108 Decree of Censure 1/29/2016 Du Bois, Marsha B. RN116207 Decree of Censure 12/30/2015 Dudenhoefer Jr, Paul A. RN000099612 Revocation 1/29/2016 Eagley, Melissa L. RN166358 Voluntary Surrender 12/3/2015 Erickson, Melissa M. RN182599 Voluntary Surrender 12/30/2015 Farley, Kerry L. RN154627 Revocation 1/28/2016 Finkle, Jennifer E. RN164378/LP045004 Decree of Censure 3/25/2016 Fisher, Nicholas A. RN198642 Probation 12/1/2015 Fraga, Jonelle L. RN196132 Probation 1/29/2016 Freytag, Alan L. RN133378 Voluntary Surrender 1/4/2016 Gallardo, Carolyn A. RN163381 Probation 12/30/2015 Gomez, Melissa S. LP039414 Revocation 12/14/2015 Graves, Jessica E. RN Endorsement License Denied 12/2/2015 Griffin, Mary E. LP011505 Voluntary Surrender 2/24/2016 Gubbels, Ann Lisa D. RN114152 Voluntary Surrender 3/3/2016 Hamm, Kristi D. RN175526 Decree of Censure 3/3/2016 Harney, Jamie L. LP049562 Probation 12/16/2015 Hector, Erik R. RN Exam License Denied 1/14/2016 Henely, Richard J. RN046579 Stayed Revocation with Suspension 3/15/2016 Hickbottom, Lytonya F. LP050532 Probation 1/29/2016 Hochman, Susan D. RN189864 Voluntary Surrender arizona STATE BOARD OF NURSING REGULATORY JOURNAL 27 RN/LPN DISCIPLINARY ACTION *Not reported in previous Journal DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 1/29/2016 Hoffend, Mary A. RN073837 Summary Suspension 12/2/2015 Hopper, Lauren S. RN Endorsement License Denied 12/14/2015 Howard, Cynthia L. RN Endorsement License Denied 12/30/2015 Hubbard, Peter C. RN155275 Suspension 3/4/2016 Hunsaker, Vickie L. LP031936 Probation 12/17/2015 Hyder, Jean A. RN032556 Voluntary Surrender 12/17/2015 Irwin, Kathryn M. RN137937/AP5452 Voluntary Surrender 12/23/2015 Iwunze, Eunice C. LP032436 Reissuance with Stayed Revocation Probation 12/30/2015 Jeffers, Sara N. RN064730 Revocation 12/18/2015 Jessup, Mark D. RN Reissuance Reissuance Denied 3/9/2016 Joaquin, Mary A. LP019500 Revocation 3/21/2016 Johnson, Dennis P. RN170254 Probation 2/11/2016 Johnson, Margene A. RN Reissuance Reissuance Denied 3/9/2016 Johnson, Sherrie A. LP035774 Revocation 2/1/2016 Johnson-Copney, Brittanie A. LP049380 Decree of Censure 12/30/2015 Kalinowski, Patricia A. RN153782 Revocation 1/22/2016 Kern, Jason A. RN124000/LP036078 Voluntary Surrender 12/30/2015 Kinkead, Lauren R. LP048640 Revocation 12/30/2015 Koppen, Deborah K. RN171730 Revocation 3/3/2016 Kwofie, Agatha J. LP047430 Decree of Censure 2/24/2016 Lamb, Carolyn A. RN093325 Decree of Censure 3/25/2016 Langrock, Sheila J. RN095006 Civil Penalty 3/28/2016 Lavin, Luann B. AP8594 Probation 12/28/2015 Lee, Kelley L. LP043218 Probation 12/14/2015 Leeper, Ashley L. LPN Endorsement License Denied 3/25/2016 Liu, Qing RN178970 Suspension 2/25/2016 Locke, Julie S. RN158299 Decree of Censure 3/25/2016 Long, Sandra K. RN079849/AP2928 Stayed Revocation with Probation 12/24/2015 Lynn, Diana M. RN045486 Probation 1/5/2016 Martinez, Michelle A. RN086968 Decree of Censure 12/24/2015 Mason, Priscilla RN085502/LP027667 Stayed Suspension with Probation 1/29/2016 Mbithi, Cyrus M. RN173726 Summary Suspension 12/28/2015 McAvoy Jr, James A. RN124750/AP3968 Revocation 12/17/2015 McKinley, Allison C. RN190340 Decree of Censure 3/9/2016 Merritt, Richard V. RN Reissuance Reissuance Denied 1/29/2016 Minch, Alice J. RN079946/LP026129 Summary