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« Concierge Medicine | Main | Defamation via Twitter? Docter Files A $1 Million Suit In Oregon »
Wednesday
Sep212011

Can Nurse Practitioners Offer Botox?

By Carolyn Buppert, NP, JD

Can Nurse Practitioners offer Botox, Restylane, Juvederm and other cosmetic treatments on their own?

The answer to this question is going to be state-specific. Here are the steps to follow:

  1. Read your state's Nurse Practice Act section on scope of practice for nurse practitioners to answer these questions: What acts require physician collaboration or supervision? How is collaboration or supervision defined? (Boards of Nursing in the United States: State-by-State Web Links)
  2. Go to your state's Board of Medicine Websites and search for any policies on provision of botulinum toxin (Botox®). Note that botulinum toxin is a prescription medication, so a prescription or order for the medication must be written and someone must administer the drug. If your state has policies on botulinum toxin, note the requirements for prescription and administration. Some states consider administration of botulinum toxin a medical act, and some states consider it to be within the scope of a registered nurse. Prescribing is always a medical act.

    If you live in a state that requires no physician collaboration when nurse practitioners prescribe, then as long as the Board of Medicine has no requirements with respect to botulinum toxin, you are free to proceed with your practice idea. If your state requires physician collaboration in order for nurse practitioners to prescribe, then you'll need to line up a collaborator. In most states, the collaborator does not need be on site, but in some states, the collaborator must practice at the site with specified frequency. Follow the rules as they relate to any prescribing.

About: Carolyn Buppert, NP, JD is an attorney practicing in Bethesda, Maryland.

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Reader Comments (13)

I can not even imagine anybody learning all this material in a short time. They obviously have no idea as to what you have to go through to be prepared to do this work effectively. You have to consider the time it takes to get "hands-on experience" too. Particularly, on ALL areas of the body on all types of skin, on patients of various ages and different color skin using a number of different lasers. I have the background in biology, physics, and chemistry plus a number of years in the pharmaceutical industry where I obtained the pharmacology training needed to understand the use of dermatologic drugs and products needed to help patients with various skin problems, consequently, my perception of this is different than the average person in this industry. Due to the inability, lack of knowledge, or unwillingness of of state governments to enforce laws that are already on the books, most of the people in the Spa and beauty business have little or NO training, and minimal experience for the procedures they do. Virtyally NO STATE ISSUES A LICENSE TO BE A LASER TECHNICIAN.

I am glad to see doctors trying to get the training needed to do this work, however, as doctors they know what it is to go through a "specialty training" program. That is why I believe many questions presented here are NOT by doctors as they would not even ask where to get training. Laser use is SURGERY. All the laser procedures were invented by Plastic Surgeons and Dermatologists. Even electrolysis was invented by a doctor but it is boring and not as gratifying as treating patients with assorted problems so it was turned over to his nurse. As medicine advanced, more information was developed and it became obvious no doctor could learn it all, consequently, we have the development of SPECIALISTS. Medical schools developed training programs to teach the various subjects as they are associated with hospitals where a large number of patients could be seen and referred to the particular department that was equipped to handle these patients and make available to doctors in training the assortment of problems they could expect to see in the office. NO LASER TECHNICIAN IN THIS COUNTRY (U. S.A.) HAS AN ADEQUATE OR PROPER SUPERVISED TRAINING EXPERIENCE to be doing these procedures. The famous Massachusetts General Hospital returned money to patients who had laser hair removal treatments and now has a rule that only Board Certified Doctors or surgical residents under the direct supervision of a Board Certified doctor can pick up a laser wand to treat anybody for anything. They no longer do laser hair removal at this hospital as a matter of policy as patients come there from all over the world to be treated by Board Certified Doctors. If they can not provide this they do not do it.


I AM AMAZED AT HOW MANY DO NOT BELIEVE ME WHEN I TOLD THEM LASER PROCEDURES ARE SURGERY. THEY CHOOSE TO IGNORE THIS FACT BECAUSE OF THE MONEY THEY THINK THEY CAN MAKE. THEY ARE IN FOR A BIG SURPRISE, Any procedure that alters the structure or function of the area being treated is SURGERY. They will have to have the same malpractice insurance as a doctor. Since they have much less instruction and education than a doctor the insurance company will be taking a huge risk for which they have to be paid. I would not be surprised if they insist on more premiums as premiums are based on the RISK they are exposed to. The greater the risk.... the greater the premium.

10.13 | Unregistered Commenterlefty2g

I checked with a few lawyers who ALL AGREED THAT... FDA regulations and rules out rank local , or state, or county, laws when they are about the same subject. NO NURSE PRACTITIONER CAN LEGALLY INJECT anything unless under a doctors ORDERS. SHE IS NOT LICENSED TO MAKE A DIAGNOSIS or administer medication by injection except what her state specifically allow. She is NOT covered by malpractice insurance for anything other than what the license allows... but.since FDA says cosmetic SURGERY AND INJECTIONS MUST BE SUPERVISED by a doctor she is stretching the definition of her license. GOOD LUCK TO THE PEOPLE SHE TREATS.

03.26 | Registered Commenterlefty2g

I work out of Massachusetts and RN's can administer Botox with training.

