I note recent great interest in the medical community concerning the regulations adopted by the Nevada State Board of Medical Examiners with respect to control of pain. I thought it would be of interest to the members of the medical community and others who receive this newsletter to understand the procedure that the board went through with respect to adoption of the regulations controlling the management of pain. Prior to adopting the regulations, the board, at the request of the Nevada State Medical Association, assembled a task force in 1998, comprised of representatives of the Nevada State Board of Osteopathic Medicine, the Nevada State Board of Pharmacy, the Nevada State Board of Nursing, the University of Nevada School of Medicine, and Larry Matheis, the Executive Director of the Nevada State Medical Association, together with other representatives of the medical profession. That task force developed proposed regulations and recommended that the board adopt those regulations. Prior to doing so, the board published notices of intent to adopt regulations in every library in the state of Nevada, as well as on the board’s Web site, and mailed copies of notices of the workshops to the media in the state of Nevada and all persons who had requests for notifications of proposed actions of the board on file with the board. The board then conducted a published and noticed hearing on March 15, 1999 in Carson City in the State Capitol Building. That meeting was the centennial meeting of the board and was attended by members of the press, Nevada State Legislature, the Governor and Lieutenant Governor, the Nevada Supreme Court, and interested citizens, together with representatives from the Nevada State Medical Association, where testimony was solicited prior to the adoption of the regulations. The board published the adoption of the regulations as temporary regulations in the April 1999 edition of the board’s newsletter, which was mailed to all licensees of the board and placed on the board’s Web site. The Legislative Counsel Bureau also put the temporary regulations on the World Wide Web.

The final form of the regulations was prepared by the Legislative Counsel Bureau, as is required by law. After review of the final language of the Legislative Counsel Bureau, the Nevada State Medical Association, a participant in the adoption of the regulations, petitioned the board for amendment of the regulations and requested that the board now adopt by reference the guidelines for pain management published by the Federation of State Medical Boards of the United States, Inc. Contemporaneously, Weldon E. Havens, M.D., J.D., petitioned for changes to the new regulations. On February 26, 2000, the board determined that it would grant the petition of the Nevada State Medical Association and go forward to adopt by reference the guidelines set forth for pain management by the Federation of State Medical Boards of the United States, Inc. That process is now underway.

As I have indicated above, the board worked with many interested parties to produce these regulations and the final submission to the Legislative Counsel Bureau was a consensus document. Thus, it is most disturbing to see in the recent edition of the Clark County Medical Society’s "County Line" newsletter an article authored by Jeffrey Cichon, M.D., President of that organization, with respect to the adoption of regulations by the board. Dr. Cichon makes many statements in the article which are unsupported by the facts, the law, and the intent of the Nevada State Board of Medical Examiners. He indicates that the regulations were inappropriately adopted by the board unbeknownst to most physicians and that they constitute a "faux pas." I trust that Dr. Cichon is simply uninformed about the very lengthy procedure the board went through to adopt regulations. To date, the Nevada State Board of Medical Examiners has never received any correspondence, suggestions, petitions or input either formally or informally from either Dr. Cichon or the Clark County Medical Society with respect to the regulations. The time to criticize regulations is in the development stage, not after they are adopted. It is difficult for me to believe that the medical societies in this state represented by the Nevada State Medical Association in the drafting of these regulations, were not kept informed so that their input could be received.

On December 22, 1999, Governor Guinn appointed Robin L. Titus, M.D. of Smith, Nevada to the board. Dr. Titus is a graduate of the University of Nevada School of Medicine, and is American Board certified in Family Practice and certified by the American Academy of Aviation Medical Examiners and American Association of Medical Review Officers. She has been licensed to practice medicine in Nevada since 1982. She currently serves as Chief of Staff of the South Lyon Medical Center in Yerington and is the Lyon County Health Officer. In addition, Dr. Titus serves as a rural preceptor for the University of Nevada School of Medicine and is the Emergency Medical Director of the Smith Valley Fire District. She is a pilot and a member of the Flying Physician Medical Association. Dr. Titus replaces Rex T. Baggett, M.D., of Carson City, who served on the board for over six years.

Assistant Chief Deputy Attorney General Leslie A. Nielsen resigned as an Attorney General to accept a position with the North Las Vegas City Attorney’s Office after the board’s February 26, 2000 meeting. At that meeting, the board presented Ms. Nielsen with a commendation for her three years of service to the board.

Ms. Nielsen is being replaced by Assistant Chief Deputy Attorney General Brian T. Kunzi. Mr. Kunzi has been admitted to practice law in Nevada since 1983, and has extensive legal experience as an Army Judge Advocate General, District Attorney, private practitioner, and Attorney General. His office is in Las Vegas.