Suspension 3/16/2016 Muchoki, Paul Abdallah K. LP043837 Decree of Censure 1/29/2016 Mueller, Brita L. RN171349 Summary Suspension 1/19/2016 Murphy, Robert A. RN102316 Voluntary Surrender 3/25/2016 Nissl, Donna L. LP041769 Summary Suspension 3/17/2016 Nuuyoma, Aina LP033276 Decree of Censure 12/2/2015 Owens, Anne M. RN115007 Revocation 12/18/2015 Padgett, Stacey M. RN131412 Voluntary Surrender 12/30/2015 Payne, Kelly J. LP035029 Voluntary Surrender 12/25/2015 Penkey, Alicia M. LPN Endorsement License Denied 3/9/2016 Perkins, Lynne A. LP038649 Revocation 28 arizona STATE BOARD OF NURSING REGULATORY JOURNAL RN/LPN DISCIPLINARY ACTION *Not reported in previous Journal DECEMBER 2015 - JANUARY - FEBRUARY - MARCH 2016 EFFECTIVE DATE NAME CERTIFICATE DISCIPLINE 1/13/2016 Quintana, Amy M. LP048140 Voluntary Surrender 12/30/2015 Quintero, Kathleen E. RN102714/LP031407 Revocation 2/16/2016 Raleigh, Cherise C. RN098313 Decree of Censure 1/28/2016 Ramirez, Gerardo RN134500 Suspension 12/21/2015 Ramsey, Prudence A. RN169503 Suspension 1/6/2016 Reagan, Bridget M. RN161514 Voluntary Surrender 12/21/2015 Reagan, Bridget M. RN161514/SN1045 Stayed Revocation with Suspension 3/23/2016 Recinos, Myrna B. RN195701 Voluntary Surrender 1/13/2016 Reichle, Lynn L. RN168901/AP4106 Revocation 12/14/2015 Rendon, Rebecca C. LP027665 Civil Penalty 2/11/2016 Reynolds, Mathew J. RN156969 Revocation 3/2/2016 Risner, Todd J. RN181729 Probation 12/3/2015 Santiago, Mario A. RN148573 Stayed Revocation with Suspension 2/22/2016 Scala, Kay M. RN049048/AP3431 Voluntary Surrender 3/23/2016 Scarfone, Helen M. LP042905 Voluntary Surrender 12/23/2015 Schatz, Paul R. RN Reissuance Reissuance Denied 12/21/2015 Schucker, Lynn A. RN045450 Probation 1/11/2016 Schumacher, Nancy A. RN048435 Voluntary Surrender 3/1/2016 Self, Cheryl L. RN063054 Reissuance with Stayed Revocation Probation 2/29/2016 Sinotte, Doris M. RN181095 Decree of Censure 3/24/2016 Smith, Beth K. RN Endorsement License Denied 12/3/2015 Spender, Neale M. RN196222/AP8338/Compact, CO RN Civil Penalty 12/9/2015 Stanley, Nancy L. RN095529 Decree of Censure 2/22/2016 Starkey, Alana M. RN175676 Decree of Censure 12/30/2015 Steigert, Andrew D. RN160712 Revocation 2/25/2016 Swanson, Renee L. RN174057 Voluntary Surrender 12/8/2015 Sykes, David A. RN171580 Voluntary Surrender 3/24/2016 Tarango, Luz M. LP008527 Civil Penalty 12/4/2015 Tremble-Webster, Crystal RN196177/LP037627 Decree of Censure 1/15/2016 Ude, Lillian J. LP037683 Decree of Censure 2/26/2016 Ussery, Vivian M. LP034864 Probation 3/8/2016 Velovich, Tamara V. LP046656 Revocation 1/29/2016 Vinyard, Laura C. RN182725 Voluntary Surrender 12/2/2015 Wakefield, Jenny A. RN196188 Probation 12/17/2015 Watson, Karen LP036032 Stayed Revocation with Suspension 3/21/2016 Watson, Patricia D. RN181734 Voluntary Surrender 3/14/2016 Weyant, Jennifer RN195344 Voluntary Surrender 3/23/2016 Wheeler, Carissa M. LPN Endorsement License Denied 3/25/2016 Williams-Tate, Nikki R. LP047258 Summary Suspension 12/16/2015 Wilmont, Korissa N. LP039253 Probation 1/13/2016 Wright, Lisa M. RN132858 Voluntary Surrender 3/24/2016 Ybarra, Cheryl J. LPN Endorsement License Denied 3/8/2016 Yeaman, Howard P. RN193789 Revocation 12/30/2015 Yonan, Alan I. LP040734 Revocation 3/22/2016 Zarate, Georgieanna P. RN