(1) The advanced registered nurse practitioner shall consider and document referring the patient for additional evaluation and treatment as needed to achieve treatment objectives. Special attention should be given to those chronic pain patients who are under eighteen years of age or who are potential high-risk patients. The management of pain in patients with a history of substance use or with comorbid psychiatric disorders may require extra care, monitoring, documentation, and consultation with, or referral to, an expert in the management of such patients.

(2) The mandatory consultation threshold is one hundred twenty milligrams morphine equivalent dose (MED). If an advanced registered nurse practitioner prescribes a dosage amount that meets or exceeds the mandatory consultation threshold of one hundred twenty milligrams MED per day, a consultation with a pain management specialist as described in WAC 246-840-493, 246-853-750, 246-854-330, 246-817-965, 246-918-880, 246-919-940, or 246-922-750 is required, unless the consultation is exempted under WAC 246-840-487 or 246-840-490. The mandatory consultation shall consist of at least one of the following:

(a) An office visit with the patient and the pain management specialist;

(b) A consultation between the pain management specialist and the advanced registered nurse practitioner;

(c) An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the advanced registered nurse practitioner or with a licensed health care practitioner designated by the advanced registered nurse practitioner or the pain management specialist; or

(d) Other chronic pain evaluation services as approved by the commission.

(3) The advanced registered nurse practitioner shall document each consultation with the pain management specialist. Any written record of a consultation by the pain management specialist shall be maintained as a patient record by the specialist. If the pain management specialist provides a written record of the consultation to the advanced registered nurse practitioner, the advanced registered nurse practitioner shall maintain it as part of the patient record.

(4) The advanced registered nurse practitioner shall use great caution when prescribing opioids to children and adolescents with chronic pain; appropriate referral to a specialist is encouraged.