Can Nurse Practitioners Prescribe Medication? – (Let’s Find Out)
Written By: Donna Reese MSN, RN, CSN
In certain states around the country, nurse practitioners are slowly being granted full practice authority. So, you may then ask, can nurse practitioners prescribe medication? The answer is yes and no and maybe with specific criteria depending on the state. The age-old debate of whether or not nurse practitioners can prescribe medication autonomously still rages on. However, progress is ongoing as NPs continue to gain ground regarding prescribing medication. So, precisely what medications can a nurse practitioner prescribe? The explanation varies widely from state to state. Read on for a full description of what types of medication a nurse practitioner can prescribe and all of the little nuances associated with prescriptive authority.
Prescriptive Authority For Nurse Practitioners – What Does This Exactly Mean?
According to the American Association of Nurse Practitioners (AANP), full prescriptive authority for nurse practitioners
is the ability to prescribe without supervision as per individual state boards of nursing. In addition to prescribing medication, NPs with full prescriptive authority may independently order controlled substances, durable medical equipment (DME), and services.
In essence, nurse practitioners can prescribe a wide variety of medications and services independently without the direction or governance of a physician if their state allows full practice authority for NPs. Nurse practitioners with full practice authority can evaluate, diagnose, interpret tests, and prescribe treatments and medication under their state board of nursing licensure authority.
AANP indicates that “nurse practitioners have prescriptive authority in all 50 states and the District of Columbia”. However, not every state grants NPs full practice authority, thereby limiting prescribing practices for nurse practitioners in certain states.
Who Grants And Regulates Prescriptive Authority To Nurse Practitioners?
AANP indicates that prescriptive authority is granted and “solely regulated by state boards of nursing and in accordance with the NP role, education, and certification.” Since this is not a national regulation, each state defines prescriptive authority with a slightly different definition.
There are 3 different categories for nurse practitioner prescriptive authority.
These levels of prescriptive (practice) authority are:
• Full practice
authority where nurse practitioners can write prescriptions legally and independently.
• Reduced practice
is where NPs can write prescriptions, but each state gives specific guidelines regulating how this practice is carried out. Some states need to have a physician onsite, while others need to have a collaborative agreement with a physician for oversight. All states with reduced practice require an NP to be supervised in some way by a physician.
• Restrictive practice
states require that a physician supervise a nurse practitioner for the duration of their career. Nurse practitioners are restricted from performing at least one function of healthcare practice, such as prescribing medication independently.
What Are The Benefits And Drawbacks Of Granting Prescriptive Authority To Nurse Practitioners?
There are many benefits for society by allowing nurse practitioners to work to the fullest extent of their ability. Depending on who you talk to, there are differing opinions regarding the debate about the pros and cons of full practice authority
Some physicians have historically shown resistance to nurse practitioners gaining full prescriptive authority. The President of the Texas Medical Association
states that NPs drive up healthcare costs by ordering too many tests and making quick referrals. In addition, he indicates that allowing nurse practitioners to practice independently will not improve access to care for patients.
Nurse practitioners, some physicians, and many government agencies argue differently.
Here are the most acclaimed pros and cons of granting full prescriptive authority to nurse practitioners.
The benefits of full practice authority are:
• Improved access to care-
Contrary to what some physician sources may claim, nurse practitioners are utilized to fill gaps where there are physician shortages, such as in rural and underserved areas. In 1977, the Rural Health Clinic Act
mandated that NPs, clinical nurse specialists, and physician assistants provide 50% of services in funded rural health clinics. Their services were to be reimbursed.
This act was the beginning of the trend for NPs to step in where there were provider shortages. Today, the provider shortage areas
continue to grow, making the need for NPs with prescriptive rights even greater. By allowing nurse practitioners full prescriptive authority in shortage areas, patients can have complete care where before there was limited to none available.
The cost of employing nurse practitioners is lower than that of all-physician provider staff.
• Delivery of care is smoother-
Waiting for a physician to sign off on orders or oversee an NP costs time. This translates to delays in treatment time for patients and wasted provider time. Nurse practitioners who work autonomously are free to move smoothly throughout their day, increasing patient care opportunities.
• Excellent job outlook-
Nurse practitioners continue to be in demand
everywhere. NPs who can prescribe are even more valuable in the job market.
• Opioid Epidemic-
The U.S. opioid crisis is not going away. NPs who can autonomously care for and prescribe medication for addicts can assist in the treatment of substance abuse, especially in rural and underserved areas.
