Advisory Ruling Number: 0901

Authority: The Massachusetts Board of Registration in Nursing issues this Advisory Ruling pursuant to Massachusetts General Laws (G.L.), chapter 30A, section 8.

Date Issued: February 11, 2009

Date Revised: November 10, 2010

Scope of Practice: Licensed Practical Nurse, Registered Nurse (RN) and Advanced Practice RN.

Purpose: To guide the practice of the Licensed Practical Nurse, Registered Nurse and Advanced Practice Registered Nurse in promoting patient access to the appropriate, therapeutic and effective assessment, diagnosis and management of acute and chronic pain. Such pain assessment and management serves to improve the quality of life for those patients who suffer from pain as well as to reduce the morbidity and costs associated with untreated or inappropriately treated pain including non-treatment, under-treatment, over-treatment and the continued use of ineffective treatment.

Advisory: A nurse licensed by the Massachusetts Board of Registration in Nursing (Board) is responsible and accountable for engaging in the practice of nursing in accordance with accepted standards of care.

It is the Board's current position that these standards, in the context of appropriate, therapeutic and effective assessment, diagnosis and management of pain, include:

  • development and implementation of a patient's pain management plan that is evidence-based and includes a comprehensive and on-going pain assessment, appropriate pharmacological and non-pharmacological modalities, and the substantiation of adequate symptom control;
  • complete, accurate and legible entries in all appropriate patient or resident records required by federal and state laws and regulations, and accepted standards of care;
  • the use, when appropriate, of controlled substances including opioid analgesics in the management of all pain types;
  • interdisciplinary consultation and collaboration;
  • recognition that tolerance and physical dependence are normal consequences of sustained use of opioids and are not synonymous with addiction: tolerance is a physiologic state resulting from regular use of a drug in which (a) an increased dosage is needed to produce a specific effect, or (b) a reduced effect is observed with a constant dose over time [i]; and physical dependence is a state of adaptation that is manifested by drug class specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist [ii];
  • exercising sound professional judgment to recognize that pseudoaddiction may develop as a direct consequence of inadequate pain management and that pseudoaddiction can be distinguished from true addiction in that inappropriate drug seeking behaviors resolve when pain is effectively treated;
  • recognition that patients with chemical dependency may require specialized pain management involving controlled substances including opioids [iii];
  • recognition that a patient who suffers from extreme pain or disease progression may require increased doses of pain medication and that the appropriate dose is the dose required to effectively manage the patient's pain in that particular circumstance;
  • adherence to system safe-guards that are designed to minimize the potential for abuse and diversion when controlled substances are used;
  • acceptance of patient self-determination and autonomy;
  • culturally sensitive patient, family/significant other, and/or caregiver education.

The nurse is also responsible and accountable for acquiring and maintaining the knowledge, skills and abilities necessary to practice in accordance with accepted standards of care for pain management. Such competencies may be acquired through basic, graduate or continuing education programs [iv], as appropriate to the nurse's scope of practice. These competencies include, but are not limited to, knowledge of the current federal and state laws and regulations for the prescription, dispensing, administration and destruction of controlled substances, current evidence-based guidelines developed by nationally recognized professional organizations in the assessment and management of pain, and the use of pharmacological and non-pharmacological modalities (e.g. heat and cold therapies).

The Advanced Practice RN with prescriptive authority, pursuant to M.G.L. Chapter 94C, Section 18(e), must in addition to acquiring and maintaining the knowledge, skills and abilities necessary to practice in accordance with accepted standards of care for pain management, must complete appropriate education [v] in the following concepts prior to initial Board authorization to practice in the advanced role, and subsequently, during each renewal period.

  1. Effective pain management,
  2. Identification of patients at high risk for substance abuse, and
  3. Counseling patients about the side effects and addictive nature of controlled substances, and proper storage and disposal of prescription medications.

[i] Adopted by the Federation of State Medical Boards of the United States from the Definitions Related to the Use of Opioids for the Treatment of Pain: A Consensus Document of the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (2001). Available at http://www.painmed.org/pdf/definition.pdf.

[ii] Adopted by the Federation of State Medical Boards of the United States from the Definitions Related to the Use of Opioids for the Treatment of Pain: A Consensus Document of the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (2001). Available at http://www.painmed.org/pdf/definition.pdf.

[iii] In the event the patient with chemical dependency is a licensee of the Board who is enrolled in the Board's substance abuse rehabilitation program, the specialized pain management plan may be developed in collaboration Board's substance abuse rehabilitation program.

[iv] Continuing education programs developed in accordance with 244 CMR 5.00.

[v] Continuing education programs developed in accordance with 244 CMR 5.00.


This information is provided by the Division of Health Professions Licensure within the Department of Public Health.