[ARNPCare] September 2014
ARNP Care Monthly NewsLetter
arnpcare at nurse.net
Tue Sep 30 21:47:56 PDT 2014
Advanced Registered Nurse Practitioner Care
Official Newsletter of ARNPs United of Washington State
Volume 25(7) September 2014
Articles
Jobs
CE
Service Ads
Meetings
Photo of the Month
Ad & Publication Information
Come to AUWS Meet & Greet 7-9pm Wed Oct 6 Seattle Sheraton
If you will be attending the upcoming 37th Annual Conference, Advanced Practice in Primary and Acute Care in Seattle ARNPs United of Washington State, the Puget Sound Nurse Practitioner Association and Phenogen invite you for a wine and appetizer event. Meet Angie Golden, past president of AANP, Tracy Klein, Region 10 Director to AANP, the board members and officers of ARNPs United of Washington State.
Nurse Practitioners from all states are welcome! For more information, email Nancy Lawton at nelawton1 at gmail.com.
This event precedes the 37th Annual Conference, Advanced Practice in Primary and Acute Care at the Washington State Convention Center in Seattle. Registration at the conference is not required for admission to this event.
Meet and Greet
Wednesday, October 8
7-9 pm
Seattle Sheraton, Redwood Room
1400 6th Avenue Seattle
2nd floor
Board of Directors Nominations
These individuals will be running for a position on ARNPs United of Washington State’s Board of Directors:
Nancy Lawton (incumbent)
Ashley Fedan (incumbent)
Joe Gardner
Becky S Carter
Voting will be at the Pacific NW Advanced Practice and Primary Care Conference. There are 6 open positions.
If you have any questions about this opportunity to serve Washington’s ARNPs, please feel free to email tracy at npcentral.net.
Ebola Virus Updates
CDC has developed new Ebola preparedness resources that have practical and useful advice:
Health Care Facility Preparedness Checklist: http://www.cdc.gov/vhf/ebola/pdf/healthcare-facility-checklist-for-ebola.pdf
· Health Care Provider Preparedness Checklist: http://www.cdc.gov/vhf/ebola/pdf/healthcare-provider-checklist-for-ebola.pdf
· Ebola Advice for Humanitarian Aid Organizations, http://wwwnc.cdc.gov/travel/page/advice-humanitarian-aid-organizations-ebola
Complete Ebola information and resources are available on the CDC Ebola main page, http://www.cdc.gov/vhf/ebola/index.html?s_cid=cdc_homepage_feature_001
NP Residency
New graduates eager to begin a first job as an independent provider and motivated to serve the neediest patients are drawn to work with Federally Qualified Health Centers (FQHCs). The VA offers challenging patients and excellent benefit packages. Both are ideal sites for new grads to begin work, but often the challenge of managing a patient panel with the added complexity of profound psychosocial needs can overwhelm a new graduate. An ideal solution to bridge the transition from graduate student to independent provider is with Nurse Practitioner Residencies. Washington is leading the country in the number of residencies available in our state.
AANP and the ANCC use the term “fellowship” but Washington State programs are currently entitled as residencies. They all provide a graduated ramp up to a full patient panel, mentorship, didactic content shared with coworkers, multidisciplinary interaction and specialty rotations. Most of the programs include a component of leadership training or a special populations project, with the goal of NPs assuming leadership roles in their organizations and communities. These are paid positions for NPs within their first year of graduation. Newly graduated Nurse Practitioners are skilled in interview techniques, history taking, physical examination, assessment and management. However new NPs may find that implementing these skills while learning organizational techniques, time management skills and establishing relationships with coworkers of multiple disciplines is challenging. This is reflected in the high attrition rate of new grads in the FQHC and VA settings, with many leaving within 1-3 years of hire. A goal of these programs is to establish the support network necessary to assure job satisfaction for the new employee and improve retention.
Six programs are evolving in Washington. The VA DNP Transition program and Tacoma’s Community Health Clinics opened in 2012. International Clinic Health Services, Yakima Valley and Columbia Basin Clinics all began this month. SeaMar will admit their first NPs in 2015. Rural community clinics are hoping to tap into these programs using remote telecommunications allowing NPs in diverse and isolated locations to participate.
Patients, clinics and our profession all benefit from these transition-to-practice programs. New employees are supported as they gain confidence and efficiency, patients enjoy a technically proficient provider, and the employing organization has a team of providers understanding how to best utilize one another’s skills. The community gains a competent leader to innovate new programs and we look forward to increasing the number of preceptors for the pool of NP students and future NP residents.