• Baby Boomers Aging-
The U.S. Census Bureau
indicates that the population of those over 65 is growing rapidly. The baby boomer population, now senior citizens, is expanding the need for healthcare, making NPs even more valuable.
• Increased patient-provider choice-
Patients may prefer a physician or a nurse practitioner based on their gender, diagnosis, and personal likes. Having an NP who can fully treat them gives patients more choice in their health decisions.
Drawbacks of granting prescriptive authority to nurse practitioners are more limited. The cons for allowing full autonomy for NPs are:
Some physicians argue that NPs are not doctors and should not function the same as those with a medical degree. They describe NPs as underqualified and undertrained to provide full and quality care to patients.
According to a statement from AANP
, “existing research suggests that NPs can perform a subset of primary care services as well as or better than physicians.”
In What States Do Nurse Practitioners Have Full Prescriptive Authority?
Can nurse practitioners prescribe medication? Yes, they can but only those with full prescriptive authority
can do so without the oversight of a physician.
Full prescriptive authority is designated as full practice authority (FPA) for nurse practitioners.
Although progress seems slow, we have come a long way from 1994 when only 5 states
granted nurse practitioners full practice authority. The states of Alaska, Iowa, Montana, New Mexico, and Oregon blazed the way for future NPs to practice without supervision.
As the graph below indicates, currently, AANP lists 24 states that have full practice authority. This includes Delaware, celebrating its recent win to join the other states who have full prescriptive authority! In addition, NPs in Washington DC, and 2 US territories can also practice independently.
| Alaska|| Arizona|| Colorado|| Connecticut|| Delaware|
| Idaho|| Iowa|| Hawaii|| Maine|| Maryland|
| Massachusetts|| Minnesota|| Montana|| Nebraska|| Nevada|
| New Hampshire|| New Mexico|| North Dakota|| Oregon|| Rhode Island|
| South Dakota|| Vermont|| Washington|| Wyoming|
In What States Do Nurse Practitioners Have Partial Prescriptive Authority?
Partial prescriptive authority is also termed reduced practice for nurse practitioners.
The 15 states under reduced practice are listed below. In addition, American Samoa, Puerto Rico, and the Virgin Islands (listed as part of the US states) are under partial prescriptive (practice) authority.
| Alabama|| Arkansas|| Illinois|| Indiana|| Kansas|
| Kentucky|| Louisiana|| Mississippi|| New Jersey|| New York|
| Ohio|| Pennsylvania|| Utah|| West Virginia|| Wisconsin|
In What States Do Nurse Practitioners Have No Prescriptive Authority?
States where nurse practitioners have the most prohibitive restrictions, fortunately, are few. Called restrictive practice, NPs in these states have no independent prescriptive authority at all.
With only 11 states remaining under restrictive practice, we see progress in this category as soon California NPs can proudly practice independently. California Senate bill 890
was recently passed to allow nurse practitioners in California to practice independently by 2023 once NPs meet specific provisions.
When California grants full prescriptive authority, as you can see in the graph below, only a handful of southern and midwestern states (with the exception of Michigan) remain. With the Covid pandemic
and provider shortages becoming critical, this restrictive category will hopefully be eliminated soon as all states realize the grave need for increased independence for NPs.
| California|| Florida|| Georgia|| Michigan|| Missouri|
| North Carolina|| Oklahoma|| South Carolina|| Tennessee|| Texas|
Can Nurse Practitioners Prescribe Medications To Be Filled Out-Of-State?
The answer to the question of can nurse practitioners prescribe medication to be filled out of state is not cut and dry. The basic response is yes and no.
To provide clarity, nurse practitioners can prescribe medication to be filled out-of-state, depending on the state where the NP is working. Also, criteria varies depending on which state she is prescribing the medication. For example, Washington state
, which allows nurse practitioners full prescriptive authority has no restrictions for prescribing medications out-of-state. Other states with reduced or restricted practice for NPs may not allow it.
Also, individual state regulations for the pharmacist filling the prescription and type of medication, such as controlled substances, all play into the decision of filling and prescribing out of state medications by a nurse practitioner.
Each state board of medicine designates the state scope of practice guidelines for NPs. In general, whether NPs can prescribe out of state can be broken down into 1 of 3 categories.
These categories are as follows:
◦ The NP prescribing medication is to follow the guidelines as written for NPs licensed in the state where they are prescribing.
◦ The NP prescribing medication is to follow the guidelines within the state in which the NP is licensed.
