Prescriptive Authority for Nurse Practitioners
The physician shortage in primary care, plus the growth of nurse practitioners and increasing need for access to health care, creates a necessity for more autonomous nurse practitioners. However, current restrictions on nurse practitioners, particularly prescription regulations for controlled substances, limit what practitioners can do for patients. These restrictions also increase wait times for patients and have the potential to increase liability claims as physicians prescribe medications for patients they have not adequately evaluated. Nurse practitioners have proven to be a safe, quality, and cost saving approach to primary care. To meet the growing needs for patients, nurse practitioners must have the ability to prescribe controlled substances in all 50 states.
The passage of the Affordable Care Act (ACA) will provide many more Americans access to health care. The ACA will reduce the cost of receiving health care, while also enabling uninsured Americans access to insurance and more affordable healthcare. The Act will "promote prevention, wellness, and the public health" (Legislative Counsel, 2010, p. 463). Although the ACA will increase accessibility to primary care and prevention of diseases, there must be an adequate number of healthcare providers who can see these patients. The Association of American Medical Colleges estimates a shortage of 46,000 primary care physicians by the year 2025 (Rouston, 2010). Nurse Practitioners can easily step into the role of primary care. There are currently 150,000 nurse practitioners in the United States, and 5,500 practitioners graduate every year (Rouston, 2010). State legislatures, however, regulate Advance Practice Registered Nurses (APRN), and only 12 states currently have no restrictions for APRN prescriptive rights (Future of Nursing, 2011). For APRNs to fully care for patients at the primary care level, state legislatures must remove prescriptive restrictions throughout the United States.
Nurse practitioners can and should help fill a void in providing primary care. As mentioned earlier, only 12 states currently allow nurse practitioners to prescribe medications without restriction; whereas the other 38 states require physician collaboration or restrictions on controlled substances (Future of Nursing, 2011). Patients routinely visit their family practice providers with concerns such as a sore throat, backache, or anxiety. The nurse practitioner is adequately trained, has completed a national certification examination, and possesses a license to care for these issues. However, only in certain states can these APRNs prescribe the necessary treatment for these patients. The practitioner may not be able to fulfill the need of the patient in states with stringent regulations limiting APRN prescription rights. In these states, the APRN must refer the patient to or consult with a physician to meet the patient's medical needs, thus delaying medical treatment. For example, a nurse practitioner in Florida caring for a patient with a persistent cough and sore throat cannot prescribe cough medicine with codeine for the patient's comfort (Nursing License Map, 2012). Therefore, the patient must see a physician to obtain a prescription for relief from a sore throat and cough, which both delays treatment and increases health care costs associated with a second visit.
Patients will benefit from minimizing restrictions on prescription authority. Not only will patients have greater access to health care with less wait times; but patients will also benefit from continuity of care. This benefit is especially true in rural areas of the United States, where an even greater shortage of primary care physicians exist (Anguita, 2011). Another problem with the prescription restrictions for controlled substances is that nurse practitioners can care for patients receiving these medications but cannot adjust or prescribe the medications. For example, a patient with generalized anxiety disorder takes Xanax, a controlled substance, and visits her nurse practitioner for a physical examination. The nurse practitioner must take into account the effects Xanax has on her patient; however, she is not allowed to write for or adjust this medication. Furthermore, nurse practitioners have authority to prescribe significantly more dangerous medications. In the state of Florida, for instance, a nurse practitioner may prescribe a potassium replacement or Coreg, a cardiac medication. These medications, if taken inappropriately, can have fatal effects on the patient, such as lowering the patient's blood pressure or causing a fatal cardiac arrhythmia. To allow the ARNP the right to prescribe such dangerous medications but limit the use of controlled substances is not logical or appropriate (The Florida Senate, 2008).
Nurse Managed Care Centers (NMCC) are prime examples of medical clinics that would benefit from lifting prescriptive authority constraints for APRNs. An NMCC offers primary care services, particularly in underserved and unemployed populations across the United States. These clinics promote wellness, disease prevention, and education for their patients. Three NMCCs exist in the state of Florida. Although most care centers have a collaborating physician who prescribes controlled substances, the physician's purpose at these clinics is also to collaborate with the nurse practitioners to maintain high quality care. This physician should not be hindered with his care because he prescribes medications the nurse practitioner cannot prescribe (Turkeltaub, 2004). Nurse Practitioners have consistently demonstrated they provide the same quality of care as physicians, but at a lower cost. In fact, in 2009, the average cost of a nurse practitioner visit was 20% less than a physician visit. The state of Massachusetts conducted a study to determine it could save 8.4 billion dollars over a 10-year period by increasing use of nurse practitioners. Patients who have greater primary care access to nurse practitioners will also benefit from cost savings associated with a reduced number of emergency room and hospital visits (The Cost Effectiveness, 2011). Unfortunately, this data does not account for the cost benefit of providing nurse practitioners full prescriptive authority. As it stands now, many nurse practitioners refer their patients to a physician for certain prescriptive needs.