Safe Prescribing of Pain Medication for Patients in Recovery: Considerations for Primary Care Providers
by Caitlin Jarvis, DNP, ARNP
Disclosure: This educational information was developed as partial fulfillment of the requirements for the Doctor of Nursing Practice degree at the University of Washington. There was no commercial or non-commercial support of this project. No products are endorsed.*
How many of your patients are in recovery from a substance use disorder? Do you know how recovery is defined? A survey1 in 2011 showed that 10% of all American adults aged 18 years and older, or approximately 23.5 million people, consider themselves to be in recovery from drug or alcohol use problems. Those with substance use disorders are less likely than others to receive effective pain treatment, primarily due to a clinician’s concern that they may misuse opioids.2 Though it is true that the use of various pain medications by a patient in recovery may trigger relapse,3 one must also consider that inadequate pain control and treatment that frustrates, stresses, or confuses patients may also lead to relapse.2,4,5 It is imperative to effectively treat a patient’s pain, yet also treat it in the way least likely to trigger relapse. The purpose of this article is to educate primary care advanced registered nurse practitioners (ARNPs) about safe and effective pain management in patients with a history of a substance use disorder who are now in recovery.
Points to Consider
Definitions of recovery vary. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as, “a process of change through which an individual with substance use disorder achieves abstinence, wellness, and improved health and quality of life.”6
When asking about current drug and alcohol use, also ask about history of use or misuse. One recommended question is, “Did you once have a problem with drugs or alcohol, but no longer do?”1 Alternative recommended questions are, “Have you used alcohol and/or drugs, including prescription drugs, in the past? Did you experience any persistent or recurring problems when using?” Also ask about history of recovery and support.
Medications are evaluated in the literature on their ability to stimulate the brain’s reward system.3,7,8 Once the brain’s reward system has been altered, or primed, by one substance, exposure to a second different but addictive substance can still trigger relapse. This is referred to as cross-priming. It is this phenomenon that is thought to be responsible for one substance triggering a relapse to use of a different substance, for instance opiates triggering alcohol misuse relapse.
These recommendations apply to a history of any substance misuse, including alcohol, cocaine, prescription medications, etc. General recommendations do not change based on the specific substance that was misused, rather they are consistent across misused substances.
The amount of literature examining pain management in patients in recovery from substance misuse is limited. No dosing guidelines were provided in the literature. There are specific guidelines for dosing patients in renal or hepatic failure but guidelines do not exist for dosing for patients in recovery. However, highlighted resources at the end of this document provide some useful information. Generally, the lowest effective dose is recommended.
Review of Medications
See below for medications reviewed in the literature. Medications in bold were reviewed and agreed upon by either more than one source or a source that performed a meta-analysis. The others were reviewed by only one source. Guidance about specific indications for medications was limited but is included when possible. Reviewed medications were limited to those commonly prescribed by primary care providers. Remember that for all patients, the consideration of non-pharmacological measures is also appropriate and is often an important first step in treatment, or a concurrent step in treatment. This can include: therapeutic exercise, physical therapy, cognitive-behavioral therapy, chiropractic care, massage, acupuncture, mind-body therapies, relaxation strategies, and the application of heat and/or ice.
Safest Pain Medications to Use in Recovery
These medications are generally considered safe for patients in recovery because they are not considered addictive medications, or do not stimulate the brain’s reward system. Other general clinical considerations that must be taken into account, for instance considering hepatic impairment before prescribing acetaminophen, are not thoroughly discussed here but are important in prescribing any medication.
Acetaminophen – contraindicated in severe hepatic impairment, including active
liver disease. Consider increasing dosing intervals for renal impairment.9
Aspirin
Nonsteroidal anti-inflammatory drugs (NSAIDS): increased risk of potentially fatal
gastrointestinal adverse effects in patients with a history of alcohol use with long-term NSAID use.
ibuprofen (Motrin, Advil)
ketorolac (Toradol)
naproxen (Naprosyn)
piroxicam (Feldene)
celecoxib (Celebrex)
diclofenac potassium / sodium (Cambia, Zipsor, Voltaren)
etodolac (Lodine)
indomethacin (Indocin)
ketoprofen
meloxicam (Mobic)
nabumetone (Relafen)
oxaprozin (Daypro)
Tricyclic Antidepressants (TCAs):
amitriptyline (Elavil) – especially helpful for chronic neuropathic pain4
nortriptyline (Aventyl) – especially helpful for chronic neuropathic pain4
doxepin (Sinequan)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
duloxetine (Cymbalta) – especially helpful for chronic neuropathic pain4
Anticonvulsants: not routinely used for pain management; indications included.
