Q: I am an adult nurse practitioner starting a new job in Texas. Occasionally, I may need to prescribe a Schedule 2 Controlled Substances for a patient, but I work in a clinic without a physician on site, and I know Texas law does not allow me to prescribe these drugs. My delegating physician is willing to write the prescriptions for my patients, but is this legal, and, if so, what do we need to consider in setting up a process to obtain the prescription for my patient?
A: Most nurse practitioners, and other types of advanced practice registered nurses (APRNs) encounter instances when a patient needs a Schedule 2 Controlled Substance in order for the APRN’s treatment to meet the standard of care. That is the reason that 40 states, and the District of Columbia, allow APRNs to prescribe these drugs (DEA, 2017, March 9). Unfortunately, Texas law leaves most APRNs and their patients in a difficult situation. Physician assistants (PAs) in Texas face the same problem.
Except in hospitals and hospices where some APRNs and PAs may order Schedule 2 medications for their patients, Texas law forces APRNs and PAs to rely upon a physician to prescribe these drugs for their patients (CNAP, 2017, February 17). In most circumstances, that physician will be the one who delegates prescriptive authority.
The following are 11 facts that APRNs, PAs, and their delegating physicians should know when establishing a process for the physician to issue a prescription based upon the APRN’s or PA’s examination and diagnosis.
- Physicians have been writing prescriptions for patients based on an APRN’s or PA’s evaluation since the professions emerged. There are no statutes or rules that forbid this practice.
- Inappropriate prescribing of muscle relaxants, such as carisoprodol, and opiate combination medications, such as hydrocodone & acetaminophen, led to deaths. As a result, hydrocodone containing medications were moved to Schedule 2 in 2014, and there is additional scrutiny and tracking of all controlled substance prescriptions (DEA, 2014). Standards now require extra vigilance and close cooperation among the patient, APRN or PA, delegating physician, and the pharmacist who ultimately fills the prescription.
- Thorough assessment, documentation, and follow-up are always keys to good practice. The patient’s history and assessment must support the diagnosis and validate the need for the prescription, and the documentation must include all these elements (J. Zych, personal communication, March 28, 2017).
- Since the physician is the one writing the prescription, the physician bears more responsibility than normally associated with delegating prescriptive authority to an APRN or PA. As a consequence, each case should be discussed with the physician, and a delegating physician located in a different location than the APRN or PA may wish to maintain a copy of the APRN’s or PA’s documentation of the patient’s history, physical, and each encounter and follow-up related to the prescription(s) the physician writes for the patient.
- All practitioners should check the prescription monitoring program (PMP) before generating a prescription for a controlled substance (CNAP, 2017, February). The Nursing Practice Act and Medical Practice Act are being amended by the 85th Texas Legislature, 2017, requiring APRNs and physicians to query a patient’s reports of controlled substances prescriptions before writing a prescription for a controlled substance (S.B 305, 2017; S.B. 315, 2017).
- Prescriptions for Schedule 2 Controlled Substances must be generated electronically or written on “official prescription forms” ordered from the Texas State Board of Pharmacy (TSBP) (TSBP Official Prescription Form Rule, 2016).
- The practitioner designated on the official prescription form must keep these forms in a secure location under their control. Therefore, if the delegating physician is in a different location than the APRN or PA, the APRN or PA may not keep official prescription forms that belong to the delegating physician at their location.
- It is illegal for a physician or other practitioner to pre-sign an official prescription form. It is also illegal for anyone, other than the practitioner designated on the form, to sign the prescription form on behalf of the practitioner.
- Section 562.112, Texas Occupations Code (in the Pharmacy Practice Act) requires pharmacists to determine that each prescription they fill is based on a valid practitioner-patient relationship.
- Jolene Zych (personal communication, March 20, 2017), Advanced Practice Nursing Consultant for the BON, recommends that APRNs document that it was the physician who issued the prescription by including a note such as “script per physician”. If a pharmacist questions the relationship between the patient and the prescribing physician, that documentation can be shared with the pharmacist along with any documentation that pharmacist might require confirming that the physician delegates prescriptive authority to the APRN.
- If the prescription is to treat pain, the APRN’s or PA’s documentation should reflect the elements that the Texas Medical Board (TMB) specifies in its pain management rules, 22 Texas Administrative Code (TAC) Chapter 170. APRNs also must follow the Board of Nursing’s (BON) pain management rule in 22 TAC, Chapter 228.
In summary, APRNs and PAs must work closely with their delegating physicians to ensure their patients get the full range of medications they require. That includes discussing a process to obtain prescriptions for medications that the APRN or PA is not currently permitted to prescribe, either because they are not within an area of competence, or, as in this situation, not permitted by state law. Often an APRN’s or PA’s most appropriate course of action is to refer the patient to another provider. However, when it is within an APRN’s or PA’s area of competence to evaluate and diagnose the patient’s condition, the delegating physician may be willing to write the prescription. APRNs and PAs are smart to develop a policy & procedure that works for them and their delegating physicians in advance of facing this situation so they can care for their patients’ full range of potential needs as efficiently and effectively as possible.
Coalition for Nurses in Advanced Practice (CNAP). (2017, February 17). Prescribing controlled substances in Texas. Retrieved from http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=85R&Bill=SB305
CNAP. (2017, February). Texas regulatory updates: Important notice from BON recommending PNP registration. Retrieved from http://cnaptexas.com/health-policy/regulatory-updates/
Drug Enforcement Agency (DEA). (2017, March 9). Mid-Level practitioners authorization by state. Retrieved from https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf
DEA. (2014, August 22). Rescheduling of hydrocodone combination products from schedule III to schedule II. Retrieved from www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0822.htm
S.B. 305 (Texas Board of Nursing Sunset Legislation), 85th Texas Legislature, 2017. Retrieved from http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=85R&Bill=SB305
S.B. 315 (Texas Medical Board Sunset Legislation), 85th Texas Legislature, 2017. Retrieved from http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=85R&Bill=SB315
TSBP Official Prescription Form Rule, 22 TAC §315.2. Retrieved from http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=15&ch=315&rl=2
If you have questions related to prescribing, or any other aspect of APRN practice in Texas, please post as a comment, or contact Lynda Woolbert directly.
Author’s Note: Special thanks to Jolene Zych, Ph.D., RN, WHNP, for reviewing this article, and contributing to its contents.