The number of states that prohibit nurse practitioners from prescribing controlled substances (CS) has shrunk to a mere handful. But among the remaining holdouts, opposition continues to loom. When asked about the status of prescribing authority in Missouri, Beth Lonberger, NP, chairwoman of the Missouri Nurses Association's Advanced Practice Special Interest Group, replied that NPs were seeking CS rights but had strategically limited their campaign to schedules III through V. "You know how dangerous it would be," Lonberger mused sarcastically, "if we could prescribe Ritalin and such."
Nurse practitioners have come a long way since the profession's establishment 40 years ago, but prescribing barriers continue to frustrate many. NPs are encountering various obstacles to full scope of practice that state legislatures are slow to tear down - in most cases, because they are swayed by organized medicine. These obstacles include: lack of written prescriptive authority in Georgia, prohibition against CS prescribing in five states, and vastly differing and convoluted prescribing laws across the country that complicate prescribing across state lines. If that weren't enough, NP names are being nixed on the labels of drugs they've prescribed, and some pharmaceutical companies are requiring NPs to sign medication sampling forms that minimize their scope of practice and authority.
If the past is any indication, the NP profession will overcome these obstacles in time. Until then, NPs are arming themselves with a strong sense of purpose (and a healthy sense of humor) as they work to make the national practice landscape a more even one.
Georgia Stands Alone
Georgia continues to distinguish itself as the only state that prohibits nurse practitioners from signing prescriptions. Although Georgia NPs can call in prescriptions to pharmacists under a collaborating physician's name, the lack of written prescriptive authority still hampers patient care, says Lenda Dillard, NP, founding member of United Advanced Practice Registered Nurses (UAPRN) of Central Georgia. Because of the prescribing obstacle, patients must wait until NPs have time in between appointments to phone in orders; if they prefer written prescriptions, patients have to wait until a physician is available to sign an NP's order.
The antiquated law has influenced the number of nurse practitioners willing to work in Georgia. Debra Fingles, NP, of Warner Robins, Ga., says she knows of a handful of NPs who deliberately steered clear of the Peach State when their families were considering moves.
Georgia NPs have tried for more than a decade to obtain the basic prescribing rights that apply to their colleagues across the country, but the Medical Association of Georgia (MAG) continues to block legislative efforts. "I once had a conversation with the president of MAG, and his whole philosophy is that every other state in the union is wrong," says Fingles, who wrote prescriptions without incident during her NP practice in the military from 1991 to 2002.
With MAG's opposition, convincing legislators to update state prescribing law has been a challenge. But NPs have been encouraged by patients who lobbied lawmakers with some 1,900 postcards calling for NPs to be granted "the right to write." UAPRN of Central Georgia plans to continue grassroots efforts with billboards, TV commercials and bus signs that promote NP care, as well as by sending NP-written articles to local newspapers.
"I'm embarrassed that our medical community and our legislators can't see what an injustice they do to the public by not allowing us to write prescriptions," Dillard says. "It's frustrating. I'm planning on retiring in a couple of years, and I probably will practice in another state - just because I need the break."
Prescribing authority continues to be limited to nonscheduled drugs for nurse practitioners in five states: Alabama, Florida, Hawaii, Kentucky and Missouri. Texas removed itself from the shrinking group of controlled substance holdouts in 2003 when its Legislature granted NPs the authority to prescribe from schedules III through V. Years of NP negotiation with the Texas Medical Association, along with the legislators' desire to catch up with rest of the country when it came to NP practice laws, helped spur the passage of the CS bill.
California nurse practitioners initially earned controlled substance rights in 1996, and in 2003 the state Legislature expanded that authority to include schedule II. In 2004, South Carolina nurse practitioners added schedules III through IV to their prescribing palette.
Recent CS authority pursuits in other states haven't been as victorious, but nurse practitioners aren't giving up hope. Last year in Kentucky, state representatives passed HB 595, which would have granted nurse practitioners the authority to prescribe medicines on schedules II through V. A companion bill died in a Senate committee, however, replaced by a resolution to study NP prescribing in other states. The initiative marked the first attempt by nurse practitioners to gain controlled substance prescribing rights in Kentucky.
"It wasn't a total wash, and we're expecting to come back to the Legislature with another bill," says Shala Wilson, NP, president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives. "We think we will be successful in 2005."
Nurse practitioners in Missouri and Florida are also hoping the new year will bring CS success. A bill to allow NPs to prescribe from schedules III through V died last year in the Missouri Senate, but nurse practitioners plan to introduce a similar bill this month, according to Lonberger. And in Florida, the death of SB 2072 last year marked 8 years of legislative and regulatory effort by NPs to obtain CS authority. Anyone remotely familiar with Florida NPs' determination knows that the group isn't about to back down, though. According to Roger Green, NP, president of the Florida Nurse Practitioner Network, NPs will "absolutely" bring the matter to the Legislature in 2005.
