Who can inject botox ? What are the state regulations for physicians, dentists, nurse practitioners, and nurses?
This is the second of a series of four blog posts interviewing Suzanne Jagger, CRNA, APRN, owner of Aura Aesthetics Med Spa and Aura Academy. Please see more about her in my previous post, How much can I make opening a botox business, or on her website at https://aura-academy.com/ . Suzanne openly and clearly provided so much insider information that anyone looking to get into this business would benefit from. Please read the next in the series How Much Should a Collaborating Physician Get Paid as well to cover all of the answers Suzanne provided.
What are the regulations for physicians and dentists injecting Botox™?
Who can practice and how? The answer to this question is shockingly complex. I spoke about it with Suzanne and here is what she said about physicians and dentists injecting neurotoxins and fillers:
“There are tiers of providers which dictate how a provider can practice. MDs can practice without restriction nationwide. For dentists, oral surgeons and naturopaths it is highly variable based on the state, but if they do have the ability to practice then they are for the most part like an MD and have carte blanche to practice however they want. Some states dentists can only inject below the jaw line-just therapeutic, not cosmetic injections. Very few states have clearly spelled out regulations for Med Spas in general dictating exact regulations.”
What are the regulations for nurse practitioners injecting Botox™?
This is such a grey area. I can speak from personal experience when I say, it is incredibly difficult to get a clear answer to this question! I spoke about it with Suzanne and here is what she said about APRNs (NPs, CRNAs, CNSs and Midwives) injecting neurotoxins and fillers:
“You see a lot of APRNs in this sphere. We need to take APRNs and break them up into NPs, CNSs, Midwifes and CRNAs. In most states NPs mostly work like MDs and have full practice authority. They are self-directed in most instances, aesthetics is in their scope of practice. That’s pretty universally the case. Clinical Nurse Specialists usually fall under the NP guidelines but not always. Then midwives and CRNAs are kind of the red-headed step children of the APRN world. Our ability to practice is highly variable and it’s a mess and there is no answer. In almost all instances there is no line item that specifically says CRNAs may do this in their scope of practice.
Where you have the most level of autonomy, like I do in Oregon, the state says that the practice of aesthetics is under the scope of APRNs. In states where CRNAs are classified as an APRN or an ARNP, depending on the nomenclature in your state, aesthetics fall in the scope of practice. You are going to find conflicting information all over the place because these governing documents are written at different times with different purposes. It is very frustrating for people.
To find out more info about your state, you need to go back to your Board of Nursing Scope of Practice document and it will define an NP is an ARNP or AANRP or whatever. Prescriptive authority is important. Most functional NPs have prescriptive authority. Maybe they need a physician for prescription privilege. So that is important because you can’t order your medications without that agreement with a physician-using their prescriptive authority to order.
CRNAs are considered APRNs in Oregon, therefore I have prescriptive authority in Oregon. I don’t bother getting a DEA # because I don’t use any controlled substances, since neurotoxin is not a controlled substance. I order my pharmaceuticals under my NPI #. You need to have some sort of prescriptive license on file to buy your (bo)tox, to buy your syringes, to buy your topical numbing, all sorts of things-that is a requirement. Your pharmaceutical rep is not necessarily going to be a good resource to help you navigate this as they are usually not familiar with CRNAs and what we do. Local pharmacies also are unlikely to know how to guide you in setting up ordering, etc.
How to get answers
There is lack of clarity on laws and people don’t want to rock the boat and they don’t want to get in trouble. That is a problem I find with getting people trained, is they don’t want to violate their scope of practice and I agree, I don’t want them to. And there is no place to find the answer without paying an attorney at ByrdAdatto which is the big med spa attorney group, which started AMSPA. They are very competent, but very expensive. And for a couple grand they will find out whether you can work or not, and most the time they will be able to say “it’s a grey area”. Since it doesn’t say a definitive yes, it’s a soft no, or since it doesn’t say definitively no, it’s a soft yes.
In some ways its simple- do you have prescriptive authority, yes or no? If you do, you provide your NPI number and go about ordering. If you don’t then you need to have an agreement with a physician or an ordering provider. Sometimes CRNAs can partner with an NP, often times not, but in states where they can that’s great.
If your state requires an ordering provider-then that physician needs to have a collaboration agreement. That does not necessarily mean a Medical Director. That has a different meaning. There is a very legal definition for that. A medical collaborator agreement might be all you need-you are just using her prescriptive authority. That level of involvement and risk is much lower. So, compensation is less.”
(See my post the difference between a Physician collaborator and Medical Director).
What are the regulations for nurses injecting Botox™?
This is one area where the rules don’t seem to line up with what is often happening in practice. Whether we are talking about a big med spa or a nurse running a mobile aesthetic injection business. Here’s what Suzanne said when I asked her about RN practice regulations:
“RNs, LPNs, and MAs (in some states) can only inject neurotoxins and dermal fillers under direct supervision of a physician or some states NP or PA. There are some nurses out there who are running in their own Botox™ side business, but legally they need a MD or possibly a NP or PA seeing the patient and creating a detailed treatment plan while on-site. Having a MD involved at this level becomes cost-prohibitive to making any profit. Most often RNs are paid an hourly rate to work in an office or med spa setting. “