Physicians are among the majorities that disagree with releasing the restrictions for controlled substances prescribed by nurse practitioners. In fact, according to an article by the Sunshine State News, The Florida Medical Association stated that, "the ability to prescribe controlled substances is limited to medical doctors for a reason: to protect patient safety. Physicians go to medical school to learn how to prescribe controlled substances safely and without interacting with other medications. ARNPs do not" (Derby, 2010, para. 9). A Fort Worth, Texas physician, Dr. Gary Floyd states that nurse practitioners should attend medical school and receive additional training if they wish to have more responsibility and function independently (Ramshaw, 2010). A study published in the Journal of the American Medical Association; however, proves the assumption that nurse practitioners cannot provide adequate care and prescribe controlled substances false. This randomized study was conducted among medical clinics in states where nurse practitioners and physicians have the same prescriptive authority. The study determines if the outcomes of patients receiving nurse practitioner care or physician care differs. At the end of one year, the study proved that patient outcomes were comparable and no significant difference existed between the care provided by nurse practitioners and physicians (Mundinger, Kane, & Lentz, 2000).
Another notable objection to granting nurse practitioners full prescriptive authority in all 50 states is the fear that doing so will increase liability claims. In a study done at the University of Central Florida, a researcher compared malpractice claims among physicians and nurse practitioners in states that allow full prescriptive authority and in those that have restrictions. The study researched malpractice claims from the National Practitioner Data Bank. In states where nurse practitioners have full prescriptive authority, including the ability to prescribe controlled substances, this study revealed that per 1000 nurse practitioners and physicians, the average rate of malpractice claims was seven claims per 1000 nurse practitioners and 234 claims per 1000 physicians (Chandler, 2010). Therefore, according to this study, the argument that increasing prescriptive rights for nurse practitioners would increase malpractice claims is not legitimate. In fact, according to an article by Kaplan and Brown (2004), liabilities may actually increase for physicians in states where the nurse practitioner does not have full prescriptive authority. Because of the restrictions, the nurse practitioner is not able to write for such medications as Ritalin for a child with Attention Deficit Disorder. Therefore, the physician may write prescriptions for patients with whom he may not be adequately familiar. (Kaplan & Brown, 2004).
In conclusion, with the expectation for nurse practitioners to appease the primary care shortage, these practitioners must be able to meet the needs of patients. Regulating the APRNs ability to order such controlled substances as Xanax or Ritalin will not only inconvenience the patient, but will also diminish continuity of care. Nurse practitioners are more cost-effective than physicians, while continuing to provide the same quality of care. Time and time again, patient satisfaction and respect for nurse practitioners is extraordinary. The appropriate action for state legislatures is to remove prescriptive restrictions permitting nurse practitioners to provide the care they were trained to provide.Last edit by tnbutterfly on Jan 7, '13
My name is Lacy Lewis. I have been a critical care RN for over 5 years and currently am attending graduate school for my Family Nurse Practitioner degree.
Joined: Jan '13; Posts: 1; Likes: 7Jan 4, '13All this is fine but we need to raise the bar for nurse practitioner education. Too many rushy, rushy programs involving inexperienced new grads.Jan 4, '13Quote from subeeSo far there are few residencies for new NP's. I have been prescribing for six years. Every year it gets easier. I think you learn enough in school to get started but you have to study a lot for a while.All this is fine but we need to raise the bar for nurse practitioner education. Too many rushy, rushy programs involving inexperienced new grads.
In psych, the only controlled substances I prescribe are clonapin and adder all. There are many drugs which have greater side effects and interactions. Everyone needs education on prescribing drugs of abuse.Jan 4, '13Respectful question, is there a reason you spelled klonopin and adderall in that fashion?Jan 4, '13Well written, Thank you for the thoughtful content and study citations. This is an intriguing topic and I appreciate your insight.
I agree with the poster above, there are too many programs taking too many RN's money and not giving them adequate preceptors and experiences to qualify them. In this way, I am afraid APRNs are short changing their future.Jan 4, '13For example, a nurse practitioner in Florida caring for a patient with a persistent cough and sore throat cannot prescribe cough medicine with codeine for the patient’s comfort (Nursing License Map, 2012). Therefore, the patient must see a physician to obtain a prescription for relief from a sore throat and cough, which both delays treatment and increases health care costs associated with a second visit.