Hawaii nurse practitioners were hoping a rule change would allow them to prescribe controlled substances, but the Board of Medical Examiners has been reluctant to approve changes to its formulary for NPs. In Alabama, the battle for CS authority has been put on the back burner while nurse practitioners there focus on obtaining direct reimbursement from private health plans.
Despite their legal authority to prescribe, NPs in many states are finding that their names are being replaced by the names of their collaborating physicians on printed prescription labels. NP-physician name swaps, which occur at the pharmacy level, have been reported to ADVANCE by readers in Alabama, Kentucky, Nevada, New Jersey and Texas.
"The primary problem is if a patient has a question about the prescription and calls the physician whose name is on the label, the physician may not be familiar with the patient and won't have the information to best answer a question," Wilson says. "The nurse practitioner who prescribed the medication in the first place is in the best position to help the patient." NPs also say that patients become confused when they see unfamiliar provider names on labels and worry that their prescriptions have been filled incorrectly.
In states such as Alabama and Kentucky, name substitutions on labels seem to be linked to the lack of controlled substance authority - and DEA numbers - for nurse practitioners. "Pharmacists are telling us that a lot of the pharmacy and insurance software is set up to identify providers by DEA numbers," Wilson says. "And if they put in a dummy number or use our license number, the computer won't accept it because the numerical sequence isn't right."
DEA guidelines prohibit pharmacists from requiring a provider's DEA number for any prescribed medication other than a controlled substance, says Carmen Catizone, RPh, executive director of the National Association of Boards of Pharmacy. But that doesn't mean that pharmacists are likely to stop using DEA numbers anytime soon. Insurance company software is set up to require a DEA number to identify providers, and when the Kansas Board of Pharmacy ruled that pharmacists could no longer require DEA numbers for non-CS prescriptions, "the community of prescribers and pharmacists went ballistic," Catizone says. "They overturned the board's regulation."
The issue? Without a DEA number, insurance companies have no way to identify providers and will reject the prescription, forcing patients to pay out of pocket for medication, Catizone explains. The DEA has since agreed not to enforce the guideline restricting DEA number use to controlled substances until the Centers for Medicare and Medicaid Services has established universal provider identification numbers (UPINs) for all prescribers. "When the UPIN becomes available, the insurance and software companies will have to change over to that, and there shouldn't be a problem with DEA numbers," Catizone explains.
In the meantime, some pharmacists have found ways to work around the software to ensure that NPs' names are on labels. "Some of them make a point of printing the labels separately, but it's time consuming for them," says Nancy Turnham, NP, past chairwoman of the Alabama Advanced Practice Council. "We have a congenial relationship with the pharmacists, and they try to help."
Whether over the phone or on the prescription pad, nurse practitioners in all states can order nonscheduled drugs for patients and rest assured that the local pharmacy will fill the prescription. Problems can arise, however, when patients use mail-order, Internet or brick-and-mortar pharmacies located in other states. Because the rules regulating NP prescribing vary significantly from state to state, pharmacists who receive an out-of-state prescription written by an NP sometimes refuse to fill it because they are unsure of the rules in other states.
In Washington state, law currently prohibits pharmacists from filling prescriptions written by out-of-state nurse practitioners. ARNPs United, the state's NP association, sought to rectify the situation in 2003 by introducing legislation that would simply add nurse practitioners to the list of out-of-state providers whose prescriptions can be filled. With the backing of the state board of pharmacy, several pharmaceutical companies and some mail-order and Internet pharmacies based in Washington, ARNPs United expected little resistance. Then the state pharmacy association came forward and opposed the bill.
"Its complaint was that there was no easily accessible national database of the prescription-writing laws governing NPs," says Marty Couret, NP, legislative committee chairman for ARNPs United. "Rather than fight a battle we could not win, we decided to table it."
In written testimony submitted to the Federal Trade Commission in 2002, Westley Byrne, NP, of Philadelphia, and Harriet Hellman, NP, of Water Mill, N.Y., documented the trouble that NPs have getting prescriptions filled by out-of-state mail-order and Internet pharmacies. But little has occurred on the national level since then to improve the situation.
As it stands, deciding whether a nurse practitioner's prescribing authority will be recognized depends on the local board of pharmacy in the state where the prescription is to be filled. Says Catizone, "If the prescribing authority of nurse practitioners were uniform across all the states, there wouldn't be an issue."
Sample Enrollment Forms
The lack of uniform prescriptive authority rules and regulations - and confusion surrounding a 1987 law that addressed drug sampling - is behind another prescribing-related annoyance that nurse practitioners across the country continue to encounter: "delegation of authority" or "prescription sample enrollment" forms.
The forms surfaced a few years ago as pharmaceutical companies scrambled to comply with the Prescription Drug Marketing Act (PDMA) of 1987. The act, which went into effect in 2003, requires pharmaceutical companies to verify a provider's prescriptive authority before providing medication samples. Nurse practitioners object to the forms for two reasons: They use language that could be detrimental to NP practice, and they do not comply with federal law.
