Updated February 17, 2017; September 19, 2018
What Is a Controlled Substance?
The United States controls certain substances because of their abuse potential.They are categorized based on the likelihood users will become dependent and whether or not the substance has a recognized medical use.
Substances in Schedule I (1) have no recognized medical use and are highly addictive.  With the exception of cannabis, these drugs are never prescribed for patients. Drugs in Schedules II (2)  – V (5) have a recognized medical use and are categorized based on the likelihood of causing drug dependence. Schedule 2 has the highest abuse potential and Schedule 5 has the least.
Listings of CSs in each schedule are available on the Drug Enforcement Administration’s Website. The Texas Controlled Substances Act (Chapter 481, Texas Health & Safety Code) requires the Commissioner of Health & Human Services to list the controlled substances that Texas identifies in each Schedule annually. Essentially these schedules are identical.
Limitations on APRNs & Physician Assistants (PAs) Prescribing CSs
Most APRNs and PAs in Texas have the following limitations on prescribing or ordering controlled substances (CSs) when properly delegated by a physician.
- Schedules 3, 4 or 5, Controlled Substances
- AÂ 90-day supply or a prescription with refills totaling a 90-day supply
- Physician must approve continuing the same CS for the same patient beyond the initial 90-days, and note the consultation in the patient’s chart
- Physician consultation required before prescribing any CS for children under 2 years without prior consultation with the physician, with consultation noted in the patient’s chart
APRNs and PAs may order or prescribe CSs in Schedule 2Â only when the APRN is facility-based and prescribing for patients admitted to:
- a hospital emergency department (This does not include any free-standing ER or urgent care, regardless of ownership.);
- a hospital in-patient unit with an intended length of stay of 24-hours or longer; or
- hospice.
While APRNs prescribing for these patients may technically prescribe Schedule 2 drugs, pharmacies outside the facility are not permitted to fill a prescription for a Schedule signed by an APRN or PA. In 2014, despite the plain language in the law, the Texas Medical Board (TMB) decided that the provision permitting physician delegation for Schedule II prescriptions only applied to filling prescriptions within the hospital or hospice.
Registration Required
For decades, Texas required any person prescribing, purchasing, or supplying controlled substances (CSs) in the state to have a Texas CS registration (CSR). This state registration was in addition to the federal CSR issued by the Drug Enforcement Administration (DEA). That changed on September 1, 2016.
In an action applauded by all health care providers, the 84th Texas Legislature (2015) triggered the demise of the Texas CSR by passing Senate Bill 195 amending the Texas Controlled Substances Act. On the law’s effective date, September 1, 2016, SB 195 eliminated the state’s CSR and transferred regulation of prescribing CSs to the Texas State Board of Pharmacy (TSBP).
Texas and U.S. law now only require those prescribing controlled substances to register with the U.S. Drug Enforcement Agency (DEA). This registration is commonly referred to as a DEA number.
Query Prescription Drug Monitoring Programs Before Prescribing
Most states, including Texas, have Prescription Monitoring Programs (PMP) . Pharmacists are required to report any CS prescription they fill for a Texas resident, regardless of whether the pharmacist filling the prescription is in-state or out-of-state. The pharmacist reports the patient’s identifying information and the prescriber’s DEA number.
The TSBP, BON, and TMB requires prescribers to register with Texas’s PMP,  the AWARxE clearinghouse, and to check the patient’s profile before prescribing a controlled substance. In February 2017, the Texas Board of Nursing (BON) notified APRNs with prescriptive authority that APRNs prescribing CSs should register with the PMP. They advise that using the PMP is important to protect your prescriptive authority by ensuring that patients are not filling prescription from multiple providers and that the APRN actually prescribed all the CSs the PMP is attributing to the APRN.
In the August 31, 2018, issue of the Texas Register, the BON proposed new Rule 228.2 and amendments to Rules 222.8 and 222.10. The new rule and amendments give APRNs details on requirements and recommendations related to checking the PMP.
Prescribing for Pain
It is particularly challenging to meet the standard of care when prescribing for pain. The BON wrote Rule 228.1 to specify the minimum standards of practice for pain management, and  published an article on pain management in April 2013 (page 4). The TMB is even more specific about the standards physicians providing pain management must meet. APRNs  are well advised to also follow the TMB rules in Chapter 170.
While the percentage of APRNs disciplined by the BON remains low, the number disciplined for inappropriate prescribing (usually related to failing to follow the standards related to CSs) is rising. These are often referred to “pill mill” cases, but reviewing the disciplinary orders reveals that discipline may result from two examples of inappropriate prescribing by an individual APRN to thousands of patient prescriptions written by an APRN.