December 25                                       Christmas Day                                                                                             HOLIDAY

1) Restricted licenses issued under NRS 630.164 (rural exemption):
                                            33 licenses issued

2) Temporary licenses issued to physicians in medically underserved rural areas:
                                            70 licenses issued

3) Unrestricted licenses issued to physicians in medically underserved rural areas:
                                            107 licenses issued

4) Temporary licenses issued to physicians in medically underserved urban areas:
                                            52 licenses issued

5) Unrestricted licenses issued to physicians in medically underserved urban areas:
                                            24 licenses issued

LICENSURE STATISTICS - MEDICAL DOCTORS

For year 1999 there were 5012 physicians holding licensure in Nevada. Of these, 3113 were actively practicing within the state, an additional 800 physicians held active licenses but did not reside in Nevada, and the remaining 1099 physicians registered their licenses in inactive and/or retired status. 377 physicians were licensed for the first time by the BME during 1999. The chart below reflects a breakdown of the number of licensed physicians practicing in Nevada, by county, from 1987 through 1999.

YEAR        1987    1988     1989    1990    1991     1992    1993    1994     1995    1996    1997     1998    1999

COUNTY

Carson City   66        74          72         73       79         90        88           95          98      104       110       109      115

Churchill        13        14            12        11      13          11        13           17          19         19         20         24       25

Clark           789       871         919   1021   1114    1199    1299      1418       1517    1701     1763    1907   2023

Douglas        21         21          23         28       22        24         30          36          37          43         48          54        57

Elko               23         21          23         29       25        24         21          26          29          39          39         41       43

Esmeralda       0          0            0            0         0            0           0            0            0            0            0          0         0

Eureka            1           1           1            1          1            1           0            0            0            2             2          1         1

Humboldt         5          6            5            5          6            6           5            5            5            7            7           8        9

Lander            3           3           3            1          2           2           2            2            2            2             2            3        2

Lincoln            2           2           2             3         2           1           2            2            2            3             3            3        3

Lyon                5           5           7           6           4          4           4            5            4            6              7           5         6

Mineral            5           5           3            3           3          3           5            6            6            7               6          6        5

Nye                     8         8           9           9           7           6           6            9             8         11             10       13    15

Pershing            2         3            4           1           2          2            2           1             0           0              1           3      2

Storey                 0         0           0           0           0          0            0            0             0           0              0           0      0

Washoe        540      572       579       617      611      636       661        693        692       734        732      778   797

White Pine        4          5            4           3          4           5            6           7             5            8          10        10     10

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Active
In-State........ 1487   1611   1666    1811    1895    2014     2144     2322     2424     2686       2760   2965  3113

Active-
Out-of-State.. 168     277    212       357      287       463       459       639        516       787        676      882     800

TOTAL
ACTIVE.......1654   1888  1878     2168    2182    2477    2603      2961     2840     3473      3436    3847   3913

Inactive and
Retired.........  982     981    993        987    1031    1003      983        960      1068     1049     1174    1158   1099

TOTAL
LICENSED..2637   2869   2871   3155    3213    3480    3586      3921     4008     4522     4610     5005   5012

LICENSURE STATISTICS - PHYSICIAN’S ASSISTANTS

For year 1999 there were 174 physician’s assistants holding licensure in Nevada. 38 physician’s assistants were licensed for the first time by the BME during 1999. The chart below reflects a breakdown of the number of licensed physician’s assistants practicing in Nevada, by county, from 1992 through 1999.

COUNTY

Carson City            5                  5               5                  3              3                  2                 5                7

Churchill                 0                  0                0                  0              0                  0                 0                2

Clark                     40                44              58                72            72               77               94            118

Douglas                 0                 0                0                    0              0                  0                 1                1

Elko                        1                 2               4                    4              4                    7                 9                6

Esmeralda             0                 0              0                    0               0                  0                  0                0

Eureka                    0                 0              0                    0               1                  1                  1                1

Humboldt                 0                 0              0                    0               0                  0                  0                0

Lander                    0                 0              0                    0               0                  0                  0                0

Lincoln                    1                 2              1                   1               1                  0                  0                   0

Lyon                         0                 0              0                   0               1                  2                   2               4

Mineral                   1                 2               2                  2                2                 1                  1                 1

Nye                          4                4               3                  3                3                  3                  3                   6

Pershing                 0                 1               1                  1               1                 1                  1                   1

Storey                      0                 0              0                  0                0                 0                  0                  0

Washoe                   3                 4              7                10              10               18               23                26

White Pine              1                 1              1                  2                 2                 1                 1                   1

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  - - -

TOTAL                    56              65           82               98             100              113             141             174

                                LICENSURE / POPULATION STATISTICS - MEDICAL DOCTORS

                                                                                                                                                                RATIO OF
                                                                                                                                                                ACTIVE
                                                                                                                                                                IN-STATE M.D.'S
                                                                                                                                                                PER 100,000
YEAR *          ACTIVE IN-STATE              NEW LICENSES              STATE POPULATION         POPULATION

1980                          1,158                                      201                                         800,000                         144

1981                            1,196                                      285                                         851,150                         140

1982                            1,308                                      234                                         878,260                         148

1983                            1,367                                      199                                         905,660                         151