gabapentin (Neurontin) – post-herpatic neuralgia and neuropathic pain9
topiramate (Topamax) – migraine headache prophylaxis9
valproic acid (Depakene) – migraine headache prophylaxis9
carbamazepine (Tegretol) – trigeminal neuralgia9
divalproex (Depakote) – migraine headache prophylaxis9
lamotrigine (Lamictal) – off-label use for migraines and trigeminal neuralgia9
levetiracetam (Keppra) – off-label use for migraine prophylaxis9
phenytoin (Dilantin) – off-label use for chronic pain9
zonisamide (Zonegran) – off-label use for refractory migraines and prophylaxis9
Topical analgesics: NSAIDs, capsaicin, local anesthetics
Antipsychotics: no specific medications listed in the literature
Pain Medications to Use with Caution in Recovery
These medications should be used with caution when clinically appropriate. They are viewed as potentially addictive medications, or as possibly stimulating the brain’s reward system, yet it is recognized that benefits may sometimes outweigh the risks of these medications.
Some Muscle Relaxants:
cyclobenzaprine (Flexeril)
metaxalone (Skelaxin)
Opioids:
In general, nonpharmacological treatments and non-opioid analgesics are considered preferable to opioids for pain control. However, it is recognized that sometimes opioids may be necessary for pain control and should NOT be ruled out based on an individual’s history of a substance use disorder.2,3,6 The decision to initiate opioid therapy should be made by the provider and patient after a clear discussion about the benefits and risks. No specific opioid medications were reviewed as safer or less safe in the literature. Measures that can be taken by the provider and patient to avoid triggering substance misuse relapse are listed below:
Discuss available social support system for the patient, whether it is family, friends, or participation in a 12-step program such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).6,10 Consider identifying a safe and reliable individual who can store the medication and dispense it to the patient.
When initiating opioid therapy, it is advisable to adopt a universal precautions approach, or minimal level of care applicable to all patients. This approach is most often recommended when treating chronic pain because there may be greater opportunity for substance use relapse, but could be used for acute pain as well.
Universal Precautions: 10 steps according to Gourley, Heit, & Almahrezi11 as published by the American Society for Pain Management Nursing.12
Make a diagnosis with appropriate differential
Psychological assessment, including risk of addictive disorders “Respectful risk assessment does not diminish a patient’s complaint of pain. Discuss adherence monitoring with all patients.”12
Informed consent “Discuss with the patient and answer any questions regarding anticipated benefits and risks of proposed treatment plan.”12
Treatment agreement “A carefully worded treatment agreement with mutually agreed upon goals will help to clarify appropriate boundaries, facilitate early identification and response to nonadherent behaviors, and include an exit strategy for possible cessation of opioid therapy.”12 Also known as a Controlled Substance Contract.
Pre/post-intervention assessment of pain level and function “Evaluation of the success or failure to meet agreed upon goals is essential to support continuation or change in the treatment plan.”12
Appropriate trial of opioid therapy with or without adjunctive medication “Use of a pharmacologic regimen must recognize that opioids are not routinely the treatment of first choice or of last resort, and should consider an individualized combination of opioids and adjunctive medications.”12
Reassessment of pain score and level of function “Regular reassessment along with confirmation from family/significant others will help support rationale for continuation or change of treatment. High self-reported pain scores are commonly seen in persons with persistent pain on opioids. Scores are often high because of distress factors that relate to patient anticipation that medication is continued only when scoring pain as high. A decision to advance opioid dosing should not be based solely on pain scores, but should include a comprehensive functional assessment.”12
Regularly assess the “five As” of pain medicine: analgesia, activity, adverse effects, aberrant behavior, and affect. “Comprehensive assessments help direct therapy and support pharmacologic options.”12
Periodically review pain diagnosis and co-morbid conditions, including addictive disorders “In the pain and addiction continuum, patients may move from dominance of one condition to another requiring a change in treatment focus.”12
Documentation “Thorough documentation along with a therapeutic relationship with the provider will (a) facilitate communication with the patient and other providers, (b) allow evaluation of clinical outcomes and further treatment planning, and (c) reduce medical-legal liability.”12
When prescribing opioids, minimize exposure to their potentially euphoric effects.
