Prescriptive Authority: A National and State Perspective

1. Prescriptive Authority:A National and State Perspective JoAnne M. Saxe, RN, MS, ANP Clinical Professor Updated: November, 2005

2. Objectives • Describe how prescriptive authority for advanced practice nurses is regulated nationally, • Identify basic requirements for prescriptive authority for advanced practice nurses from a national perspective, • Define furnishing/ordering and dispensing as described in the CA. Nursing Practice Act, • Determine when CNMs and NPs may furnish/order drugs or devices, and • List limitations of furnishing/ordering privileges by CNMs and NPs.

3. Prescriptive Authority Regulation • Credentialing/licensure occurs at the state level. • May be regulated by the Board of Nursing, Board of Pharmacy, or a triad of Boards (Nursing, Pharmacy and Medicine) Hamric, Spross, & Hanson (2005)

4. Prescriptive Authority: Basic Requirements for Most States • Graduation from an approved master’s-level advanced practice nursing program • Licensure/recognition in good standing as an advanced practice nurse (APN) • National certification in an APN specialty • A recent pharmacotherapeutics course • State prescribing and national Drug Enforcement Administration numbers in some instances • A pharmacy formulary • Ongoing CE hrs. in pharmcotherapeutics to maintain prescribing status Hamric, Spross, & Hanson, 2005, p.791

5. Summary of Advanced Practice Nurse (APN) Legislation: Prescriptive Authority(Phillips, 2005) • Full and independent prescriptive authority • CNMs- AK, AZ, DC, IA, ME, MT, NH, NM, UT*, WA, WY • CNS- AK, DC, IA, MT, NH•, UT*, WA•, WY • NPs- AK, AZ, DC, IA, ME, MT, NH, NM, OR, UT*, WA,WI, WY • Psych./Mental Health CNS only *Schedule IV and/or V controlled substances only

6. Summary of APN Legislation: Prescriptive Authority(Phillips, 2005) • Prescribing (including controlled substances) with some degree of physician involvement • CNMs- AR, CA, CO, CT, DE, GA†, HI, IN, KS, MA, MD, MI, NC, ND, NE, NY, OH, OK, PA, RI, SC*, SD, VA, VT, WI, WV • CNS- AR, CO, CT, DE, GA†, HI, ID, IL, IN, KS, MA•, MI, MN, ND, NJ, NY, OH, OK, RI•, SC*, VT•, WI, WV • NPs- AR, CA, CO, CT, DE, GA†, HI, ID, IL, IN, KS, LA, MA, MD, MI, MN, NC, ND, NE, NJ, NY, OH, OK, PA, RI, SC*, SD, TN, VA, VT, WV † State does not have written prescribing or dispensing authority; falls under delegated medical authority • Psych./Mental Health CNS only *Schedule IV and/or V controlled substances only

7. Summary of APN Legislation: Prescriptive Authority(Phillips, 2005) • Prescribing (excluding controlled substances) with some degree of physician involvement or delegation of prescription authority • CNMs- AL, FL, KY, LA, MO, MS, NV, TX • CNS- KY, LA, MO, NV‖, TX • NPs- AL, FL, KY, MO, MS, NV, TX ‖ Nurse psychotherapists with masters degrees

8. History of Prescribing by APNs in CA. • Early 1970's - Nurse Practice Amended. Overlapping functions with medicine pursuant to Standardized Procedures (SPs). • 1981 - Attorney general opinion: RNs could NOT prescribe, dispense or administer meds. via SPs. • 1982 - Prescribing and Dispensing Pilot Projects show NPs, PAs and Pharmacists prescribe safely. • 1983, 1984 & 1985 - Prescribing bills for the above providers were defeated.

9. History of Prescribing by APNs in CA.(continued) • 1986 - AB 4372 (Isenberg)- NPs could "furnish". • 1991 - AB 1350 (Vasconcellos)- CNMs can furnish. Sites where NPs and CNMs may furnish is expanded. • 1996 - AB 1077 (Hannigan)- NPs (only) may furnish controlled substances from category III - V. Site restrictions are discontinued. Current legislation does not allow NPs to apply for DEA numbers, however.