1984                            1,366                                      205                                         933,010                          146

1985                          1,442                                     192                                          969,370                          148

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

1986                         1,524                                     134                                        1,010,280                          151

1987                         1,487                                     142                                        1,057,030                          141

1988                         1,611                                     216                                        1,124,650                          143

1989                         1,666                                     199                                        1,197,260                          139

1990                         1,811                                     202                                        1,283,490                          141

1991                         1,895                                     233                                        1,300,000                          146

1992                         2,014                                     241                                        1,348,400                          149

1993                         2,144                                     308                                        1,389,000                          154

1994                         2,322                                     333                                        1,493,000                          155

1995                         2,424                                     331                                        1,583,000                          153

1996                         2,686                                     427                                        1,638,000                          158

1997                         2,760                                     442                                         1,741,000                         159

1998                         2,965                                     391                                         1,875,000                         158

1999                           3,113                                     377                                          2,034,000                         153

* CALENDAR YEAR (JANUARY - DECEMBER)

                1980 - 1999:                      Total new licenses issued                             5,292
                   20 years                           Average new licenses per year                        265
                                                            Net gain in population                             1,234,000
                                                            Net gain in M.D.'s                                            1,955
                                                           Average net gain in M.D.'s per year                    98

 YEAR         REVOCATION          PROBATION          SUSPENSION          MISCELLANEOUS *              TOTAL

1999                  10                                  1                                                                           4                                     15

1998                    8                                   5                                                                           3                                    16

1997                    8                                   2                                                                           6                                    16

1996                    9                                   7                                                                           4                                    20

1995                     1                                   1                                 2                                      21                                     25

1994                     2                                   4                                                                            8                                    14

1993                    1                                   3                                 1                                       10                                   15

1992                    3                                                                      1                                         9                                     13

1991                     3                                                                                                              10                                     13

1990                     1                                   2                                                                          11                                     14

1989                     2                                  1                                  1                                       8                                     12

1988                      6                                 4                                  2                                       5                                     17

1987                      2                                 4                                  3                                       3                                    12

1986                      2                                 1                                  1                                       3                                      7

1985                    11                                 3                                  3                                      11                                   28

* MISCELLANEOUS actions include:             - License Restriction
                                                                             - Public Reprimand
                                                                             - Licensure Denied    
                                                                             - CME Ordered
                                                                             - Drug or Alcohol Treatment Program Ordered
                                                                             - Competency Exams (Medical, Physical, Mental) Ordered

Physicians may charge up to .60 cents per page for photocopies and a reasonable cost for copies of X-ray photographs and other health care records produced by a similar process. No administrative fee or additional service fee of any kind may be charged for furnishing such a copy. See NRS 629.061(2). Health care records may not be withheld because a patient has an outstanding bill.

In order to apply for an initial physician’s assistant license, the physician’s assistant, not the hiring office, should contact the board office. Specific information needs to be obtained from the physician’s assistant in order to determine if he/she meets the eligibility requirements for licensure. The physician’s assistant, not an employer representative, is responsible for contacting the board office at the time he/she obtains new employment or wishes to change employers.

Prior to supervising a physician’s assistant or collaborating with an advanced practitioner of nursing, the physician must be approved by the board and have paid the required fee. All physicians who act as supervising/collaborating physicians must be approved by the board, regardless of whether they work with the physician’s assistant or advanced practitioner of nursing on a full-time, part-time, per diem or vacation-covering basis.

Reminder #3: Responsibility of a Supervising Physician

At the time a physician’s assistant begins the application process and indicates that you will be his/her supervising physician, you will be sent a letter notifying you of the following:
                The physician’s assistant is just beginning the application process, and cannot see
                patients, provide medical care or assist in providing medical care until his/her
                application is complete, approved and the licensure identification card has been
                received by the physician’s assistant.

Reminder #4: Temporary Licensure for Physician’s Assistants

Under NAC 630.320, the board is allowed to issue a temporary license to any qualified applicant who:

(1) (a) "Meets the educational and training requirements for certification as a physician’s assistant of the National Commission on Certification of Physician Assistants and is scheduled to and does sit for the first proficiency examination offered by the National Commission on Certification of Physician Assistants following the completion of training;" and

(2) "A physician’s assistant with a temporary license may perform services only under the immediate supervision of a supervising physician."

Reminder #5: Medical Services List and Prescribing Privileges for Physician’s Assistants

Under NAC 630.290, the supervising physician must provide the board with a description of the medical services to be performed by the physician’s assistant and a list of any poisons, controlled substances, dangerous drugs or devices which the supervising physician prohibits the physician’s assistant to prescribe, possess, administer or dispense in or out of the presence of the supervising physician. This paperwork must be signed by both the supervising physician and the physician’s assistant.

