Collaborative Practice for Chronic Pain Management
A family practice physician approaches you, a pharmacist at an independent pharmacy, to enter into a collaborative practice agreement (CPA) for managing chronic pain patients. The physician wants you to adjust opioid doses, order urine drug screens, and renew prescriptions for patients with stable pain. The physician will see the patients every six months. The CPA would cover 50 patients. The physician is board-certified in family medicine and has a DEA registration. You are not a pain specialist but have completed a certificate program in pain management. The physician proposes that you have authority to modify therapy without contacting him each time, as long as you document in the shared EHR. What are the requirements for a CPA in Texas, and what should you consider before agreeing?
1. What are the legal requirements for a collaborative practice agreement in Texas?
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Under Texas Occupations Code Chapter 157 and 22 TAC §193.7, a CPA must be in writing, be between a physician and a pharmacist, and define the scope of practice, including the types of patients, the drugs and devices, and the conditions. The CPA must be reviewed and updated at least annually. The pharmacist must have access to the patient's medical records and must communicate with the physician. The CPA must not allow the pharmacist to practice medicine independently. The physician retains ultimate responsibility. The CPA must be available to the Board on request. The pharmacist must have adequate training and competence.
2. What specific concerns arise from this proposed CPA regarding controlled substances and pain management?
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The CPA would allow the pharmacist to adjust opioid doses and renew prescriptions, which are controlled substances. Under Texas law, a pharmacist may not prescribe controlled substances except as allowed by a CPA. The CPA must comply with DEA regulations and Texas PMP requirements. The pharmacist must check the PMP before dispensing or prescribing opioids. The CPA should include protocols for urine drug screening, pill counts, and referral to specialists. The physician's six-month follow-up may be insufficient for chronic pain patients; the CPA should require more frequent communication. The pharmacist should ensure that the CPA does not violate the Texas Medical Board rules on pain management. Also, the pharmacist's malpractice insurance should cover these activities.