◦ NPs are not allowed to prescribe medications out of state.
Nurse practitioners should check with their individual state criteria and that of the state where they will be prescribing before writing scripts out of state.
What Are The 10 Most Common Medications That Nurse Practitioners Prescribe?
Common medications that an NP can prescribe vary according to specialty and population age. However, in general, nurse practitioners tend to prescribe certain medications
more than others.
The top 10 most common medications nurse practitioners can prescribe are:
◦ Cardiovascular drugs
◦ Diabetics medications
◦ Cholesterol medication
◦ Thyroid medication
CAN A NURSE PRACTITIONER PRESCRIBE THE FOLLOWING MEDICATIONS?
(Let us find out if an NP can prescribe the following medications or not.)
1. Can An NP Prescribe Abortion Pills?
Abortion by pills is called medication abortion. Medication abortion is accomplished by taking 2 different abortion pills at a health facility.
Each state regulates
how the abortion pills are to be administered. Currently, 32 states do not allow nurse practitioners to prescribe abortion pills. 19 states allow NPs to administer the abortion pill but only in the presence of a physician. No medication abortions can be done via telemedicine.
Pro-abortion advocates argue that current laws restrict free and easy access to healthcare for women, particularly in rural areas.
2. Can An NP Prescribe Accutane?
Accutane or isotretinoin (generic) is a medication to treat severe acne. Accutane belongs in the drug class of miscellaneous antineoplastics and miscellaneous uncategorized agents. Due to the many and sometimes severe side effects and blood work necessary to monitor Accutane, most physicians and NPs refer patients to a dermatologist who may benefit from this treatment.
Although rare, primary care providers may prescribe Accutane, NPs included within specific guidelines.
A nurse practitioner can write prescriptions for Accutane based on the individual state criteria set forth where she works.
However, the distribution of Accutane is restricted by the Food and Drug Administration (FDA) due to the complex and serious nature of the side effects. Accutane must only be prescribed by prescribers who are registered and activated with the iPLEDGE program
. The FDA has instituted the iPledge program to avoid unintentional exposure of Accutane to pregnant women and the fetus, which can cause lethal damage to the unborn child.
3. Can An NP Prescribe Adderall?
Adderall is a CNS stimulant used to treat attention deficit hyperactivity disorder (ADHD). Used primarily in school-aged children and teenagers, adults with ADHD also can benefit from this medication. Adderall is classified as a Schedule II/IIN Controlled Substances due to a high potential for abuse and dependency.
All states now allow NPs to prescribe controlled substances, although some have certain guidelines to follow as set forth by their state. The American Medical Association (AMA) provides a helpful table listing
all states with guidelines for what nurse practitioners can prescribe.
An example is Alabama. The medical board stipulates that although nurse practitioners can prescribe Adderall and Schedule II controlled substances, NPs must first obtain a permit from the Alabama Medical Examination Board.
Strangely, in Arizona, an NP can prescribe Adderall but not refill it.
Florida, which is restrictive practice for NPs, makes it difficult for a nurse practitioner to prescribe Adderall and other Schedule II controlled substances. Florid regulations state that NPs are limited when prescribing in this category. The AMA indicates that Florida NPs can prescribe Schedule II drugs “only if the APRN has graduated from a program leading to a master’s or doctoral degree in a clinical nursing specialty area with training in specialized practitioner skills”.
4. Can An NP Prescribe ADHD Medication?
Can nurse practitioners prescribe medication for ADHD? As I described above, the answer is yes based on individual state criteria set forth for nurse practitioners. For restrictive practice states such as Arkansas, Georgia and Missouri, the chart listed above shows that NPs in these states cannot prescribe schedule II drugs such as Adderall, Vyvanse, Ritalin, and Dexedrine. All of these drugs are common in the treatment of ADHD.
Of note, not all ADHD medications are classified as schedule II drugs. ADHD medications such as Strattera, Intuniv, and Clonidine ER are non-stimulant medications and therefore are not controlled substances. This opens the door for nurse practitioners in states that do not allow them to prescribe CNS stimulants for ADHD. They can still prescribe other types of non-stimulant ADHD medications.
Although many nurse practitioners monitor ADHD medication, most prefer to refer children and adults for initial treatment and further evaluation to a physician specializing in ADHD.