Reminder #6: Advanced Practitioners of Nursing

The change of a supervising/collaborating physician should be received in the board office at least one week prior to the effective date in order to allow adequate time for processing. If the change in a supervising/collaborating physician results in the physician’s assistant or advanced practitioner of nursing working with a physician in a different specialty from that previously approved, then a new medical services list and drug "prohibition" statement needs to be submitted to the board office by the supervising/collaborating physician for approval prior to the change taking place. In addition, NAC 630.340 requires that both the supervising physician and physician’s assistant notify the board of any changes in the physician’s assistant’s employment status.

You may contact the board office in Reno with any questions with respect to the above by calling 775/688-2559, or if calling from the Las Vegas area simply call 486-6244, and your call will come up to our office in Reno with no long distance fee charged to you. Also, the licensure requirements for a physician’s assistant and information on making application to be approved as a supervising/collaborating physician can be obtained through the board website at www.state.nv.us/medical/.

Please feel free to directly contact the following license specialists at the board office Monday through Friday, 8:00am to 5:00pm, for information on obtaining physician’s assistant licensure or supervising/collaborating physician approval:

Elizabeth A. Zarubi - physician assistant last names beginning with the letters "A" – "M"
Betty L. Tonner               - physician assistant last names beginning with the letters "N" – "Z"

In addition, Nevada Administrative Code 630.080 was also amended to reflect those requirements for licensure examinations recommended by the Federation of State Medical Boards of the United States, Inc., which have been adopted by a majority of licensing boards across the country. A physician must now have passed all parts of the licensing examinations in the combinations of examinations approved by the board within seven years after the date on which the physician first took the initial examination in the combination of examinations. This would apply to all physicians regardless of whether he/she sat for the examinations of the National Board of Medical Examiners, the Federation Licensing Examinations, the United States Medical Licensing Examinations or the examinations to become a licentiate of the Medical Council of Canada.

The following are the current statutes and regulations regarding eligibility for medical licensure in Nevada:

1. Every person desiring to practice medicine must, before beginning to practice, procure from the board a license authorizing him to practice.

2. Except as otherwise provided in NRS 630.161 or 630.164, a license may be issued to any person who:

(a) Is a citizen of the United States or is lawfully entitled to remain and work in the United States;

(b) Has received the degree of Doctor of Medicine from a medical school:

(1) Approved by the Liaison Committee on Medical Education of the American Medical Association and Association of American Medical Colleges; or

(2) Which provides a course of professional instruction equivalent to that provided in medical schools in the United States approved by the Liaison Committee on Medical Education;

(c) Has passed:

(1) All parts of the examination given by the National Board of Medical Examiners;

(2) All parts of the Federation Licensing Examination;

(3) All parts of the United States Medical Licensing Examination;

(4) All parts of a licensing examination given by any state or territory of the United States, if the applicant is certified by a specialty board of the American Board of Medical Specialties;

(5) All parts of the examination to become a licentiate of the Medical Council of Canada; or

(6) Any combination of the examinations specified in subparagraphs (1), (2) and (3) that the board determined to be sufficient;

(d) Has completed 3 years of:

(1) Graduate education as a resident in the United States or Canada in a program approved by the board, the Accreditation Council for Graduate Medical Education of the American Medical Association or the Coordinating Council of Medical Education of the Canadian Medical Association; or

(2) Fellowship training in the United States or Canada approved by the board or the Accreditation Council for Graduate Medical Education; and

(e) Passes a written or oral examination, or both, as to his qualifications to practice medicine and provides the board with a description of the clinical program completed demonstrating that the applicant’’s clinical training met the requirements of paragraph (b) of this subsection.

[Part 8:169:1949; A 1953, 662; 1955, 103]——(NRS A 1969, 211; 1971, 220; 1973, 508; 1977, 1564; 1985, 2229; 1987, 193, 1673; 1989, 416; 1991, 1068, 1884, 1887; 1993, 2298; 1997, 680)

1. The degree of Doctor of Medicine or its equivalent, as determined by the board; and

2. The standard certificate of the Educational Commission for Foreign Medical Graduates or a written statement from that commission that he passed the examination given by it.

(Added to NRS by 1969, 214; A 1973, 509; 1975, 960; 1977, 1564; 1983, 304; 1985, 2230)

1. A board of county commissioners may petition the board of medical examiners to waive the requirements of paragraph (d) of subsection 2 of NRS 630.160 for any applicant intending to practice medicine in a medically underserved area of that county as that term is defined by the officer of rural health of the University of Nevada School of Medicine. The board of medical examiners may waive that requirement and issue a license if the applicant:

(a) Has completed at least 1 year of training as a resident in the United States or Canada in a program approved by the board, the Accreditation Council for Graduate Medical Education of the American Medical Association or the Coordinating Council of Medical Education of the Canadian Medical Association, respectively;

(b) Has a minimum of 5 years of practical medical experience as a licensed allopathic physician or such other equivalent training as the board deems appropriate; and

(c) Meets all other conditions and requirements for a license to practice medicine.

