Prescriptive Authority

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Chapter 1

Prescriptive Authority

Jacqueline Rosenjack Burchum DNSc, FNP-BC, CNE

Our purpose in writing this book is to prepare advanced practice providers to provide safe and competent medication therapy to patients. This role requires the ability to select, prescribe, and manage medications. In this chapter we examine issues surrounding prescriptive authority and how those issues affect this fundamental aspect of comprehensive patient care.

What Is Prescriptive Authority?

Prescriptive authority is the legal right to prescribe drugs. Full prescriptive authority affords the legal right to prescribe independently and without limitation. Physicians have full prescriptive authority. For nonphysician providers, the degree of prescriptive authority varies. Some have full prescriptive authority; however, for many, prescriptive authority is restricted. Limitations are generally tied to oversight by a doctor of medicine (MD) or doctor of osteopathy (DO) as part of the provider’s scope of practice.

Recall that there are two components of prescriptive authority: (1) the right to prescribe independently and (2) the right to prescribe without limitation. The provider who prescribes independently is not subject to rules requiring physician supervision or collaboration. The provider who prescribes without limitation may prescribe any drugs, including controlled drugs, with the exception of Schedule I drugs which have no current medical use.

Full practice authority is sometimes interpreted differently for advanced practice registered nurses (APRNs) and physician assistants (PAs) because supervisory requirements vary for the two professions. (See Box 1.1 for information on other professions seeking and obtaining prescriptive authority). PAs are required to practice and prescribe under the supervision of a physician. All PAs, including those in a solo practice, must have a supervising physician who can be reached by telephone or other means of telecommunication. (See Guidelines for State Regulation of Physician Assistants available at www.aapa.org/Workarea/DownloadAsset.aspx?id=795 for additional information.) If the PA-physician arrangement does not limit drugs that may be prescribed and if the law allows the PA to prescribe Schedule II to V drugs, the PA may enjoy a type of quasi-full prescriptive authority. Indeed, some have referred to this as full prescriptive authority; however, the issue of supervision still applies. Hence, PAs do not have the legal right to prescribe independently of a supervisory arrangement. Even for those in solo practice, there is always the possibility of dissolution of the PA-physician arrangement. In the event this occurs, the PA must affiliate with another physician or physician group in order to continue prescribing.

 

Box 1.1

Selected Professions Seeking and Obtaining Prescriptive Authority

APRNs and PAs are not the only professions concerned with prescriptive authority. The number of professions seeking to obtain or expand prescriptive authority has increased dramatically in the past decade. Here is the current status of a few of those:

Chiropractors: New Mexico approved the new title of “certified advanced practice chiropractic physician” to identify chiropractors with prescriptive authority. For additional information see New Mexico State Law Title 16, Chapter 4, Part 15 (16.4.15.7B) at 164.64.110.239/nmac/parts/title16/16.004.0015.htm.

Naturopathic doctors (NDs): Several states, including California, Hawaii, Oregon, and Maine, have given prescriptive authority to NDs. Pending legislative action is available at www.naturopathic.org/lac.

Pharmacists: California, Montana, New Mexico, North Carolina, North Dakota, and Oregon give pharmacists varying degrees of prescriptive authority. For additional information see www.nabp.net/news/tagged/prescribing-authority.

Psychologists: Illinois, New Mexico, and Louisiana have given psychologists limited prescriptive authority. See www.apapracticecentral.org/advocacy/authority.

Whether APRNs possess full prescriptive authority depends on their legal right to prescribe without a supervisory or collaborative requirement. APRNs are educated to practice and prescribe independently without supervision; however, some state laws require that they practice in collaboration with or under the supervision of a physician. In these situations, some physicians limit the types of drugs that the APRN can prescribe. State laws may place additional restrictions with regard to controlled drugs.

Table 1.1 provides prescriptive authority status for PAs and the four categories of APRNs—clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, and certified nurse practitioner. Information regarding the right to prescribe controlled drugs is available at www.deadiversion.usdoj.gov/drugreg/practioners.

TABLE 1.1

Advanced Practice Provider Prescriptive Authority by State

State Clinical Nurse Specialists (CNS) Certified Registered Nurse Anesthetists (CRNA) Certified Nurse Midwives (CNM) Certified Nurse Practitioners (CNP) Physician Assistants (PAs)
AL FA NA LA LA PL
AK FA FA FA FA PL
AZ FA LA FA FA PL
AR FA LA LA LA SR
CA ND NA LA LA PL
CO FA FA FA FA PL
CT FA FA FA FA PL
DE LA LA LA FA PL
FL NA LA LA LA SR
GA LA LA LA LA SR
HI FA FA FA FA PL
ID FA FA FA FA PL
IL LA LA LA LA PL
IN LA LA LA LA PL
IA FA FA FA FA SR
KS LA NA LA LA PL
KY FA LA LA LA SR
LA LA LA LA LA PL
ME FA NA FA FA SR
MD FA NA FA LA PL
MA LA LA FA LA PL
MI ND NA LA LA PL
MN FA FA FA FA PL
MS ND NA LA LA PL
MO LA LA LA LA SR
MT FA FA FA FA PL
NE FA FA LA FA PL
NV FA FA FA FA PL
NH ND FA FA FA PL
NJ LA NA LA LA PL
NM FA FA FA FA PL
NY ND ND LA LA PL
NC FA NA LA LA PL
ND FA FA FA FA PL
OH LA LA LA LA PL
OK FA LA LA LA SR
OR FA FA FA FA PL
PA NA ND LA LA PL
RI FA FA FA FA PL
SC LA LA LA LA PL
SD LA NA LA LA PL
TN LA LA LA LA PL
TX LA LA LA LA PL
UT FA FA FA FA PL
VT FA FA FA FA PL
VA NA NA LA LA PL
WA ND FA FA FA PL
WV FA LA LA LA SR
WI FA LA LA LA PL
WY FA FA FA FA PL
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