06.1 | Unregistered Commentersg

The ans currently is yes they can in collaboration with a MD or DO. THe botox has to be perscribed.
There may come a time in the near future when the NP can work indempndently.

06.2 | Unregistered Commentergm

Doesn't it seem odd that there are so many different answers to a single question?

The reason for that is the fact that EACH state makes it's own regulations. If it is not policed that does not make it legal.
Why don't you ask your state authorities? Why is everybody beating this dead horse for so long? There are answers if you really want the scoop in your state as that is the only one that counts. What has to be done to make these people understand a simple answer to a very simple question?

06.5 | Unregistered Commenterlefty2g

It is possible, however, the NP will have to have malpractice insurance and if she is INDEPENDENT the cost wil be the same as for a doc because the risk is what they insure. IF the Nurse makes a WRONG DIAGNOSIS SHE IS LIABLE FOR THAT or any one of many possibilities regarding drug interaction and incompatibilities.
I would never want that responsibility unless I was a doc who was getting paid for it because a lot of the fee goes to insurance companies. If you charge less than a doc that does not mean the risk is less. They insure against risk. More risk means higher premiums. you never get the same instruction in your few years of instruction as a NP as a doc gets in all the years of his/her training. as a Doc. Who are you kidding? You are not kidding me.

IF it is good for the insurance company .. it is NOT good for you or me.

06.6 | Unregistered Commenterlefty2g

I work as a nurse injector in GA. We are under the supervision of physicians and they are around during injection days. Our MDs prescribe the dosing but we still do the injecting.

06.7 | Unregistered Commenter12ynes

To lefty--I think it is extra funny when people make completely false statements in ALL CAPS--as if you know what you are talking about! Obviously you don't know the first thing about a Nurse Practitioner, the role and responsibility. And then in a later post you say you inject and are only an RN... funny

09.25 | Unregistered CommenterREM

Yes. NP's can inject in some states independently.
It is important to discuss if your malpractice carrier will cover you or not.

09.29 | Unregistered Commentergm

I'm curious. Does anyone know of a single instance where a NP has gotten into any kind of trouble at all for administering Botox? I'm not aware of any at all and I'm assuming that NPs are performing something like 10-15% of all Botox treatments, at least in the US.

If anyone's aware of ANY blowback on a NP for injecting Botox or fillers, please post.

Dr Harold
In several states the NP can function independent of an MD, in other stated they need the collaboration. They can make medical decisions so can choose the dosage to deliver to each injection point.

I am not aware of anyone having a legal issue other than a few cited for Canadian product. My wife is an NP PhD who reviews malpractice cases fro NP's and they indeed are getting medical malpractice suits where it was basically unheard of seven years ago. There are some for botox but the botox was not the problem they were being sued for somehow injecting a nerve causing a neuralgia. Currently NP's are cited a majority of the time for pharmacological errors followed by injection complications and diagnosis errors to a much lesser extent

10.1 | Unregistered Commentergm

Injecting Botox is easy... so is injecting dermal fillers.... so is operating lasers... if you are experienced.

To inject, obviously one must meet the states' licensure requirements, but assuming a person meets those requirements, I would suspect people are much better off in the hands of an experienced injector over one who is not.

I inject approximately 60,000 units of Botox per year and I'm a PA. Would you rather come to me for Botox or a recently board-certified dermatologist who has only ever injected it a small handful of times?

Always a turf war, with people stressing degree over experience...

10.5 | Registered Commenterpacfl

It is amazing to me to find anybody still asking if it is legal to inject anything. This is not the proper place to ask that question. Why don't you go to your state authorities about that? The very fact that there are conflicting answers to a simple question means there are many who do not know if what they do is legal or not. You should know the answer before you open an office.

FDA says all these products are prescription items, therefore, you are not supposed to have them as you cannot write a script to obtain them. That is a Federal crime the same as posession of any prescription drug without a script including controlled substances. If you inject it you are liable as you are not supposed to posess it. If you commit a crime it is a police matter and you will have to pay a lawyer as no insurance will cover a crime. If it is a malpractice issue and you are being sued that is a tort case. There is always the possibility no lawyer will take the case because you can only be sued for damages and the procedures you do have very little permanent damages unless you include scars from burns due to poor treatments, therefore, there is very little money involved. Lawyers will not take a case if there is not enough money involved. If a client is persistent and is out for revenge you might lose your license. FDA has posted on the web the following (about lasers, all light emitting devices and electrolysis machines). "These devices are prescription devices that can only be sold to and used by those who are licensed to use them in the state where they are licensed." The original crime was committed by the companies who sold the devices to those who were not licensed.All devices made in a foreign country are not legal unless the FDA visited the companies to check manufacturing procedures (I have a friend who worked for, and traveled for, FDA to foreign countries to check them out.)

No insurance covers anything illegal. Even if the insurance companies sell the policy you will find there is a clause in all policies that covers them against illegal acts. What is worse than that is the fact any town, city, county, or state can make a law that is in effect in that particular area and you still may be in trouble whether or not the state allows it. Read your policy. FDA maintains all the drugs and fillers used are prescription items, therefore, you should not even have them.

10.5 | Unregistered Commenterlefty2g

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