Use long-acting opioids rather than short-acting when possible.2,6
Schedule medications around-the-clock rather than prn to avoid euphoric peaks and to avoid getting behind in pain control.2
Have only ONE provider prescribing pain control medications. (Best practice is to consult the Washington Prescription Drug Monitoring program each time a controlled substance is prescribed.)6
Discontinue opioid medication when it is no longer necessary for adequate pain control. Consider weaning to non-opioid medication when appropriate.6
Pain Medications to Avoid in Recovery
These medications are generally viewed as addictive and are not recommended in pain management for patients in recovery.
Benzodiazepines
Cannabinoids
Some Muscle relaxants:
carisoprodol (Soma)
Summary
Ask your patients about their current and past drug and alcohol use, including any treatment or perceived problems with these substances.
Non-pharmacological and non-opioid treatments are generally considered first-line therapy in outpatient pain management for patients in recovery, though other medications may be considered.
Opioids are appropriate for use in pain management when necessary for effective pain control, though the risk of relapse does exist.
Consider using strategies to decrease chances of relapse:
Universal Precautions
Use long-acting rather than short-acting opioids
Schedule medications around-the-clock rather than prn
Only one provider should prescribe and manage pain medication
Discontinue or wean to non-opioid when possible
Encourage social support in the form of family, friends, or a 12-step program
Carisprodol (Soma), cannabinoids, and benzodiazepines should generally be avoided for acute and chronic pain management in this population.
Additional Resources
American Society for Pain Management Nursing Position Statement: Pain Management in Patients with Substance Use Disorders
SAMHSA's Treatment Improvement Protocol #54: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders
Opioid Risk Tool – Assesses risk of aberrant behaviors when patients are prescribed opioids for chronic pain
Sample Treatment Agreement from the American Academy of Pain Medicine
Urine Drug Testing: Current Recommendations and Best Practices
Helping Patients Who Drink Too Much: A Clinician's Guide - Information on screening and counseling for alcohol use disorders as well as medication for alcohol dependence from the National Institute on Alcohol Abuse and Alcoholism
Washington Prescription Drug Monitoring Program
*Note: These general guidelines are based on a review of the literature and are intended to highlight considerations that clinician’s should take into account when making prescribing decisions. These are not a substitute for clinician assessment of an individual patient’s needs or safety factors.
References
1. Rhondo J, Feliz J. Survey: Ten Percent of American Adults Report Being in Recovery from Substance Abuse or Addiction. http://www.oasas.ny.gov/pio/press/20120306Recovery.cfm. Updated March 6, 2012. Accessed May 8, 2014.
2. Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract. 2008;4(2):4-25. doi:10.1151/ascp08424
3. Seppala M. Patients with pain and addiction: What’s a doctor to do? Minn Med. 2006;89(9):41 -43. http://www.minnesotamedicine.com/PastIssues/Past Issues2006/September2006/ClinicalSep palaSeptember2006.aspx. Accessed May 8, 2014.
4. Markowitz J, Francis E, Gonzales-Nolas C. Managing acute and chronic pain in a substance abuse treatment program for the addicted individual early in recovery: A current controversy. J Psychoactive Drugs. 2010;42(2):193-198. http: //www.ncbi.nlm.nih.gov.offcampus.lib.washingt on.edu/pubmed/20648914. Accessed May 8, 2014.
5. St. Marie B. Coexisting addiction and pain in people receiving methadone for addiction. West J Nurs Res. 2014;36(4);534-51. doi: 10.1177/0193945913495315
6. Substance Abuse and Mental Health Services Administration (SAMHSA). Managing chronic pain in adults with or in recovery from substance use disorders. Rockville, MD: U.S. Dept of Health and Human Services; 2012.
7. Gardner EL. What we have learned about addiction from animal models of drug self-administration. Am J Addict. 2000;9(4):285-313. doi:10.1080/1055049 00750047355
8. Hyman SE. Addiction: A disease of learning and memory. Am J Psychiatry. 2005;162(8):1414
-22. doi:10.1176/appi.ajp.162.8.1414
9. Specific Medication. In:DRUGDEX System (Micromedex 2.0). Greenwood Village, CO: Truven Health Analytics; c1974-2014. http://www.micromedexsolutions.com/micromedex2/libra rian#. Accessed May 8, 2014.
