Definition/Introduction

Prescriptive authority is the ability of healthcare providers to prescribe specific medications, including controlled substances. Physicians of either Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) designations have the highest degree of prescriptive authority. MD and DO clinicians can prescribe medications, including controlled substances. In addition, physicians can prescribe Schedule II to V medications with a valid Drug Enforcement Administration (DEA) license. Other healthcare providers also have varying degrees of autonomy to prescribe medications but must undergo physician supervision or delegation. This article will discuss the increasing prescriptive authority of advanced practice providers and the overlapping role of physicians.

The first physician assistants (PAs) class was formed in 1965 and trained using an accelerated, two-year curriculum.[1] This new category of healthcare professionals was created as a novel solution to the physician shortage. All PAs are required to have some level of physician supervision; however, the relationship varies by state law. Some states also have restrictions on the medications that PAs are legally allowed to prescribe. The original graduate programs for nurse practitioners (NPs) were created in the 1960s to improve public access to pediatric care.[2] These advanced practice providers were similarly designed to address a growing physician shortage. Unlike their PA counterparts, NPs have broader prescriptive privileges in some states and do not require physician supervision. Nonetheless, certain states also prohibit NPs from prescribing controlled substances.

The PA and NP professions have increased in recent years.[3] Although there is a lack of literature describing the changes in PA and NP prescriptive authority, the scope of practice for both professions appears to have expanded over time and continues to evolve.[4] Advanced practice providers' progressively increasing prescriptive authority has occurred mainly through changing individual state laws. Therefore, improving the understanding of regulations surrounding advanced practice provider prescriptive autonomy will lead to better healthcare team dynamics moving forward.

Understanding the importance of Advanced Practice Registered Nurses (APRNs) is necessary. This classification includes Certified Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Certified Nurse-Midwives (CNMs). In response to the COVID-19 pandemic, the federal-level Centers for Medicare & Medicaid Services (CMS) took measures to alleviate certain constraints on APRN practice, ensuring that healthcare needs could be met effectively.[5]

Issues of Concern

In general, PAs can prescribe medications in collaboration with supervising physicians. However, specific states prohibit PAs from prescribing Schedule II controlled substances. As of 2010, PAs were allowed to prescribe controlled substances except for in Kentucky and Florida.[4] However, in 2016, Florida approved House Bill 423 to allow PAs and NPs to prescribe Schedule II-V drugs. One stipulation of HB 423 includes limiting the prescription of Schedule II substances to a 7-day supply. Other conditions include requiring continuing education to ensure the safety of prescribing controlled substances.

Georgia and Texas restrict PAs from prescribing Schedule II medications; however, they can prescribe Schedule III-V drugs.[6] Additionally, Arkansas and Missouri only allow PAs to prescribe hydrocodone combination products listed under Schedule II medications. Many other states have limited supplies that may be prescribed and dispensed. For example, PAs' prescription of Schedule II drugs is limited to a 30-day supply in Arizona, Illinois, Montana, North Carolina, Pennsylvania, and South Dakota. Certain states also restrict the ability of PAs to prescribe refills for Schedule II drugs by requiring supervising physician approval. Some states also require PAs to complete board-approved courses on controlled substances before they are allowed to prescribe scheduled medications.[4]

Some state laws also specify a formulary of drugs that PAs are unable to prescribe—for example, Florida Admin. Code R. 64B8-30.008 sets multiple stipulations for PA prescribing capabilities.[7] The Florida formulary does not allow PAs to prescribe general anesthetics or psychiatric medications for patients under 18 years of age. Other states with a restricted medication formulary include Georgia, New Mexico, Ohio, Oklahoma, and West Virginia. PAs' scope of practice laws is expanding, with prescriptive restrictions being lifted over time.[8]

State laws to determine NPs' prescriptive authority differ considerably. Some states allow the full practice of NPs where they may prescribe medications with a level of autonomy comparable to physicians. On the other hand, many states restrict NP prescriptive authority and require physician supervision. The American Association of Nurse Practitioners categorizes state practices into three divisions: restricted, reduced, and complete practice authority. Twenty-two states are classified as full practice where NPs have similar prescriptive authority to physicians. In 16 states, NPs have reduced authority and work alongside physicians in joint practice agreements. States with reduced prescriptive authority have varying limitations on medications that NPs can prescribe to patients. NPs are categorized as restricted in the remaining twelve states and require physician supervision or delegation when prescribing controlled substances. NPs have a broader scope of practice and fewer limitations on prescriptive authority than PAs, particularly in states that allow full practice.