10. History of Prescribing by APNs in CA.(continued) • 1999 - AB 1545 (Correa)- NP's name on medication and device label as well as the M.D.'s name. Also, NPs may sign for sample meds. and dispense prepackaged meds. in their practices pursuant to a standardized procedure. • 1999 - SB 816 (Escutia)- Requires NPs who have a furnishing to obtain a DEA registration number to "order" controlled substances, schedule III-V. Also, furnishing is defined as being synonymous with the term "order[ing]" and can be considered the same as an order initiated by a M.D. • 2002 - CNMs may prescribe controlled substances.

11. History of Prescribing by APNs in CA.(continued) • 2002 – SB 1558 (Figueroa)- NPs and CNMs may sign for pharmaceutical samples. • 2003 – AB 1196 (Montanez)- NPs and CNMs may prescribe schedule II controlled substances. • 2004 – AB 2560 (Montanez)- Removal of all site furnishing restrictions and “essentially healthy” language. • 2004- AB 2660 (Leno)- A physician’s name and license is no longer required to appear on the prescription blank (Secure or Non-secure).

12. Furnishing /Ordering • Furnishing or ordering of drugs or devices is defined to mean the act of making a pharmaceutical agent(s) available to the patient in strict accordance with a standardized procedure. BRN (2000). Nurse Practitioners: Division 2…pg. 1

13. Standardized Procedures “Standardized Procedures is a term specified in the CA. Nursing Practice Act that refers to the legal mechanism designed to allow registered nurses to amplify their practice into areas traditionally considered to be within the realm of medical practice.” CNA (1984), pg. 1

14. PHYSICIAN SUPERVISION Furnishing/ [ordering] of drugs and devices by the authorized NP and CNM occurs under the supervision of a physician. Board approval of the supervising physician is not required. The physician may supervise a maximum of 4 NPs and 4 CNMs who are certified to furnish [order] drugs or devices at a set point in time... The physician supervisor is not required to be physically present...but must be available, at least, by telephone. BRN (2000). Nurse Practitioners: Division 2..., p.2.

15. Categories of Controlled Substances that may be Furnished/Ordered by CNMs & NPs • Category II: High abuse potential with severe psychic and/or physical dependence liability (e.g. morphine) • Category III: Some potential for abuse. Use may lead to low-to-moderate physical dependence or high psychological dependence (e.g., acetaminophen with codeine) • Category IV:Low potential for abuse. Use may lead to limited physical or psychological dependence (e.g., Restoril™) • Category V: Subject to state and local regulation. Abuse potential is low; a prescription may not be required (e.g., Lomotil ™)

16. Furnishing/Drug Ordering Limitations • The NP and CNMs may not furnish Schedule I controlled substances under the CA. Uniform Controlled Substance Act. • CNMs may order Schedule II controlled substances under the CA. Uniform Controlled Substance Act only in hospital-based settings. BRN (2000). Nurse practitioners: Division 2…p.3 & BRN (2002). Nurse midwives furnishing controlled substances

17. Dispensing by NPs and CNMs • Enables NPs and CNMs to dispense drugs, including controlled substances, pursuant to a standardized procedure or protocol in the following settings: • Licensed clinic classified as "community clinic" or "free clinic", • Any federally-operated clinic, • Any primary care clinic operated by the State of CA. or any of its cities and counties; and • Any “American Indian” health clinic. BRN (2000). Nurse practitioners: Division 2…, pg. 1 BRN (2001). Certified nurse midwives…pg. 2

18. SIGNING FOR SAMPLE MEDICATIONS NPs and CNMs [may] sign for the request and receipt of complimentary samples that have been identified in the standardized procedure…that has been approved by a physician. Figueroa (2002). Senate bill 1558

19. Required Documents • Standardized Procedures • Furnishing/Ordering Drugs and Devices • Furnishing/Ordering Controlled Substances • Dispensing • Signing for Sample Medications (See course resources for examples) • Drug and Device Formulary (See course resources for an example)