2. Any person licensed pursuant to subsection 1 must be issued a license to practice medicine in this state restricted to practice in the medically underserved area of the county which petitioned for the waiver only. He may apply to the board of medical examiners for renewal of that restricted license every 2 years after he is licensed.

3. Any person holding a restricted license pursuant to subsection 1 who completes 3 years of such practice may apply to the board for an unrestricted license. In considering an application for an unrestricted license pursuant to this subsection, the board shall require the applicant to meet all statutory requirements for licensure in effect at the time of application except the requirements of paragraph (d) of subsection 2 of NRS 630.160.

1. For the purposes of paragraph (e) of subsection 2 of NRS 630.160, an applicant for a license to practice medicine must pass:

(a) A written examination concerning the statutes and regulations relating to the practice of medicine in this state; and

(b) The Special Purpose Examination, unless within 10 years before the date of his application for a license to practice medicine in this state, the applicant has passed:

(1) Part III of the examination given by the National Board of Medical Examiners;

(2) Component II of the Federation Licensing Examination;

(3) Step III of the United States Medical Licensing Examination;

(4) All parts of the examination to become a licentiate of the Medical Council of Canada;

(5) The examination for primary certification by a specialty board of the American Board of Medical Specialties and received primary certification from that board; or

(6) The Special Purpose Examination.

2. For any examination conducted by the board for a license to practice medicine, an applicant must answer correctly at least 75 percent of the questions propounded. The board will use the weighted average score of 75, as determined by the Federation of State Medical Boards of the United States, Inc., to satisfy the required score of 75 percent for passage of the Special Purpose Examination and the United States Medical Licensing Examination.

3. The board will authorize the Federation of State Medical Boards of the United States, Inc., to administer the Special Purpose Examination or the United States Medical Licensing Examination on behalf of the board.

4. For the purposes of subparagraph (3) of paragraph (c) of subsection 2 of NRS 630.160, a person must:

(a) Complete 1 year of postgraduate training before taking Step III of the United States Medical Licensing Examination and, except as otherwise provided in paragraph (b), is entitled to an unlimited number of attempts to pass that examination; and

(b) Pass Steps I, II and III of the United States Medical Licensing Examination within 7 years after the date on which the person first took Step I of the United States Medical Licensing Examination.

5. For the purposes of subparagraph (6) of paragraph (c) of subsection 2 of NRS 630.160, a person must pass all the examinations in the combination of examinations approved by the board within 7 years after the date on which the person first took the initial examination in the combination of examinations.

6. An applicant for a license to practice medicine and a person who holds a license to practice medicine shall pay the reasonable costs of any examination required for licensure and any examination ordered pursuant to NRS 630.318.

Please feel free to directly contact the following license specialists at the board office Monday through Friday, 8:00am to 5:00pm, for information on obtaining medical licensure:

Rebecca A. Gaul-Richard    - applicant last names beginning with the letters "A" – "G"
Elizabeth A. Zarubi            - applicant last names beginning with the letters "H" – "O"
Betty L. Tonner                      - applicant last names beginning with the letters "P" – "Z"

It is with great pleasure that the Foundation announces the addition of Carol R. Bowers, R.N., C.D. to the position of Executive Director of the Foundation. Ms. Bowers comes to us from Talbott Recovery Campus in Atlanta, Georgia, where she spent the last sixteen years intervening, assessing, treating and monitoring health professionals. She is nationally recognized as an expert in and a speaker on the field of addiction, and has appeared on numerous television programs such as Good Morning America, Nightline and CNN in this capacity. She has co-authored a chapter in the textbook "Addiction in the Nursing Profession," as well as numerous other articles on chemical dependency in health professionals. Ms. Bowers is now located in Las Vegas and serves as the seventh member of the Board of Directors of the Foundation. Please join us in welcoming Carol to Nevada.

Referrals to the Diversion Program come from a variety of sources, although the majority of those referrals come from partners or colleagues, hospitals, or through law enforcement channels. Occasionally, referrals are anonymous. Physicians are also referred to the Diversion Program when undergoing board investigation for other matters and impairment is suspected. In all cases, no records are kept at the board level. If someone calls the board to report a physician suspected of practice impairment, the caller will immediately be referred to the Diversion Program. Dr. Rueckl is always available at 775/742-1171, and Carol Bowers can be reached anytime at 702/233-6393 or 702/521-1398.

Confidentiality and anonymity are goals of both the board and the Diversion Program. Information is gathered and verified before any action is taken by the Diversion Program. Should circumstances necessitate, appropriate intervention is planned. Every effort is made to help the physician in a kind, respectful, confidential and therapeutic manner.

The Diversion Program currently has sixty participants under contract and there are two Caduceus Clubs, one in Reno and one in Las Vegas. The Caduceus Club groups meet weekly, and are both beneficial and supportive of health professionals in all stages of recovery.

Diversion is successful. The Nevada State Board of Medical Examiners recognizes the value of supporting physician’s health and has continued to pledge its support. The success rate of physicians in our Diversion Program is at ninety percent. This success rate is unique and astounding in the treatment of alcoholism and drug addiction, and can be attributed to the commitment of the board and the Foundation.

