Healthcare Consideration: Although marijuana remains a federal Schedule I controlled substance, many states have approved or are considering supporting the medical and recreational use of marijuana. As these regulations differ from state to state, NPs must carefully review regulations and applicable requirements in their practice state. PRESCRIBING PRACTICES FOR CONTROLLED SUBSTANCES A physician, dentist, podiatrist, veterinarian, or advanced
● The hospital or institution authorizes the practitioner to dispense or prescribe under its registration and assigns a specific internal code for each practitioner so authorized. In response to the opioid epidemic, many states have enacted policies to address the crisis yet still provide access to appropriate pain management. Procedures include guidelines for or limits on opioid prescriptions in Title 21 of the CFR, Sections 1308.11 through 1308.15 (DEA, 2018c). The DEA (2010a) defines a prescription as an order for medication dispensed to or for an end user. Furthermore, to be effective, a prescription for a controlled substance must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of their professional practice. The responsibility for properly prescribing and dispensing controlled substances is upon the prescribing practitioner, but a corresponding responsibility rest with the pharmacist who fills the prescription (DEA, 2010b). Laws and regulations vary from state to state; thus, the prescribing clinician must ensure that the prescription follows all requirements. Prescriptions for controlled substances must be written in indelible ink or typewritten. The controlled substance prescription must be dated and signed on the date issued. Additional requirements for a controlled substance prescription include the following: ● Patient’s full name and address. ● Prescriber’s full name, address, and DEA registration number. ● Drug name. ● Strength. ● Dosage form. ● Quantity prescribed. ● Directions for use. ● Number of refills authorized (not applicable for Schedule II drugs). ● Prescriber’s signature. ● Date issued. The regulations provide that “the secretary or agent may prepare [a] prescription for the signature of a practitioner, but the prescribing practitioner is responsible in case the prescription does not conform in all essential respects to the law and regulations” (DEA, 2010b). The CSA does not permit a prescribing practitioner to delegate to an agent or any other person the practitioner’s authority to issue a prescription for a controlled substance. A practitioner acting in the usual course of their professional practice must determine a legitimate medical purpose for a controlled substance prescription; an agent may not make this determination. Dental Considerations: The American Dental Association (2018) became the only major health professional organization to support mandatory continuing education on safe prescribing of controlled substances https://www.ada.org/-/ media/project/ada- organization/ada/ada-org/files/resources/ practice/legal-and-regulatory/faq_mate-act.pdf? rev=2d62d02 8e6cf49869624d1cfa4e442c3&hash=A7D5EB01BC19DA0ADC 5968E336996DA5 hand, many states restrict NP prescriptive authority and require physician supervision. The American Association of Nurse Practitioners categorizes state practices into restricted, reduced, and complete practice authority (AANP, 2022). Twenty-two states allow full practice, where NPs have similar prescriptive authority to physicians. In 16 states, NPs have reduced authority and work alongside physicians in joint practice agreements. States
practice provider (i.e., chiropractor, nurse practitioner, midwife, optometrist, pharmacist) may issue a prescription for a controlled substance. Others may give a prescription under the following conditions: ● Authorized to prescribe controlled substances by the jurisdiction of practice. ● Registered with the DEA or exempted from registration (e.g., U.S. Public Health Service, Federal Bureau of Prisons, or military practitioners); to obtain a DEA registration, the clinician must complete DEA Form 224 (http://www. DEAdiversion.usdoj.gov). ● Effective May 11, 2022, DEA now requires all registration applications and renewal forms to be submitted electronically. ● An agent or employee of a hospital or other institution acting in the normal course of business or employment under the registration of the hospital or other institution that is registered instead of the individual practitioner being registered, provided additional requirements as outlined in the CFR (DEA, 2018c). DEA registration grants federal authority to practitioners to handle controlled substances as part of their professional practice or research. A clinician may prescribe controlled substances only under the state laws where their practice is located. When federal and state laws differ, the practitioner should follow the more stringent aspects of both the federal and state requirements. This principle has led to much concern about the state legalization of medical marijuana, despite the DEA maintaining its controlled substance Schedule I status. The DEA may deny, suspend, or revoke a clinician's DEA registration upon finding the registrant has: ● Materially falsified any application filed. ● Been convicted of a felony relating to a controlled substance or a Schedule I chemical. ● Had their state license or registration suspended, revoked, or denied. ● Committed an act that would render the DEA registration inconsistent with the public interest. ● Been excluded from participation in the Medicaid or Medicare program. Clinicians who are agents or employees of a hospital or other institution (e.g., interns, residents, staff physicians, advanced practice providers) may, in the normal course of their duties, administer, dispense, or prescribe controlled substances under the registration of the hospital or other institution provided that: ● The dispensing, administering, or prescribing is in the ordinary course of practice. ● Practitioners are authorized by the state in which they practice. ● The hospital or institution has verified that the practitioner is permitted to dispense, administer, or prescribe controlled substances within the state. ● The practitioner acts within the scope of employment in the hospital or institution.
Prescribing controlled substances: Nurse practitioner requirements While the CSA allows NPs to prescribe controlled substances, each state has different regulations (DEA, 2022). Nurse
practitioners may prescribe Schedules III, IV, and V controlled substances in all states. However, state laws to determine NPs' prescriptive authority differ considerably. Some states allow full practice for NPs where they may prescribe medications with a level of autonomy comparable to physicians. On the other
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