5. Can An NP Prescribe Adipex?
Adipex (generic name Phentermine) is a weight loss medication. It is designed to be used in conjunction with a low-calorie diet and an exercise and behavior modification program to achieve safe weight loss over time. Adipex, an appetite suppressant, belongs to the drug class of sympathomimetic amines.
acts as a CNS stimulant and is addictive. Therefore, it is classified as a controlled substance. Since it is a Schedule IV-controlled substance, some states have a few stipulations for how an NP can prescribe Adipex.
The American Medical Association indicates that NPs from every state can prescribe Schedule IV-controlled substances such as Adipex. However, some states such as North Carolina, limit the supply to 30 days when prescribed by a nurse practitioner. Alabama also has a stipulation from the Alabama Board of Medical Examiners
stating, “Certified Registered Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants are not authorized to prescribe or dispense any controlled substance for the purpose of weight control”.
Refer to practice guidelines by state
for specifics about the state where you practice, as many states have more specific guidelines for prescribing, especially for controlled substances.
6. Can An NP Prescribe Antibiotics?
Antibiotics are the most prescribed medication in the U.S. Fortunately for patients, nurse practitioners from all 50 states in the U.S. can prescribe antibiotics. Although some states require physician supervision, nurse practitioners can write prescriptions for antibiotics as needed since they are not controlled substances and do not pose a risk for addiction.
NPs have proven to be good antibiotic stewards
by following safe prescription practices. By judiciously prescribing and educating patients about the importance of finishing a prescribed antibiotic and only prescribing when necessary, NPs adhere to measures to avoid antibiotic strain-resistant infections.
Can nurse practitioners write prescriptions for all antibiotics? The answer is yes. Antibiotics like amoxicillin, Keflex, or doxycycline are the more common antibiotics prescribed by NPs. Also, nurse practitioners can write prescriptions for broad-spectrum antibiotics such as Vancomycin.
But what about IV antibiotics? An NP can prescribe IV antibiotics as necessary, including the newer intravenous antibiotics such as Zerbaxa.
7. Can An NP Prescribe Anti-Depressants?
Antidepressants are drugs used to treat patients with depression. In addition, some antidepressants are used to treat eating disorders, chronic pain, and erectile dysfunction. There are 5 classes of antidepressants
that help with mood regulation.
These categories are as follows:
◦ Selective Serotonin Reuptake Inhibitors (SSRIs)- Used as the first line of treatment, SSRIs such as Celexa, Prozac, Lexapro, and Zoloft work by inhibiting the reuptake of serotonin. SSRIs are one of the newer categories of antidepressants and are popular due to lesser side effects compared to other antidepressants.
◦ Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) work similarly to SSRIs. Medications such as Cymbalta, Effexor, and Pristiq are popular SNRIs for depression.
◦ Tricyclic Antidepressants (TCAs) are an older class of antidepressants. Although not used as much as Elavil, Pamelor and Tofranil are still occasionally used for treatment.
◦ Monoamine Oxidase Inhibitors (MAOIs) are one of the first classes of medication used to treat depression. Not commonly used anymore due to the potential for severe side effects, MAOIs are potent drugs that still treat more severe mental disorders such as personality disorder, bulimia, and PTSD.
◦ Atypical Antidepressants do not fit into any category and are not used commonly with the exception of Wellbutrin.
Surprisingly, antidepressants are not controlled substances
. Therefore, nurse practitioners can write prescriptions from all 50 states for antidepressants since they do not pose a threat for abuse.
8. Can An NP Prescribe Anxiety Pills?
Some anxiety medications are in a drug class called benzodiazepines. Benzodiazepines are central nervous system stimulants and can cause dependence. Due to the addictive property of benzodiazepines, this class of drug is listed as a controlled substance. Ativan, Xanax, and Valium are all benzodiazepine drugs and therefore are classified as Schedule IV controlled substances. Due to their sedative and tranquilizing effect in treating anxiety disorder, this class of anxiety medication is quite popular.
Schedule IV controlled substances can be prescribed by nurse practitioners across the US with some states stipulating certain criteria. Such an instance is Pennsylvania and West Virginia, where the NP is limited on how much she can prescribe. It is wise to refer to your state’s regulations for prescribing anxiety medication.
Can a nurse practitioner prescribe medication for anxiety other than a Benzodiazepine? Besides Benzodiazepines for anxiety treatment, there are many other medications to help with this condition.
Some other drug classes to treat nervousness are:
◦ Tricyclic Antidepressants
◦ Some antipsychotic drugs
This list of anxiolytic drugs are not CNS stimulants and are non-addictive. Therefore, they are not controlled substances.
So yes, nurse practitioners can write prescriptions for these anxiety medications in all 50 states, according to each state's guidelines for prescribing.