For years, Percocet has been a single strength dose. The addition of three additional strengths, while providing a range of analgesic therapy, creates pharmacy quandaries when the specific strength is not indicated.

You must specify the strength of the oxycodone and acetaminophen on all Percocet prescriptions. They are:

Percocet        25 / 325
Percocet          5 / 325
Percocet       7.5 / 500
Percocet        10 / 650

Failure to specify the strength may result in the prescription not dispensed to your patient and returned to you from the pharmacy for clarification.

PLEASE NOTE: A pharmacist by Nevada law cannot add the correct strength by an oral order or confirmation.

Pain is one of the most common presenting complaints to the medical provider's office. The diagnosis and treatment can be at times complex and challenging. Differentiating the types of pain, whether due to malignant or non- malignant disease can represent a disproportionate problem for the physician assistant in primary care and the specialties. Patients are entitled to appropriate and effective pain relief. It is the responsibility of the physician assistant or medical provider to be knowledgeable of up to date treatment modalities including the pharmacology of the drugs used. Physician assistants being dependent practitioners must also stay within the scope of practice of their supervising physician, and in difficult cases it is always wise to have the physician involved in the management of these patients. Goals of treatment are to prevent severe uncontrolled pain with adequate treatment of acute pain to prevent chronic pain and impairment of daily function.

The relief of pain and the treatment of chronic pain invoke many issues, including prescribing and if opioids are used, not deviating from federal and state regulations controlling the use of these drugs. Controlled substances such as opioid analgesics are often used for the treatment of acute and chronic pain of both cancer and non-cancer origin. Providing adequate pain relief for the patient and preventing iactrogenic dependence is a major concern to medical providers, patients and regulatory bodies. There are many articles in the medical literature and popular press about the undertreatment of pain. This presents a dilemma for even the most knowledgeable of practitioners who have concern about both overprescribing and underprescribing analgesics that are controlled substances for pain. Recognizing that patients taking opioid analgesics will develop a degree of physical dependence and are at risk of withdrawal symptoms if the drug is withdrawn abruptly further exacerbates the concerns and risks of prescribing these medications.

Common reasons for inadequate prescribing of controlled substances for pain are an inadequate or suitable provider knowledge base of these medications and the fear of investigation by federal and state agencies. The physician assistant is capable of providing patients who have acute, chronic or pain due to terminal illness effective treatment if the physician assistant is current in pharmacologic and non-pharmacologic modalities of pain treatment and utilizes the model pain management guidelines of the Federation of State Medical Boards of the United States, Inc. as proposed for adoption by the Nevada State Board of Medical Examiners. These are guidelines the Federation of State Medical Boards has adopted as policy and, if followed, can allay the uncertainty that medical providers have in treating pain with controlled substances.

The Federation’s model pain management guidelines are divided into two sections: the Preamble and the Guidelines. The full text of the Guidelines may be obtained by sending your request to the Federation of State Medical Boards of the United States, Inc, Federation Place, 400 Fuller Wiser Road, Suite 300, Euless, Texas 76039-3855, for the cost of $0.50, or they may be viewed or downloaded online at www.fsmb.org/

A summary and some key points taken from the Preamble: The "State Medical Board recognizes that quality medical practice dictates that the people of the state have access to appropriate and effective pain relief." It then emphasizes some important aspects of quality pain management, including knowledge of effective pain treatment, as well as statutory requirements for prescribing controlled substances. The inappropriate prescribing of these drugs can lead to drug diversion and abuse. The physician assistant need not fear disciplinary action from the board or other regulatory agencies if these drugs are prescribed or dispensed for legitimate medical reason and if based on accepted scientific knowledge and sound clinical grounds. Selecting a drug appropriate for the diagnosis and controlling pain while addressing the patient’s functioning both physically and psychologically are the goal. Thorough documentation of reasons for prescribing (unrelieved pain), validity and the treatment outcome are important for the medical provider staying in compliance with applicable state or federal law. The Preamble closes with the statement that the "guidelines are not intended to define complete or best practice but rather to communicate what the board considers to be within the boundaries of professional practice."

The Guidelines used for evaluating the use of controlled substances for pain are an excellent model to follow for the purpose of thorough evaluation, treatment goals and all inclusive chart documentation, if the format is followed. The following are highlights of the seven guidelines with some added examples from the literature on chronic pain management that may be helpful in patient evaluation and monitoring.