This should not deter APRNs from prescribing appropriately to manage a patient’s pain, since failing to do so does not meet the standard of care. Following pain management guidelines and position statements issued by professional organizations such as the American Pain Society and American Society of Pain Management Nursing helps ensure appropriate assessment, treatment, and prescribing.
When prescribing CSs for pain, follow these tips.
- Do a thorough history & physical examination with complete documentation.
- Recognize drug-seeking behaviors.
- Know and apply clinical guidelines for treating pain.
- Unless there is a clear indication to do so, never prescribe CSs for pain before determining if other types of pain management strategies are effective.
- Check the PMP for the patient’s history of filling CS prescriptions before prescribing and when refilling a CS prescription. Use that information in treatment decision-making.
- Use pain management contracts when treating patients with chronic pain. Consider if any findings indicate a pain management contract is advisable for short-term management.
- Consider drug testing to verify the patient is taking CSs as ordered.
Summary: APRNs prescribing CSs must know the following facts and act accordingly.
- APRNs must have a current federal DEA registration. Read more about maintaining a current DEA registration in a December 22, 2016, notice from the BON.
- A physician must delegate prescriptive authority for CSs to the APRN before the APRN orders or signs a prescription for a CS.
- Most APRNs are limited to prescribing a 90-day supply of CSs in Schedules 3 -5, to persons age 2 years and older.
- Controlled substances prescriptions are tracked through the prescription monitoring program (PMP) established by the TSBP through the AWARxE clearinghouse.
- Register and check the AWARxE clearinghouse before prescribing a CS. and check your prescribing profile regularly.
- APRNs with DEA numbers should regularly query AWATxE to confirm the APRN actually issued all the prescriptions linked to the APRN’s DEA number.
- APRNs prescribing for pain must meet standards of care identified in clinical guidelines, BON Rule 228.1, and TMB rules, Chapter 170.
Resources
- American Pain Society Clinical Guidelines
- American Society of Pain Management Nursing
- BON Pain Management Rule, Chapter 228
- BPN RN Update article on pain management, April 2013 (page 4)
- Access a patient’s Schedule II, III, IV, or V prescription history through the Prescription Monitoring Program
- Drug Enforcement Agency Registration
- TMB Pain Management Rules, Chapter 170
- TSBP statement that pharmacists may dispense refills of a controlled substance prescribed by an APRN or PA if the total supply does not exceed 90 days.
I am a retired ophthalmologist who works as a locum in several states, including Texas. Until my Texas Controlled Substance Registration Certificate expired 05/31/2016, I worked on occasions at the Children’s Eye Center of El Paso. ( I have not worked since July 2016, and no controlled substances were prescribed.) Is a Texas DEA certificate required to work under similar circumstances? I may work for only one to two weeks out of each year. I have active DEA certificates for Arkansas and North Dakota.
Texas no longer requires state registration to prescribe controlled substances. Physicians need to have a full and active license from the Texas Medical Board and federal DEA registration to practice and prescribe controlled substances in Texas. You can go to the following Texas Medical Board link for verification. http://www.tmb.state.tx.us/page/renewal-useful-information
If a Nurse Practitioner prescribe schedule 2 they can if they have a DEA and is delegated to do so by the physician?
Lauren,
APRNs in Texas may not prescribe Schedule 2 Controlled Substances and have those prescriptions filled at an outpatient pharmacy. If delegated by a physician, APRNs may order Sch. 2 drugs for in-patients and emergency room patients in hospitals and for hospice patients. If you have further questions, let me know.
Lynda
Does this include stopping an ordered Schedule II drug?
I am seeking some clarification on controlled substances. I understand that NPs can order schedule 2 controlled substances in the hospital setting, but must the NP be employed by the hospital to do so since the law states “in a hospital facility based practice”?
I will be employed by a clinic based surgical practice and receive delegation under a prescriptive authority agreement. I will also see our surgical patients admitted in the hospital. If delegation for ordering schedule 2 drugs to hospital inpatients is included in my prescriptive authority agreement, can I do that while not being a “facility based practice” employee?
If so, must I have schedule 2 designation listed on my DEA registration card?
Only if you are facility based. That means you can order schedule II for your patients in the hospital or hospice only. If you try tp prescribe outside of a facility, the pharmacy will not fill your rx.