Terms such as "delegation" "supervision" and "collaboration" are common on the sample enrollment forms, despite the fact that NPs in many states practice independently. Experts warn that NPs who sign forms stating their practice is less autonomous than it actually is could provide ammunition for supporters of more restrictive NP scope of practice.
Nurse practitioners also point out that PDMA rules require pharmaceutical companies to verify the prescriptive authority of the prescriber with the appropriate state authority - not another provider. "Under the PDMA, a collaborating physician can't confirm for a pharmaceutical company that I'm compliant with the law, only the board that regulates my practice and licenses me can do that," Byrne says. In Pennsylvania, the state Board of Nursing regulates NP practice, and anyone interested in confirming an NP's practice and prescribing licensure can do so online at www.licensepa.state.pa.us. By meeting with representatives and directing them to the licensure verification site, Byrne convinced Astra Zeneca and Merck to do away with sample enrollment forms in Pennsylvania.
Nurse practitioners in New York and Florida have also reported success in convincing pharmaceutical companies to drop the forms after directing them to Web sites where NP licensure can be verified online.
After trying to work with pharmaceutical companies on a national level to convince them to drop the forms in all states, the American College of Nurse Practitioners has determined that, with the varying rules for prescriptive authority and methods for verifying licensure, a local approach is indeed best.
"In my personal opinion, until we can develop a uniform scope-of-practice statement for the nation, uniform standards for education and for practice, and a uniform credentialing process, we will continue to have problems with this and other issues," says Cathryn Wright, NP, ACNP state affiliate representative.
Jolynn Tumolo is the managing editor. Reach her at firstname.lastname@example.org.
Prescribing-Related Obstacles Encountered by NPs
lack of written prescriptive authority for NPs in Georgia
lack of controlled substance authority for NPs in Alabama, Florida, Hawaii, Kentucky and Missouri
physicians' names on medication labels for drugs prescribed by nurse practitioners
pharmacists' refusal to fill prescriptions written by out-of-state nurse practitioners
"prescription sample enrollment" forms that inaccurately reflect NP scope of practice and authority
What Drug Companies Don't Know Can Hurt You
When a physician's name appears on the label of an NP-written prescription, the potential harm goes beyond incorrect contact information and confused patients. Incorrect labeling affects pharmaceutical company budgets that pay for marketing campaigns and advertising as well as free prescription pads, drug detailing and samples. It also affects spending on sponsorships for NP professional meetings and continuing education events.
It all comes down to money - and the data to back up spending that money. When NP prescriptions are attributed to physicians, pharmaceutical companies overestimate the extent of physician prescribing and underestimate the value of NP prescriptions. According to the data, it's safe and prudent to ignore nurse practitioners.
So how do drug companies learn who is prescribing? The data collection process begins when a pharmacist fills a prescription. Carmen Catizone, RPh, executive director of the National Association of Boards of Pharmacy, explains that to get reimbursed by a patient's insurance plan, the pharmacist enters the health care provider information into a database that tracks the information insurance companies need for reimbursement. The software almost universally requires a DEA number, even if the prescription isn't written for a controlled substance.
If the prescription was written by an NP who doesn't have a DEA number, the pharmacist often takes the path of least resistance and enters an associated physician's number. And even when the prescribing NP has a DEA number, some programs automatically fill "Dr." or "MD" into the data.
According to Catizone, pharmacists are prohibited from sharing this confidential information with pharmaceutical companies. But once personal identifiers are removed, pharmacists may supply the data to companies that compile and analyze health statistics and in turn sell these analyses to other market research firms and pharmaceutical companies. NPs can get lost in the analyses if the statistics don't distinguish them from physicians.
But do NPs, when properly counted, write enough prescriptions for pharmaceutical companies to take notice? According to the results of a 2004 American Academy of Nurse Practitioners member survey, almost 97% of NPs prescribe pharmacotherapy, and almost 65% are authorized to prescribe at least some controlled substances. In 2004, they wrote a mean number of 19 prescriptions per day. That's about 1.5 million prescriptions written by NPs per day.
Pharmaceutical companies that miss those prescriptions are losing money, says Roger Green, NP. Green pitched the potential value of NP prescribing to drug company executives when he led a panel discussion on strategies for marketing to nurse practitioners at the Pharmaceutical Marketing Congress in September. Green told participants that from a percentage standpoint, NPs prescribe more antibiotics and pain medications than primary care physicians do. And since NPs spend more time with individual patients than doctors do, patients don't leave their offices with undiscussed ailments - providing opportunities to prescribe multiple medications.
NPs are particularly receptive to pharmaceutical company efforts to track them, Green emphasized. As president of Florida Nurse Practitioner Network, Green led the fight in that state to get NP names on medication bottles.
"We're expecting to finally get some solid data that captures NP prescribers in the state," Green told ADVANCE. "I wish all states had laws that require the prescription to have the NP's name on the label. Think of the great data we would have!"