10. Covington EC. Pain and addictive disorder: Challenge and opportunity. In Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s practical management of pain. Philadelphia: Elsevier Mosby; 2008:793-808.
11. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-12. doi:10.1111/j.1526-4637.2005.05031.x
12. Oliver J, Coggins C, Compton P, et al. American Society for Pain Management nursing position statement: Pain management in patients with substance use disorders. J Addict Nurs. 2012;23(3):210-22. doi:10.1097/JAN.0b013e318271c123
Job Opportunities
NP Positions NW Washington-Three County Area
Home Health company seeking NP Independent contractors wanting to build their own practice without marketing and billing hassles.
Entrepreneurial spirited-build your own practice-set your own schedules with patients
Independent contractor to a referral, marketing and billing company
In-home diagnosis and care for trauma patients-travel to patients near your home. No office required
Will teach you medical-legal forensic care documentation and presentation skills without charge to you
No non-competes-when and if you are ready go out on your own with no obligations
Compensation based on number of patients you choose to see
Back up by board certified pain specialist osteopthic doctor anesthesiologist
Immediate openings
Medical-Legal Therapeutics Inc.-Michael Tomkins or Richard Tomkins
206-547-1000 * aadmt at aol.com / rmtomkins at gmail.com * website in process-other practice information available upon request.
PointNurse Virtual Healthcare Clinic Weekend Event (November 8-9)
PointNurse, a new online video healthcare service, is running a paid weekend pilot in Washington November 8-9 to test its new telehealth video call app. We are seeking a team of Nurse Practitioners to be on call from home during select weekend shifts ($200/8hr shift +$25/call) to answer consumer/patient video calls via PC, Mac or iPhone. Through various digital marketing campaigns, we will be redirecting consumers in your state seeking healthcare related information on Google, Bing or Yahoo to the PointNurse site for on-demand video consultations. We will be testing various positioning, fees and pricing scenarios.
Please contact us for more information:
Victoria Madden or Cyrus Maaghul
(917) 940-9943
www.pointnurse.com
info at pointnurse.com
www.linkedin.com/in/cyrusmaaghul
CE Opportunities
Twenty First Annual NWone Fall Conference & Meeting of the Membership
The Affordable Care Act as Opportunity: Advancing the Contribution of Nursing to the Public’s Health
October 1-3, 2014
Seattle Airport Marriott, SeaTac, Washington
Want to learn more about the impact and implications of the Affordable Care Act on nursing practice? Then this is the conference for you! NWone’s fall conference has a line-up of nationally recognized speakers who are experts in the areas of advanced practice nursing, health care workforce, nursing productivity and financial issues associated with labor costs, health care law and issues related to restraint of trade as we attempt to ensure that all nurses work to the top of their license. Speaker line-up includes:
Peter Buerhaus, PhD, RN, FAAN, a nationally recognized expert in the area of health care workforce and is a prolific researcher in the areas of both nurse staffing and the outcomes of Advance Practice Nursing.
Jack Needleman, PhD, FAAN, is the Professor of Health Services in the Department of Health Services at the UCLA School of Public Health. Jack is known for his research in the area of nurse staffing and the impact of nurse staffing on patient mortality.
Joanne Spetz, PhD, is an expert in labor economics, and has published on the impact of nursing ratios in the state of California.
Tara Isa Koslov, JD, is the Director of the Office of Policy Planning at the Federal Trade Commission and has worked through the FTC to promote fair and equitable competition within the healthcare industry.
Barbara Safriet, JD, is currently a Visiting Professor of Law for the Lewis & Clark Law School after serving as the Associate Dean for Academic Affairs at the Yale Law School. Her area of expertise is in Health Law & Policy and the Regulation of Health Care Providers.
David DeLong, PhD, is a Research Fellow at the MIT Age Lab. His research is focused on the organizational and personal challenges imposed by an aging workforce and is the author of Lost Knowledge: Confronting the Threat of an Aging Workforce.
Deborah Gardner, PhD, RN, is the Immediate Past Executive Director of the Hawaii State Center for Nursing and a member of the Editorial Board of Nursing Economic$.
Darcy Jaffe, RN, MSN, is the CNO and VP for Patient Care Services at Harborview Medical Center, a certified Advanced Practice Nurse and a local expert for mental health care and advocacy.