       -  complete history and physical examination
        -  current and past treatments (medication compliance, surgery, physical therapy, chiropractic,
            psychological treatment)
        -  nature and intensity of pain (description, pain diagram)
        -  effect on physical and psychological function (social, work related issues, disability)
        -  history of substance abuse (be aware of dual diagnosis)
        -  documentation for one or more medical indications for the use of a controlled substance

2. Treatment Plan:

        -  discuss risks and benefits of use of controlled substances
        -  prescription from one physician and pharmacy where possible (no other pain medication prescribers),
            written prescriptions in duplicate or triplicate
        -  high risk for substance abuse: use written agreement or contract
        -  reasons for drug therapy discontinuance (agreement violation)

Physician assistants have both the privilege and responsibility in prescribing controlled substances. As medical providers we have the unique opportunity to form therapeutic relationships with patients and to provide care to those suffering from pain. The Federation’s model guidelines are beneficial, if followed, to our staying in compliance with the state and federal regulations, and promote treating these patients in a thorough manner and with integrity.

The board will hold a public hearing at 4:30 p.m., Thursday, May 4, 2000, or as soon thereafter as it may be heard on that date, by telephone conference call to be conducted from the conference room of the board office at 1105 Terminal Way, Suite 301, in Reno.

There will be two locations where members of the Board of Medical Examiners will be physically located. One location is in the conference room of the board office at 1105 Terminal Way, Suite 301, in Reno, and the other location is at the offices of the Legislative Counsel Bureau at the Sawyer State Office Building in Room 4406 at 555 E. Washington Avenue in Las Vegas. Interested persons may appear at either location.

The purpose of the hearing is to receive comments from all interested persons regarding the adoption, amendment, or repeal of regulations pertaining to Chapter 630 of the Nevada Administrative Code.

The following information is provided pursuant to the requirements of NRS 233B.060:

The proposed revocation of NAC 630.015, 630.020, 630.030, 630.193, 630.195, and 630.197, is the result of hearings held by the board on petitions to revoke the new regulations on "pain control" and adopt the Federation of State Medical Boards of the United States, Inc.’s, Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.

The proposed revocation of the language of paragraph (m) of NAC 630.230, is the result of hearings held by the board on petitions to revoke the new regulations on "pain control" and adopt the Federation of State Medical Boards of the United States, Inc.’s, Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.

The proposed amendment to the language of paragraph (m) of NAC 630.230, incorporates part of the language of deleted paragraph (n) and adds language thereto adoption by reference, the Federation of State Medical Boards of the United States, Inc.’s, Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.

The proposed changes to Chapter 630 of the Nevada Administrative Code, are set out hereinafter and are proposed to read as follows:

                                              PROPOSED REGULATIONS OF THE NEVADA STATE
                                                              BOARD OF MEDICAL EXAMINERS

AUTHORITY: NRS 630.130, NRS 233B.040(3).

NAC 630.010 Definitions. (NRS 630.130) As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 630.010 to 630.025, inclusive, and NAC [630.015 to 630.030, inclusive 630.025 have the meanings ascribed to them in those sections

(e) "Tolerance" means a physiological state resulting from regular use of a medication in which an increased dosage is needed to produce the same effect or a reduced effect is observed with a constant dosage.]

NAC 630.230 Prohibited professional conduct. (NRS 630.130, 630.275)

1. A person who is licensed as a physician or physician’s assistant shall not:

(a) Falsify records of health care;

(b) Falsify the medical records of a hospital so as to indicate his presence at a time when he was not in attendance or falsify those records to indicate that procedures were performed by him which were in fact not performed by him;

(c) Render professional services to a patient while the physician or physician’s assistant is under the influence of alcohol or any controlled substance or is in any impaired mental or physical condition;

(d) Acquire any controlled substances from any pharmacy or other source by misrepresentation, fraud, deception or subterfuge;

(e) Prescribe anabolic steroids for any person to increase muscle mass for competitive or athletic purposes;

(f) Make an unreasonable additional charge for tests in a laboratory, radiological services or other services for testing which are ordered by the physician or physician’s assistant and performed outside his own office;

(g) Treat any patient in a manner not recognized scientifically as being beneficial;

(h) Prescribe controlled substances listed in schedule II pursuant to NAC 453.520 or schedule III pursuant to NAC 453.530, controlled substance analogs, chorionic gonadotrophic hormones, thyroid preparations or thyroid synthetics for the control of weight;

(i) Allow any person to act as a medical assistant in the treatment of a patient of the physician or physician’s assistant, unless the medical assistant has sufficient training to provide the assistance;

(j) Fail to provide adequate supervision of a medical assistant who is employed or supervised by the physician or physician’s assistant;

(k) If the person is a physician, fail to provide adequate supervision of a physician’s assistant or an advanced practitioner of nursing;

(l) Fail to honor the advance directive of a patient without informing the patient or the surrogate or guardian of the patient, and without documenting in the patient’s records the reasons for failing to honor the advance directive of the patient contained therein; or,

(m) [Fail to adequately prescribe controlled substances for the control of pain in accordance with prevailing standards of acceptable practice of medicine as described in NAC 630.193; or

(n) Engage in the practice of writing prescriptions for controlled substances to treat acute or chronic pain in a manner that deviates from the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain, published by the Federation of State Medical Boards of the United States, Inc., which the board hereby adopts by reference. A copy of the publication may be obtained from the Federation of State Medical Boards of the United States, Inc., Federation Place, 400 Fuller Wiser Road, Suite 300, Euless, Texas 76039-3855, for the cost of $0.050. prevailing standards of acceptable practice of medicine as described in NAC 630.193.