9. Can An NP Prescribe Birth Control Pills?
Birth control pills are a type of contraception that is designed to prevent pregnancy. To be taken orally, there are 2 types of hormone birth control pills, progestin-only and a combination pill of progestin and estrogen. Neither of these types of oral contraceptives are controlled substances.
Therefore, there are no special stipulations or criteria for a nurse practitioner when prescribing birth control pills. Nurse practitioners can write prescriptions for birth control pills and frequently do so in their practice.
10. Can An NP Prescribe Botox?
Botox is actually a toxic substance produced by the bacterium Clostridium Botulinum. Although Botox contains the same substance found in food poisoning caused by botulism, Botox is safe when used for medical treatment if injected in small doses.
Botox is popular in the treatment of wrinkles but is also utilized in numerous other conditions.
Some other uses for Botox are for the treatment of:
◦ Severe underarm sweating
◦ Chronic migraines
◦ Eye conditions such as strabismus and uncontrolled blinking
◦ Overactive bladder
Botox is listed as a controlled substance due to the expertise necessary for skilled injection. A nurse practitioner can prescribe and administer Botox. Whether or not there are any restrictions or supervision needed depends on whatever criteria is established for the state an NP is working.
Notably, 92% of physicians
do not take any special training to administer Botox injections. On the other hand, most NPs take some type of post-graduate training to become adept at Botox treatments and often work under a physician's direction.
11. Can An NP Prescribe Clozapine?
Clozapine (Clozaril) is an antipsychotic drug used to treat schizophrenia. Clozapine needs to be prescribed judiciously due to severe side effects such as heart issues, seizures, and low immunity. In addition, Clozapine can interact negatively with many other medications. Although careful monitoring is necessary for treating a patient with Clozapine, it is not a controlled substance.
Important prescribing information is that prescribing providers and their patients must enroll in the Clozapine Risk Evaluation and Mitigation Strategy
(REMS) program through the FDA. Once registered, a nurse practitioner can prescribe Clozapine. Check with your state NP prescribing criteria for further directives.
12. Can An NP Prescribe Diabetic Shoes?
AANP indicates that “NPs are recognized as Part B Medicare providers who can order DME but are still unable to certify their patients with diabetes need for therapeutic shoes”.
This is disappointing as nurse practitioners have proven to be very effective at caring for diabetic patients and their needs. A bill is in place to fight this current regulation against NPs, called Promoting Access to Diabetic Shoes Act, S. 800/H.R. 4870
. Consider advocating to further NP access to their diabetic patient’s care by writing to your state senators to support this bill.
13. Can An NP Prescribe Dietary Pills?
Diet pills come in an array of supplements and prescription drugs. For the sake of this article, I am going to concentrate on prescription dietary medication. Prescription diet medication is given in hopes of weight loss in the patient.
There are 4 different categories for weight loss medication. They are:
◦ Appetite suppressants
◦ Fat blockers
◦ Carb blockers
◦ Fat binders
Medications vary as to how they work and what class of drug they are. Appetite suppressants such as Phentermine (Adipex) are effective and therefore popular with patients. However, they are CNS stimulants and controlled substances. An NP can prescribe Phentermine but with some restrictions for certain states. Alabama Board of Medical examiners states, “Certified Registered Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants are not authorized to prescribe or dispense any controlled substance for the purpose of weight control”.
Weight loss drugs that are carb and fat blockers and binders are not controlled substances and therefore, have fewer constraints for NP practice. An NP can prescribe these types of diet pills.
14. Can An NP Prescribe Hydrocodone?
Hydrocodone is a CNS stimulant that is an opioid pain medication. It is also classified as an antitussive drug. The brand name for hydrocodone is Hysingla ER and Zohydro ER. Both are extended-release drugs used to treat severe pain around the clock.
Hydrocodone is habit-forming and is classified as a schedule II-controlled substance.
An NP can prescribe hydrocodone in all but 4 states, Georgia, Oklahoma, West Virginia, and Ohio. In Arkansas, hydrocodone is the only opioid pain medication that they are allowed to prescribe.
Several states, including Florida, have limited prescribing privileges for hydrocodone, with different criteria listed for each state.
15. Can An NP Prescribe Methadone?
Methadone is a narcotic analgesic used to treat withdrawal symptoms of substance abusers on heroin and other opioid drugs. It is used routinely in substance abuse programs. Methadone is also a pain reliever. Methadone is a DEA schedule II-controlled substance.