20. OTHER IMPORTANT INFORMATION • Prerequisites • Completion of clinical pharmacology course • Completion of a continuing education course related to furnishing schedule II controlled substances • Completion of 520 hrs. of a M.D. - supervised furnishing experience after completion of an approved N.P. and/or CNM program

21. OTHER IMPORTANT INFORMATION(continued) 2. Furnishing Application and Fee 3. Request for Schedule II CS Privileges 4. DEA Application and Fee 5. Standardized Procedures 6. Drug Formulary 7. Questions: • BRN: (916) 322-3350; www.rn.ca.gov • CANP, Government Relations: www.canpweb.org • CNA: (415) 864-4141; www.calnurse.org • CA Legislation information: www.leginfo.ca.gov

22. References Board of registered nursing (BRN) (1997). Standardized procedure guidelines, Sacramento, CA: State of CA. BRN (1998). Explanation of the RN scope of practice and nurse practitioner practice, Sacramento, CA: State of CA. BRN (2000). Nurse practitioners: division 2. Healing arts; Chapter 6. Nursing; Article 8. Nurse practitioners, Sacramento, CA: State of CA. BRN (2000). Nurse practitioners: new authority to provide medications, effective January 1, 2000, Sacramento, CA: State of CA. BRN (2001). Certified nurse midwives: New Authority to provide medications. Sacramento, CA: State of CA. BRN (2002). Nurse midwives furnishing controlled substances. Effective January 2002, Sacramento, CA: Stateof CA. BRN (2003). Criteria for furnishing number utilization by certified nurse midwives, Sacramento, CA: State ofCA.

23. References BRN (2004). Nursing Practice Act, Sacramento, CA: State of CA. BRN (2004). CE course for schedule II controlled substances furnishing by nurse practitioners, effective April 8, 2004,Sacramento, CA: State of CA. BRN (2004). 2003 Legislative Updates, Sacramento, CA: State of CA. BRN (2004). 2836.1 Furnishing drugs or devices. In nurse practitioner laws & regulations. Sacramento, CA: State of CA. California coalition of nurse practitioners (CCNP) (1996). The history of NP prescribing in California, Rx fornurse practitioners, Sacramento, CA: CCNP. California Legislature (1986). Assembly bill number 4372, Isenberg, Nursing, Sacramento, CA:State of CA. California Legislature (1991). Assembly bill number 1350, Vasconcellos, Nursing, Sacramento, CA: State of CA.

24. References (continued) California Legislature (1996). Assembly bill number 1077, Hannigan, Nursing, Sacramento, CA: State of CA. California coalition of nurse practitioners (CCNP) (1996). The history of NP prescribing in California, Rx for nurse practitioners, Sacramento, CA: CCNP. California Legislature (1986). Assembly bill number 4372, Isenberg, Nursing, Sacramento, CA: State of CA. California Legislature (1991). Assembly bill number 1350, Vasconcellos, Nursing, Sacramento, CA: State of CA. California Legislature (1996). Assembly bill number 1077, Hannigan, Nursing, Sacramento, CA: State of CA. California Legislature (1999). Assembly bill number 1545, Correa, Nursing, Sacramento, CA: State of CA.

25. References (continued) California Legislature (1999). Senate Bill number 816, Escutia, Nursing, Sacramento, CA: State of CA. California Nurses Association (CNA) (1984). Statement on the implementation of Standardized Procedures, San Francisco: CNA. California Nurses Association (CNA) (1987). Furnishing and Dispensing... San Francisco: CNA. Figueroa (2002). Senate Bill 1558, Sacramento, CA: Legislative Counsel’s Digest Government relations committee of the California coalition of nurse practitioners (2000). GR Update, March 2000, Santa Rosa, CA: CCNP Hamric, A.B., Spross, J.A., Hanson, C.M. (2005). Advanced practice nursing: An integrative approach, 3rd ed., pp. 688-689, Philadelphia: Harcourt. Phillips, S. J. (2005). Legislative update. The Nurse Practitioner, 30(1), pp. 14-47.