To the best of my knowledge there is no state or federal requirement for drug testing when a Schedule II drug is prescribed for a short period of time. However, if controlled substances are prescribed for managing chronic pain, the Texas Medical Board Rule 22 TAC 170.3 states:
(v) The physician must periodically review the patient’s compliance with the prescribed treatment plan and reevaluate for any potential for substance abuse or diversion. In such a review, the physician must consider reviewing prescription data and history related to the patient, if any, contained in the Prescription Drug Monitoring Program described by §§481.075, 481.076, and 481.0761 of the Texas Health and Safety Code and consider obtaining at a minimum a toxicology drug screen to determine the presence of drugs in a patient, if any. If a physician determines that such steps are not necessary, the physician must document in the medical record his or her rationale for not completing such steps.
Hello all,
I will be starting work at a autism clinic with inpatient privileges consults. Am I allowed to write for schedule II for the austim clinic? I am so confused.
No Michelle,you will not be permitted to prescribe Schedule II Controlled Substances in an autism clinic. Let me know if you have other questions.
Lynda
What schedule II meds would you be writing for? ADD meds I presume?
I am an FNP with a DEA and I prescribe C3 controlled substances. I do not prescribe C2.
Is a face to face office visit required for a refill of a C3 controlled substance?
Can a C3 be refilled by phone consult? Telemedicine?
You can prescribe up to a 90-day supply of a Schedule 3 – 5 Controlled Substance, or any number of refills of quantities that do not exceed a 90-day supply. Refills can be managed in any manner that is appropriate, based on patient risk factors and circumstances. The initial prescription should included a face-to-face visit. You need to be aware that you must check the Prescription Monitoring Program (PMP) before giving an initial prescription, or refilling a prescription, for a controlled substance prescribed for pain.You should be aware that, in the August 31, 2018, Texas Register, the Board of Nursing (BON) proposed rule amendments to Rules 222.8 and 222.10, and a new Rule 228.2 requiring APRNs to check the PMP. You can read the proposed rules using this link. August 31st issue of the Texas Register
When you are prescribing for pain, you should also follow guidelines established by the Texas Medical Board in Chapter 170.
I know some pharmacies are limiting the amount of a controlled substance it dispenses unless the prescriber certifies that the medication is being prescribed for a patient with chronic pain. The pharmacists also have rules on professional responsibility regarding dispensing controlled substances that may be of interest in Rule 291.29(c) – (f).
Finally, APRNs should read a document on shared responsibility when prescribing and dispensing controlled substances on the Texas Board of Pharmacy Website.
I hope you find this information helpful.
Lynda
Hi Lynda,
It has been forever. Happy to see you here still leading and guiding APRNs.
1.) If a APRN or PA is employed by a freestanding, private practice and has a Prescriptive Authority Agreement with that practice, may they order C2 drugs to be given to hospital inpatients that the delegating physician has asked them to see. This question regards only inpatient drug orders not a prescription to be filled at a retail pharmacy. Of course, proper credentialing will be done for the hospital facility. If they may write C2 orders, are there any restrictions on those inpatient orders for the employee of a freestanding private practice?
2.) May the APRN or PA write C2 prescriptions in a freestanding, private practice if they have been given that privilege in a Prescriptive Authority Agreement signed by all parties to the agreement?
Could you please include the references for your answers? thank you.
Ann,
The answer to #1 is not definite. There are circumstances in which an APRN or PA employed by a private practice might be considered facility-based, and therefore, able to order Schedule 2 drugs for inpatients. I refer you to the article posted on the CNAP website titled “Is an APRN or PA Hospital Facility-Based?” in the APRN Practice section.
The answer to #2 is no. Under current law an APRN or PA may never sign a prescription for a C2 drug in a freestanding ER or any other ambulatory care setting. You may refer to BON Rule 222.8.
If you have follow-up questions, send an email to me at lynda.woolbert@gmail.com.
Lynda
I am employed in a Pychiatric office for out patient medication management and I work under the supervision of an MD Specializing in Psychiatry. Currently, I do not prescribe Sch 2 medications.ie Adderall, Vyvanse etc. but I do have a few patients with anxiety issues for which Xanax a schedule 4 medication is needed. Currently my supervising physician will also see these patients, and he will prescribe these types of meds to the patient..ie schedule 4 med. my question is….am I permitted to prescribe schedule 4 medications to patients since I do not have my own DEA number, only my supervising physician has a DEA number. But if we have a collaborative agreement, would I be able to prescribe sag 4 drugs to my patients?
Susan,
You may not prescribe any controlled substances unless you have your own DEA number and the delegating physician has a DEA number. Therefore, under the conditions outlined in your question, you may not sign a prescription for a Schedule 4 drug.