NPs have the prescriptive authority to prescribe controlled substances in all fifty states. However, NPs cannot prescribe Schedule II medications in Georgia, Oklahoma, South Carolina, and West Virginia.[4] Furthermore, state legislation in Arkansas and Missouri restricts NPs to prescribing only hydrocodone combination medications listed under Schedule II. Notably, surveys have shown that many NPs have used strategies to prescribe controlled substances that were not strictly legal. These strategies included using pre-signed prescription pads, having a physician sign the prescription without consulting them, and prescribing scheduled medications without physician involvement.[9]

Notably, the passage of legislation allowing for greater prescriptive authority does not equate to uptake by advanced practice providers. For example, in 2001, Washington state passed laws to allow NPs to prescribe Schedule II-IV medications under a joint practice agreement with a physician. However, NPs were required to apply to the DEA to obtain the increased prescriptive authority. Surprisingly, only 60% of NPs submitted applications to prescribe Schedule II-IV drugs following the new law's implementation.[10] Reasons for the low uptake of expanded prescriptive authority included concerns about knowledge, questions regarding discipline by regulatory agencies, and concerns about working with patients with drug-seeking behaviors.

Some physician groups have expressed concern about advanced practice providers' increasing prescriptive authority. The current literature is mixed with differences in provider care concerning physicians and advanced practice providers. Certain studies have highlighted higher average opioid prescriptions written by NPs and PAs compared to physicians.[11][12] However, other studies have shown that the overall prescribing patterns of advanced practice providers are comparable to those of physicians.[13] One study found that PAs were slightly more likely to prescribe controlled substances to patients than physicians or NPs.[14] Moreover, researcher bias may contribute to the often opposing conclusions demonstrated in the literature.DEA Regulations by State

The prescription authorities for scheduled substances, varying by state, are outlined by DEA regulations and can be accessed through the provided link. It's important to note that this authority is subject to change. Therefore, prescribers should stay updated and adhere to the current guidelines to ensure proper and legal prescription practices.[See DEA Regulations by State]

Clinical Significance

Regardless of the specific prescribing patterns of different provider types, all providers must focus on patient-centered care. The growing PA and NP professions are essential to alleviate the burden of a physician shortage, especially in primary care settings.[15] In addition, employing advanced practice providers is a cost-effective means of supplying comparable health services to the public.[16] The Affordable Care Act has increased workload and patient demands for primary care, further necessitating the full utilization of advanced practice providers. Expanding the prescriptive authority of PAs and NPs is one mechanism to alleviate the increased healthcare needs of the public. 

The state-by-state legislation on advanced practice provider prescriptive authority continuously changes and expands. Given the current trends, it is likely that advanced practice providers will continue to have increasing prescriptive authority over time. Therefore, creating a dialogue between physician groups and advanced practice provider organizations can improve understanding of the attitudes towards increasing autonomy. Such discussions have shown that physicians and NPs have similar beliefs surrounding increasing prescriptive authority.[17] Both physicians and NPs were concerned for patient safety, and both agreed that most NPs understand when it is necessary to refer patients to a specialist. Interprofessional communication between different provider groups can enhance team performance while reducing polarizing beliefs.

Nursing, Allied Health, and Interprofessional Team Interventions

Risk Evaluation and Mitigation Strategies (REMS) are protocols that the FDA may mandate to confirm that the advantages of a drug outweigh its potential risks. Some examples of high-risk medications in the REMS program include clozapine, sodium oxybate, tolvaptan, and sufentanil.[18] These measures are instituted as interventions to safeguard public health.[19] Healthcare providers with prescribing privileges, such as physicians, physician assistants, nurse practitioners, and other qualified healthcare professionals (HCPs), play a crucial role in ensuring that products with serious risks requiring REMS are prescribed and used safely.[18]

Nursing, Allied Health, and Interprofessional Team Monitoring

Prescription Drug Monitoring Programs (PDMPs) are crucial in monitoring drug misuse. They enhance care consistency for prescribers, heighten awareness of controlled substance usage, and identify potential cases of "doctor shopping." This monitoring tool aids in making well-informed treatment decisions. For pharmacists, PDMPs identify at-risk patients, ensure continued access to essential medications, and receive alerts regarding prescriptions with potential illicit use. Additionally, PDMPs are instrumental in monitoring and recognizing irregularities in prescriber behavior, prompting further evaluation when necessary.[20][21]