Eileen O’Grady, PhD, RN, is a certified adult nurse practitioner and a certified wellness coach. She is passionate about working with people interested in living a life that they truly want.
Additionally we will be presenting NWone’s launch of the CAP2 database into the northwest. CAP2 was developed by the Center for Advancing Provider Practices and is a new national database that examines organizational credentialing practices for both Advance Practice Nurses and PAs while also providing a toolkit with APN job descriptions, orientation tools, and credentialing process tools. We hope that you will be joining us for this great educational opportunity and also choose to attend our annual Legislative Boot Camp which is offered as a preconference. To view the full brochure and to register visit www.NWone.org or contact SarahS at wsha.org.
Pacific Northwest National Advanced Practice in Primary & Acute Care
October 9-11, 2014
Seattle Conference Center, Seattle, WA
This conference offers healthcare providers an opportunity to validate and enhance clinical competencies, acquire new assessment and management skills, examine critical issues in health care at the state and national level, foster a strong coalition of providers in advanced practice and learn about new products, services and pharmacotherapeutic agents. Conference faculty include distinguished national, regional and local experts. Concurrent sessions allow participants to design their own educational tracks in the areas of acute, adolescent, adult, family, geriatric, midwifery, pediatric, psychosocial and women’s health care. In addition, special interest group meetings on Thursday and Friday and workshops on Saturday provide a broad spectrum of learning opportunities for providers in all settings. Teaching methods include lecture, discussion, case studies, demonstration and practica.
For more information
Visit the Conference Details
Visit UWCNE on the web: www.uwcne.org
Register by phone: 206-543-1047
Email UWCNE for more information: cne at uw.edu
Limited exhibit space is available. Please contact Corie Goodloe at corie at uw.edu or 206-616-3826 or visit our Exhibitor Portal
Service Ads
Interested in Mentoring the Next Generation of ARNPs?
Pacific Lutheran University in Tacoma, WA is looking for preceptors in the south Puget Sound area for the Family Nurse Practitioner program. Your commitment requires a minimum of 1 day a week for a semester. We need preceptors Fall (Sep to Dec), Spring (Feb to May) and Summer (May to August) semesters. If interested, please contact Dr. Lorena Guerrero at guerrelc at plu.edu or call (253) 535-7374.
Meetings
Puget Sound Nurse Practitioners Association
Join us! Puget Sound Nurse Practitioners Association is a non-profit
organization supporting ARNPs in Puget Sound since 1998. We meet
every other month and offer a social hour/networking and a speaker presentation.
Annual dues are $60/$20 for students. $20 per meeting for guests. Apply for membership and find meeting information at http://PSNPA.org
West Sound Advanced Practice Association
Meets the second Thursday of the month. Meetings include networking/dinner/educational session. E-mail Fionafnp at centurytel.net for more information.
Photo of Month
Sunrise in South Africa. This yellow fever tree was believed at one time to cause yellow fever.
Ad & Publication Information
ARNP Care Ad Information
Copy deadline is the second Tuesday of the month prior to publication. Ads may be accepted later than this on a space-available basis. Position Available and Continuing Education Ads of less than 66 words are $45, of 66 to 130 words are $75, 131-180 words are $105, and greater than 181 words are $175. Position Available Ads are priced per insertion. Continuing Education Announcements are per offering for up to three (3) consecutive insertions. New Product Announcements per product for one insertion of 130 words or less are $75, more than 130 words are $175. Ad Inserts are $750 for one issue. All ads are subject to space limitations and editing. Call for detailed rate information. Mail copy to ARNP Care, 10024 SE 240th St, #230, Kent, WA 98031. Phone 253.852.9042. Fax 253.852.7725. Email care at nurse.net.
ARNP Care Editorial Board
Editors:
Robert T. Smithing, MSN, ARNP, FAANP
Madeline D. Wiley, MSN, ARNP, FAANP
Contributing Editors:
Nancy Lawton, MN, ARNP (President)
Louise Kaplan, PhD, ARNP, FAANP (Legislative Chair)
Production Staff:
Tracy Kiele, Managing Editor
Sarah Abid, Production Staff
NP Central, Publisher
Copyright 2014 NP Central
ARNPs United of Washington State
Website: www.auws.org
Facebook: facebook.com/ARNPsUnited
Email: au at auws.org
Address: 10024 SE 240th St, #230, Kent, WA 98031
p. 253.480.1035 f. 253.852.7725
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