Lynda
I am applying for my DEA, I work for a hospice company and take call for the MD’s. Since it is for hospice patients will I beable to prescribe schedule 2 for those that need it? Or is that just for in pt hospice?
Kim,
Under current law, you my only prescribe Schedule 2 drugs for your patients who are in the hospice program.
Lynda
I was hoping to come across this question and answer, but the response is not very clear. Can you clarify, do the patients have to be in an inpatient hospice program, or can NPs write for schedule 2s if they are in a home hospice program? Thank you.
NPs and PAs working for hospice programs may prescribe Schedule 2 drugs for patients being cared for in outpatient (including the patient’s home) or inpatient settings, as long as: 1) a physician in the program delegates the authority to prescribe schedule 2 drugs, 2) the NP or PA has a DEA controlled substances permit that includes schedule 2 drugs, and 3) the schedule 2 drugs being prescribed are consistent with the patient’s plan of care.
Sorry, it took so long to see your follow-up question. Hopefully you found the answer from another source last year when you asked. The law does not draw a distinction between inpatient hospice and hospice programs caring for patients in their homes, so you should be able to prescribe Schedule 2 drugs for hospice patients in both settings.
Hello,
Can I call my supervising doctor with a suggestion for a CS 2 or a dose change to a CS 2 so he can call the order to the pharmacy or fax it if he knows the patient already but I am seeing the patient as an NP?
If an APRN or PA is employed by a hospital but does NOT have their own DEA number, can they order any controlled substances for inpatients?
Weather APRNs in hospital facility-based practices may order controlled substances without an individual DEA number depends upon facility policies. The hospital may allow APRNs and PAs with delegated authority to order controlled substances to do so under the institution’s DEA number or the delegating physician’s DEA number. Hospitals, however, have the right to establish a policy requiring the APRNs and PAs to have their own DEA number.
Is there any clarification available regarding continuing a prescription for a CS as a chronic medication?
I understand that a “Physician must approve continuing the same CS for the same patient beyond the initial 90-days, and note the consultation in the patient’s chart” but if the medication to be prescribed will be a chronic medication, how frequently does the physician need to approve the continuation or does it only need to happen after the 1st initial approval? Or is managing chronic controlled substance (i.e testosterone) as ARPN not possible /feasible?
Current law requires that you discuss continuing treatment with the controlled substance every 90 days. This must be noted in the chart every 90 days for as long as the medication is prescribed by the APRN. This does not prohibit the APRN from managing the condition, but it does required writing a new prescription every 90 days, instead of every 6 months, and noting the consultation in the chart. I hope that you and your delegating physician will talk with your legislators about eliminating such unnecessary requirements in 2021 when the next Texas Legislative Session occurs.
Hello. I am slightly confused. I did a clinical NP rotation in a pain clinic (not an inpatient facility) and all of the NPs and PAs wrote for schedule 2 medications with their DEA number and a physician’s DEA number. How is this possible if they are not a hospital or hospice? Do pain clinics have special privileges for the mis-levels to be able to write for controlled substances?
So sorry for the slow reply. Your question is very important. If this pain clinic is in Texas, and the NPs and PAs are signing prescriptions for Schedule 2 drugs, then all the NPs, PAs and delegating physicians are practicing illegally. The NPs and PAs would be able to make out the prescriptions and then the physician could sign them. If you wish to communicate further, please contact me through my personal email, lynda.woolbert@gmail.com
Do I need to have a collaborative/prescriptive authority agreement in place prior to applying for my DEA number? I don’t mind paying for it prior to finding a job but I don’t want to forfeit the money either.
Hi Toni,
Yes, you must have a Prescriptive Authority Agreement in place before you apply for a DEA number. Also, not all physicians delegate authority to prescribe controlled substances and there is no reason to get a DEA number unless you are prescribing controlled substances.
Lynda
I am applying for my DEA license for the first time in Texas. I am aware that NPs cannot prescribe schedule 2, 2N unless working inpatient. I will be working in a clinic for a hospital based facility. My question is about the DEA application. It asks me to check the boxes for which scheduled controlled substances I am applying for. So I know I’ll check the boxes for 3-5 but should I also check 2 & 2N or not since I’ll be working in clinic only as of now.
Only check Schedules 3 – 5. The employer does not determine if you are facility-based. You must be treating in-patients or patients in the hospital emergency department.
I have a DEA number and is for 3-5, but if I am seeing patients in the hospital as CNM, and will need to order schedule 2N medications during labor, do I need to check mark 2, 2N on my DEA registration?
