CRNAs can build careers in nonsurgical pain management, treating chronic and acute pain outside the operating room. The field has its own NBCRNA subspecialty credential, the NSPM-C, and since the rules changed for 2027 the main entry path runs through an accredited pain fellowship.
Scope depends heavily on your state, so the same skill set supports a full interventional practice in one state and a limited one in another.
Key points
- From 2027, new NSPM-C candidates need a COA-accredited pain fellowship.
- The NSPM-C documents competence; your state sets the actual scope.
- Rural, underserved markets are where CRNA pain practices thrive.
- Get your board of nursing's scope position in writing first.
What nonsurgical pain practice involves
Pain-focused CRNAs typically work in pain clinics, rural hospitals, and independent practices. Depending on training and state scope, the work includes:
- Evaluating patients with chronic pain and building treatment plans
- Image-guided injections: epidural steroid injections, facet and medial branch blocks, joint injections
- Radiofrequency ablation and, with advanced training, procedures like spinal cord stimulator trials
- Medication management, which raises its own DEA registration and state prescribing questions
- Coordinating with surgeons, physical therapy, and behavioral health
Rural areas are where CRNA pain practices matter most, because physician pain specialists concentrate in cities. Many CRNA-owned pain clinics exist for exactly that reason; if that is your direction, see how to start a CRNA group and the practice owners hub.
The NSPM-C credential
The Nonsurgical Pain Management credential (NSPM-C) is NBCRNA's voluntary subspecialty certification, established in 2014. It is accredited by the NCCA and ABSNC, the same bodies that accredit the core CRNA credential.
Verified details from NBCRNA:
- The exam is computer-based, 200 questions, with 240 minutes allowed. It is offered once a year at U.S. test centers. For 2026, applications run March 9 to September 17 and testing runs September 21 to October 30.
- Eligibility requires current NBCRNA certification plus the criteria in the NSPM handbook. Check the current handbook on nbcrna.com for the exact practice-hour and continuing-education requirements before you plan around them.
- The big change: starting January 1, 2027, first-time NSPM-C candidates must complete a COA-accredited post-master's pain management fellowship. NBCRNA names Texas Christian University and the University of South Florida as current options, with more programs expected as they earn accreditation.
- Maintenance moves to a longitudinal model from October 2026. Instead of a point-in-time assessment every eight years, NSPM-C holders answer quarterly NSPM knowledge questions inside the MAC Check dashboard and renew every four years in line with their MAC cycle.
The NSPM-C does not grant scope. It documents competence. What you may actually do is set by your state.
State scope variation
Pain management is where CRNA scope varies most. The spread looks like this:
- Broad-scope states allow CRNAs to practice interventional pain independently, including fluoroscopy-guided procedures and, in some, prescribing.
- Middle states allow pain procedures with physician collaboration, facility-level restrictions, or limits on specific procedures such as fluoroscopy use.
- Restrictive states have board of nursing opinions or statutes that keep chronic pain management effectively off-limits to CRNAs.
Medicare opt-out status affects supervision requirements for anesthesia services, but pain scope is a separate question answered by your state's nurse practice act, board opinions, and sometimes radiology rules about who may operate fluoroscopy.
Before relocating or building a pain practice, read your board of nursing's position statements directly and get the answer in writing. This is also a reimbursement question: payer policies on CRNA-performed pain procedures differ by state and plan, so verify enrollment and coverage before you count the revenue.
Training and fellowship paths
Until the 2027 rule, CRNAs entered pain practice through mentorship, workshops, and cadaver courses, then sat the NSPM exam once they met the practice-hour requirements. That window is closing.
The path now runs through formal training:
- COA-accredited pain management fellowships. Post-master's or post-doctoral programs built for CRNAs, currently at TCU and USF, combining didactics with proctored procedural training. These become mandatory for new NSPM-C candidates in 2027. See CRNA fellowships for the current list and how to compare them.
- Shorter courses and workshops. Ultrasound-guided and fluoroscopy-guided injection courses still matter for skill building and count toward continuing education, but they no longer substitute for a fellowship on the credentialing path.
- On-the-job development. Acute pain and regional anesthesia skills built in regular practice, such as block programs, are the usual on-ramp that makes a fellowship application credible.
Fellowships cost real money and usually a year or more of part-time study. Weigh that against the market you intend to serve. In a rural, underserved area with supportive state scope, a pain practice can justify the investment. In a saturated urban market with restrictive scope, it often cannot.
Do CRNAs need the NSPM-C to practice pain management?
No state requires it today. It is voluntary, but hospitals, payers, and malpractice carriers increasingly look for it, and it is the field's recognized competence standard.
Can CRNAs do interventional pain procedures?
In many states yes, with training. The specific procedures allowed, supervision rules, and fluoroscopy authority vary by state, so check your board of nursing in writing.
What does the NSPM-C require after 2026?
Current NBCRNA certification, the handbook's eligibility criteria, and from January 1, 2027 a COA-accredited pain fellowship, then the annual 200-question exam.