Reissuance Reissuance Denied 12/28/2015 Zuniga, Brianna M. RN169195 Decree of Censure arizona STATE BOARD OF NURSING REGULATORY JOURNAL 29 Correctional Care. Committed Careers. We're hiring! Registered Nurse Mental Health RN Nurse Practitioner Mental Health NP Licensed Practical Nurse Our College of Nursing and Health Care Professions has been providing an outstanding health care education for over 30 years. The College prides itself on the ability to create degree programs based on the demand for highly qualified health care professionals. We currently have the following Full-Time Faculty positions available at our main campus in Phoenix, Arizona: • MSN Education & Leadership Lead • Critical Care • ACNP CorizonJobs.com | Follow Corizon Health Careers Contact Kelly Herberholt Kelly.Herberholt@CorizonHealth.com | (800) 325.4809 X 9536 We also have Full-Time Faculty positions available at our site in Albuquerque, New Mexico. In addition, we are also hiring Adjunct Faculty: • Multiple Campus Skills and Simulation Lab Positions • Clinical Rotations Founded in 1949, GCU is a private, Christian university serving nearly 15,473 students on our main campus in Phoenix, Arizona and an online student population of more than 59,600. HOW TO APPLY jobs.gcu.edu Please apply online by visiting RNs LPNs CNAs OWN YOUR OWN BUSINESS ASSISTED LIVING HOME FOR LEASE in Upscale Community Surprise, AZ Licensed: 8 (602)410-7654 EXPERIENCED NURSE –ATTORNEY NURSE ADVOCATE The “NEW” Classifieds (1.5” wide x 1” high) Get the representation you deserve when you need it most. Reach every nurse in Arizona for as little as $290. FREE Contact Laura Wehner Phone Consultation 602-993-3215 Tsanziolaw@gmail.com 30 Nurse Network Teressa M. Sanzio, RN, JD arizona STATE BOARD OF NURSING RegulatoRy JouRnal RESERVE YOUR SPACE NOW! lwehner@pcipublishing.com 1-800-561-4686 ext. 117 Fact: Knowing if you have HPV—especially the most dangerous strains, HPV types 16 and 18—can help protect you from developing cervical cancer. If you are 30 or older, ask your health care provider about getting an HPV test with your Pap test. Learn more at www.healthywomen.org/hpv. This resource was created with support from Roche Diagnostics Corporation. ARIZONA STATE BOARD OF NURSING 4747 North 7th Street, Suite 200 Phoenix, AZ 85014-3655 PRESORTED STANDARD U.S. POSTAGE PAID LITTLE ROCK, AR PERMIT NO. 1884 MIHS… It’s Who I Am “When I tell people where I work and what I do, I do it with pride. We are that slice of the community that people can depend on.” At Maricopa Integrated Health System, we wear this badge with pride. Like Greg, our staff is dedicated to providing a high quality integrated system of care for patients and families. We’re all committed to continuous teaching, learning and improvement. That’s the power of an environment driven by values like respect, leadership, and education. Join MIHS as a Registered Nurse and enjoy: s (IGHLY COMPETITIVE WAGES s !RIZONA 3TATE 2ETIREMENT 3YSTEM Plan with a lifelong pension upon retirement s 'ENEROUS 04/  holidays per year s #OLLABORATIVE WORK environment s 3ATISFYING .URSE TO Patient ratio Connect with us at: JOBS.MIHS.ORG MARICOPA INTEGRATED HEALTH SYSTEM Maricopa County Special Health Care District Greg Scaggs McDowell Healthcare #ENTER #LINICAL -ANAGER