Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A nurse practitioner is newly licensed to practice. Which of the following best describes the NP's ability to prescribe controlled substances?
A. Any nurse practitioner who meets state-level requirements for a license to practice is able to prescribe controlled substances.
B. NPs are significantly restricted from prescribing controlled substances nationally. C. NPs are able to prescribe controlled substances with significant physician oversight.
D. Controlled substance prescribing authority for NPs is regulated at the state and national level.
The correct answer here is D. Controlled substance prescribing authority for NPs is regulated at the state and national level.
Where should you start with a question like this? First, determine what kind of a question it is. And this is a professional issues question because it's talking about our practice as nurse practitioners.
Let's take a look at some background information. In this brief scenario, the NP is reported to be newly licensed to practice. NP licensure is regulated at the state level, as each state has its own NP practice act. In contrast to RNs, where there are compact states where if you get a license in one place, it's like a driver's license, you can go practice someplace else. The nurse practitioner profession is truly in the infancy of compact licensure. Part of this is because the scope of these practice acts varies so much state to state, ranging from full practice authority to more restrictive practice. Prescriptive authority is part of the NP scope of practice and licensure. Prescriptive authority refers to the legal and regulatory authority for an NP to prescribe medications, including controlled substances. For the day-to-day medications that are not restricted or not scheduled, such as therapies for the treatment of diabetes, dyslipidemia, hypertension, antimicrobials, meds that we prescribe every single day, state-level prescriptive authority suffices. However, for controlled substance authority, application to the federal DEA is required for DEA licensure. And to be honest with you, this is one of the few parts of our practice that's regulated at the federal level is our controlled substance authority.
The DEA, or Drug Enforcement Administration, was established by the federal government in the early 1970s. The agency's origin arose in part due to the growing concern about prescription and recreational drug misuse. The DEA provides significant oversight to controlled substance authority for all health care providers who are eligible, including granting this authority. The DEA has oversight on NPs, PAs, DOs, MDs, dentists, the list goes on and on. Anyone who would be a member of a profession who can prescribe controlled substances.
The drugs and drug products that come under the Controlled Substance Act are divided into five schedules. Some examples are of these schedules are outlined below. And they are scheduled from 1 to 5, depending on the potential for misuse and or diversion. And I don't believe I need to spend much time discussing the significant problem that we have had in this nation with prescription drug misuse and diversion.
Anyway, back to the topic here. Schedule I medications: These are considered to have high abuse potential or diversion potential or considered to have no therapeutic use in clinical practice. These include LSD, heroin, cocaine. Interestingly, marijuana is included in this class, causing considerable confusion since cannabis use is legal in many states, but not at the federal level. And I'm well aware that there is considered to be a therapeutic use for hallucinogenics such as LSD.
But this is where schedule I sits. In other words, none of us in regular day-to-day practice have schedule I prescriptive authority, regardless of the letters after our names. So, one more time, NPs, DOs, MDs, PAs, etc., none of us have a schedule I prescriptive authority. Who has this? A handful of people who are usually involved in some kind of research and are using these substances in laboratory situations under highly, highly regulated situations.
Schedule II: These are medications of significant therapeutic benefit, but also misuse potential and diversion. This includes products like oxycodone, hydrocodone, and morphine. So, one more time, yes, we don't ever want to say nobody should get a product like oxycodone or morphine, something along those lines, because we do use those medications to treat post-operative pain, end of life pain. They still do have significant therapeutic benefit, despite the fact that often we hear about the terrible parts of opioid use disorder.
Schedule III: These are medications of potentially therapeutic use but perceived, though likely not actually, less diversion or misuse potential. This includes lower dose of codeine, benzos, and many stimulant weight products Suboxone used for opioid use disorder, as well as pain management, is also included in this schedule level.
By the way, just this as an aside, before you would ever consider prescribing codeine, make sure you know a lot about that medication because a significant percentage of the general population cannot biotransform that into an active metabolite that actually controls pain. So, I'm going to leave you to look that up on your own. I'll cover it for future program.
Schedule IV: Meds in schedule IV are considered to have less abuse potential than in schedule III. This includes some select skeletal muscle relaxers and some benzos, so the benzos can be III or IV.
Schedule V: Hardly any meds are in this class. One example is prescription cough medicine with small amounts of codeine.
All licensed nurse practitioners are eligible to obtain DEA licensure in all 50 states and the District of Columbia. I have to tell you, because I was there when this first started happening, when we first started to lobby a controlled substance authority, many, many, many decades ago. This represents a tremendous amount of work, literally decades of advocacy and lobbying by state and national NP organizations. In many states, such as my home state, where I hold my NP license, the state of Massachusetts, we have controlled substance prescriptive authority for schedule II through V as guided by state regulations in other states. The authority is unfortunately limited to schedule III through V.
Another really unfortunate issue: the federal government refers to nurse practitioners as well as a number of other APRNs who do have prescriptive authority and physician assistants as problematic term: mid-level providers. This is outdated terminology of unclear origin that inaccurately describes nurse practitioner practice. Again, let's have that discussion on another program because I could spend the rest of the day talking about that. With that as background information, let's turn our attention back to the question. The NP is newly licensed to practice. Which of the following best describes the NP's ability to prescribe controlled substances?
A. Any NP who meets state-level requirements for a license to practice is able to prescribe controlled substances. This is, of course, incorrect. State-level licensure often includes prescriptive authority. As I mentioned, for those non-controlled medications, but DEA authority is required for controlled substances. It’s an extra layer of licensure, if you will.
Option B: NPs are significantly restricted nationally from prescribing controlled substances. The good news is, after decades of work and in the face of considerable challenges, this answer is incorrect. NPs, in all 50 states and the District of Columbia, are able to obtain DEA licensure to prescribe controlled substances. But as I mentioned, it does vary state to state.
Option C: NPs are able to prescribe controlled substances with significant physician oversight. This is, of course incorrect, particularly in states where NPs have earned full practice authority, physician oversight is not required.
What's then our correct answer? D: Controlled substance prescriptive authority for NPs is regulated at a state and national level. This is the correct answer, of course, as with all health care providers with prescriptive authority, including NPs, DOs, PAs, MDs, our ability to prescribe controlled substances is regulated at both the state and national level.
Key takeaway: While graduating from your NP program represents a great accomplishment, there are many steps prior to being able to practice. These include NP certification, state licensure, and prescriptive authority. Once all of those are in place, obtaining DEA approval or a controlled substance authority, is the next step.
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