2. As used in this section:

(a) "Controlled substance analog" means:

(1) A substance whose chemical structure is substantially similar to the chemical structure of a controlled substance listed in schedule II pursuant to NAC 453.520 or schedule III pursuant to NAC 453.530; or

(2) A substance which has, is represented as having or is intended to have a stimulant, depressant or hallucinogenic effect on the central nervous system of a person that is substantially similar to, or greater than, the stimulant, depressant or hallucinogenic effect on the central nervous system of a person of a controlled substance listed in schedule II pursuant to NAC 453.520 or schedule III pursuant to NAC 453.530.

(b) "Medical assistant" means any person who:

(1) Is employed by a physician or physician’s assistant;

(2) Is under the direction and supervision of the physician or physician’s assistant;

(3) Assists in the care of a patient; and

(4) Is not required to be certified or licensed to provide such assistance by any administrative agency.

[Bd. of Medical Exam’rs, § 630.230, eff. 12-20-79]—(NAC A 6-23-86; 9-19-90; 1-13-94; 7-18-96; R007-99, 9-27-99)

Complaint Filed: 09/08/99 - Charged with a violation of NRS 630.304(1), attempting to renew a license to practice medicine by fraud or misrepresentation or by false, misleading, inaccurate or incomplete statement, and a violation of NRS 630.306(2)(a), engaging in an act of conduct intended to deceive.

Board Action: 02/26/00 - The board found Dr. Lybbert guilty of both counts of the Complaint and ordered that his license to practice medicine in the state of Nevada be revoked.

Complaint Filed: 06/22/99 - Charged with 14 violations of NRS 630.305(5), aiding, assisting, employing or advising, directly or indirectly, any unlicenced person to engage in the practice of medicine contrary to the provisions of chapter 630 of the Nevada Revised Statutes or the regulations of the board, 14 violations of NRS 630.305(1)(f), delegating responsibility for the care of a patient to a person if the licensee knows, or has reason to know, that the person is not qualified to undertake that responsibility, 9 violations of NRS 630.305(1)(a), directly or indirectly receiving from any person, corporation or other business organization any fee, commission, rebate or other form of compensation which is intended or tends to influence the physician’s objective evaluation or treatment of a patient, 9 violations of NRS 630.305(1)(g), failing to disclose to a patient any financial or other conflict of interest, and 13 violations of NRS 630.3062(1), failure to maintain medical records relating to the diagnosis, treatment and care of a patient, constitutes grounds for initiating disciplinary action against a licensee.

Board Action: 12/04/99 - The board found Dr. Murray guilty of all 59 counts of the Complaint, revoked his license to practice medicine in the state of Nevada, fined him $5,000.00 and assessed him $19,637.10 for all costs involved in the investigation and prosecution of the case against him.

Dr. Murray has appealed the action of the board to the District Court.

Complaint Filed: 03/17/99 - Charged with 2 violations of NRS 630.306(2)(a), engaging in any conduct which is intended to deceive.

Board Action: 02/26/00 - The board found Dr. Niles guilty of both counts of the Complaint and ordered that he be issued a public reprimand, perform 40 hours of uncompensated public service in the community in which he currently resides, be fined $2,000.00 and pay the costs of the proceedings against him in the sum of $8,590.00.

Complaint Filed: 03/17/99 - Charged with 1 violation of NRS 630.301(1), conviction of any offense involving moral turpitude.

CHAD REED NILES, M.D.

Dear Dr. Niles:

On Saturday, February 26, 2000, the Nevada State Board of Medical Examiners found you guilty of Two Counts of violation of the medical practice act of the state of Nevada.

The Board found you Guilty of engaging in conduct intended to deceive in your involvement with advertisements on the World Wide Web advertising products for "Penis Enlargement", wherein you represented yourself to be a physician by the name of C. Iles, M.D., of Boca Raton, Florida, who had conducted his own research and was recommending the "Penis Enlargement" to a number of his own patients; and, the Board found you Guilty of engaging in conduct intended to deceive by making representations to members of the medical staff of the Resident program of the University who were questioning your internet activities which contained information which was deceptive, not the full truth, and misleading.

As a result of their findings of Guilty of Two Counts of violations of the medical practice act, the Board entered its ORDER as follows:

1. That you be issued a public reprimand.

2. That you be required to perform forty (40) hours of community service in the community in which you currently
     reside.

3. That you be fined $1,000.00 on each count for a total fine of $2,000.00

4. That you pay the costs of the proceedings in the sum of $8,590.00

Accordingly, it is my unpleasant duty as President of the Nevada State Board of Medical Examiners to formally and publicly reprimand you for your conduct which has brought personal and professional discredit upon you, and which reflects unfavorably upon the medical profession as a whole.

Arne D. Rosencrantz,
President