Here is one point I find interesting. We already have health care providers (MDs/DOs) wast majority of whom trained and practice strictly within model of health care services which openly encourages over-testing and over-prescribing and who, by their wast majority, are opposed to using alternative/naturopathic therapies and have little experience in patients' teaching. Should nurses just become second-tier providers within the same model, especially if we already know that the system itself is broken (as evidenced by epidemic of over-prescribing and overusing of addictive painkillers, for just one example)?
In the above example, if patient complains on recent seemengly uncomplicated sore throat with cough, he/she probably shouldn't be prescribed codeine if "comfort" is the only one indication found during assessment. He, on the other hand, can significantly benefit from education about comfort non-medicinal measures (avoiding fumes/stopping smoking/air humidification/etc) and appropriate over-the-counter meds which can safely help him to cope with cough, and an APN/FNP is just the right person for doing this. On the other hand, if the patient has some special needs (like if he'd got a important speech to deliver and so absolutely must stop coughing to keep his job) or his symptoms do not react on treatment as expected, then he should be evaluated by a physician (or specialist mid-level provider) anyway and indications for codeine can be reconsidered.
While educational standards for advanced nursing practice should probably be raised, I really doubt that it must be done strictly within the allopathic model's framework.Jan 5, '13For the above pt I would likely not give Xanex since there are safer more effective meds for anxiety. But I do think NPs should be able to prescribe controlled substances. I always try non controlled first, try to get patient into psychotherapy, give addictive substances cautiously or not at all to known addicts. I have my own allgorisms for when I prescribe controlled substances and will require participation in therapy when possible. Other providers require drugs screens, counting pills, ordering one week at a time etc. and i always provide psychoeducation!Jan 5, '13Quote from PsychcnsI had a persistent cough for six weeks, self treated rigorously, finally went to my provider and two doses of cough medicine with codeine and I was cured- a five minute visit- of course APRN's should be able to prescribe cough medicine with codeine. It is part of the continuum of tools to treat a cough..For the above pt I would likely not give Xanex since there are safer more effective meds for anxiety. But I do think NPs should be able to prescribe controlled substances. I always try non controlled first, try to get patient into psychotherapy, give addictive substances cautiously or not at all to known addicts. I have my own allgorisms for when I prescribe controlled substances and will require participation in therapy when possible. Other providers require drugs screens, counting pills, ordering one week at a time etc. and i always provide psychoeducation!Jan 5, '13I actually see PAs taking the primary care provider role in the future. In the military my primary care provider was a PA as is are most other Units. We see him or her first for whatever issues we may have. Then if lets say they feel we need a specialist like Oncology then they refers us, and they take it form there. As for pain issues the usual pain meds, physical therapy consult, splints, low duty, sutures, medications etc are all handled by the PA. Regular routine hospital visit stuff anyway.
I mean the MD primary care provider is based on the medical model. The PA is also based off of the same model, except that they only take 6 years to make. Makes sense to me. Its been a proven system for years. The framework is already there.Last edit by kalevra on Jan 5, '13Jan 5, '13I appreciate the OP sharing this article on allnurses.
Having said that, I would like to encourage readers to put the article in perspective. While only a minority of states have independent prescribing for NP's (17 per the NCSBN website at: https://www.ncsbn.org/2567.htm), NP's who practice outside of those states are not completely helpless in initiating drug therapy. All 50 states allow NP's to prescribe within protocols that include various levels of physician involvement. In most states, a collaborative agreement allows NP's to initiate drugs and monitor patient response during the course of the treatment without having to consult the collaborating physician each time. There are states where rules are more strict. Florida is probably by far one of the more restrictive states and this seems to be where the OP resides.
Controlled substance prescribing is another story. While the DEA, a federal agency, provides DEA licenses to NP's and PA's. Two states in the union do not allow NP's to prescribe controlled substances. It comes to no surprise that Florida is one of them (Alabama being the other). In Florida, both PA's and NP's can not prescribe controlled substances (Source: http://www.deadiversion.usdoj.gov/dr...p_by_state.pdf).
We've definitely had a long rocky course as far as achieving a goal of uniformity in terms of NP training, core competencies, and scope of practice but for a profession that only arose since the 1960's, I think we've come a long way.Jan 5, '13Interesting that per the CDC, Florida has the highest per-capita sales for prescription pain killers - all prescribed by doctors, right? Hmm, maybe there's a lot of money to be made in writing these prescriptions, and that is more the issue here? CDC - State Rates - Unintentional Poisoning Policy Impact Brief - Home and Recreational Safety - Injury CenterJan 6, '13I had wondered the same thing. I thought maybe this person meant clonidine (catapres), however that is a cardiac med not a psych med. Still makes you wonder.
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