CNMs have been permitted to provide and order necessary controlled substances for their intrapartum and immediate postpartum patients for decades, as long as that authority is delegated in writing by a physician (See BON Rule 221.14, https://www.bon.texas.gov/rr_current/221-14.asp.html). I cannot, however, give a definitive answer to your question. I suggest you check the hospital’s policies and/or check with the head hospital pharmacist to see if any policy addresses APRNs providing Sch. 2 drugs under delegated prescriptive authority. Some hospitals fill the order using the physician’s DEA number, even though you are the practitioner signing the order. If the hospital is not using your DEA number, then you probably do not need to modify your registration. If the pharmacy is going to use your DEA number, then I think you do need to change your registration, but DEA would be the final authority on that. Of course, changing your DEA registration does not affect the controlled substances you may prescribe under Texas law, which would not include Schedule 2 drugs at this time.
I work at the VA and long-term facility and rehab and my unit is consider inpatient – AS APRN do i need a delegating physician to write for schedule II/III as this consider inpatient. I understand I would need to get one of my Physician collogues to write for them if they were discharge on any- most are not . But I was told I needed a delegating physician to write for these medications when at my previous facility i did not.
It is my understanding that VA facilities started allowing APRNs to practice independently, eliminating state restrictions, several years ago. However, if the policies in your facility require APRNs to follow state restrictions, then you must follow facility policies. Regardless, you should be able to prescribe and order Schedule 3 Controlled Substances, as long as you have a DEA permit that includes those drugs. Ordering Schedule 2 drugs in Texas long-term care facilities is not permitted because those facilities follow the same prescribing restrictions as outpatient facilities, even if those nursing facility beds are located within the walls of the hospital. Those beds are licensed separately. However, since you are in a VA facility I am not sure any VA facilities are subject to state licensing laws. I suggest you start by checking to see if the policies for your current unit differ from policies in the rest of the VA. Also, are you employed by the VA?
Can you clarify how often patients should follow up that take a scheduled 4 drugs like valium/diazepam? I know as an APRN we can only prescribe a 90-day supply. Do patients need to follow up in the office very 3 months or every 6 months? Some providers say every 3 months and others say every 6 months. Thank you!
Prescriptions for Schedule 4 drugs are good for 6 months, if signed by a physician, but, as you know, an APRN may only prescribe a 90-day supply. I imagine that is the source of the differences in opinion. If you are the one signing the prescription, probably the safe answer is for you to see the patient each time you prescribe the drug to do due diligence that the drug is not being abused or diverted, and that the patient actually needs to continue that drug. Obviously, it makes more sense for follow-up to be based on clinical judgement, the length of time you have known the patient, etc. rather than the type of provider. If you are confident that the patient does not require more frequent follow-up than 6 months, you can send a new 90-day prescription to the pharmacy without seeing the patient, or ask your delegating physician to sign a 6 month prescription.
Do civilian nurse practitioners employed by the military have exemption from state prescribing limitations?
Your practice in a federal facility allows you to follow the federal facility policies, and usually eliminates the limitations that other Texas NPs have on their practices and prescriptive authority.
I work as a civilian in the army outpatient clinic. I have schedule 2 DEA privileges. Does the federal employment for the military negate my prescribing limitations on schedule 2 CS in the on base environment?
As long as the prescription is filled at a base pharmacy, you may prescribe Schedule 2 drugs(as long as that is consistent with your clinic’s policies. However, those prescriptions cannot be filled off the base. Outpatient pharmacies off the base have to follow Texas law.
I’m having prescriptions bounce back due to lack of physician signature on schedule 4 meds. Is there a new update?
No update to the best of my knowledge. I normally recommend calling the pharmacist in charge to understand why the prescription was not filled. Often, it is just a misunderstanding.
Hello, I am a CRNA APRN with Prescriptive Authority in Texas-I am currently in need of getting my own DEA for C3 (ketamine and Esketamine) prescribing and administration for treatment of MDD/TRD(Esketamine)- Ketamine IV/IM for mental health and chronic pain in a clinic setting. Please advise/direct (kind of on a time crunch), any input is greatly appreciated. Do you have any idea on the length of time in aquiring a DEA?
From my research, it appears that the average time for processing a DEA permit application is 6 to 8 weeks. I am concerned about scope of practice issues. It seems questionable for CRNAs to be prescribing these drugs, particularly for a mental health diagnosis. Are patients being referred to you to administer these medications? You might seek information from the Texas Association of Nurse Anesthetists, https://www.txana.org/