An NP can write prescriptions for Methadone in the states that allow NPs to prescribe schedule II substances. NPs in the states of Georgia, Missouri, Ohio, Oklahoma, West Virginia, and Arkansas cannot prescribe Methadone. Some states have additional requirements for treating with Methadone, so it is advised to review your state's criteria.
16. Can An NP Prescribe Methylprednisolone?
Can a nurse practitioner prescribe medication such as methylprednisolone? The answer is yes.
Methylprednisolone is a steroid medication used to decrease inflammation. Methylprednisolone is used commonly to treat chronic inflammatory conditions such as Lupus and rheumatoid arthritis. Short-term use of methylprednisolone is also prescribed for acute allergic reactions like poison ivy and exacerbations of lung conditions such as asthma and bronchitis. Injectable methylprednisolone is also available.
Careful prescribing is necessary due to severe side effects such as suppression of the adrenal glands and immunosuppression or when withdrawing too quickly,
Methylprednisolone is from the drug class of glucocorticoids and is not a controlled substance. Therefore, any nurse practitioner can prescribe methylprednisolone, although with caution. It is recommended that you refer to your individual state NP criteria for prescribing methylprednisolone.
17. Can An NP Prescribe Narcotics? Narcotics
are (in general) opioid medications that include many street drugs such as heroin. According to the United Nations definition of narcotics
, Cannabis and Cocaine also fall in the category of narcotics. Due to the negative connotation of narcotics, the medical world rarely uses the term anymore. Law enforcement has mainly accepted the term narcotics to be associated with illegal drug use.
Legal narcotic medications such as morphine and codeine are used widely for pain management. Illegal narcotic drugs such as heroin have no acceptable medical use in the U.S. and are classified as Schedule I drugs. Schedule I substances cannot be prescribed by any provider due to the high abuse potential.
Legal narcotics such as opioid medication for pain are listed as Schedule II drugs. A nurse practitioner can prescribe narcotics in states where NPs are permitted to prescribe Schedule II-controlled substances and have a registered federal DEA number. Some states provide a formulary listing which narcotic medication can be prescribed by an NP. It is wise to refer to your state's individual detailed criteria before prescribing.
18. Can An NP Prescribe Opioids?
All opioids are narcotic medications. Once again, there are legal and illegal opioid medications. Legal opioids are used primarily for severe pain reduction. Judicial use is recommended due to the highly addictive nature of opioid medication, even in smaller doses.
Nurse practitioners can prescribe legal opioids such as morphine and codeine in states where they are permitted to prescribe schedule II medication. The exception being Arkansas which only allows NPs to prescribe hydrocodone under the schedule II category.
Other states have additional regulations regarding the prescribing of schedule II drugs. Some of the individual state criteria are listed as additional training, limitations on the length of treatment, special permissions needed, or physician oversight. Many states require that NPs enroll in the Prescription Drug Monitoring Program
and/or Controlled Substance Reporting System
in order to prescribe opioids.
Please refer to your individual state's NP practice regulations to be sure that you are in adherence. As these regulations are constantly changing, make sure that you are familiar with the most up-to-date individual state citations for prescribing for NPs.
19. Can An NP Prescribe Oxycodone?
Oxycodone is a synthetic analgesic medication similar to morphine. Oxycodone is used to control severe pain and is classified as a narcotic analgesic. This medication is generally taken by mouth and comes in immediate release and sustained release formulas. Familiar oxycodone drugs are Percocet and Oxycontin.
Oxycodone is very addicting and has a high street value. Thus, it is classified as a schedule II-controlled substance due to the increased potential for abuse and addiction. Careful administration and tapering are recommended due to the addictive nature of this drug.
Nurse practitioners can prescribe Oxycodone in states that permit NPs to prescribe Schedule II-controlled substances. Refer to your state's protocol for schedule II prescription authority for any specific directives regarding Oxycodone.
20. Can An NP Prescribe Phentermine?
Phentermine is a CNS stimulant weight loss prescription medication that is a schedule IV-controlled substance. Phentermine is one of the most popular amphetamine appetite suppressants used for weight loss and energy. It is supplied in tablet, capsule, or orally disintegrating form. Commercial Phentermine is sold as Adipex, Qsymia, and Lomaira.
Nurse practitioners can prescribe Phentermine in states where they can prescribe Schedule IV-controlled substances for weight loss. Some states, such as Florida, have a formulary of controlled substances that an NP can prescribe along with stipulations for additional training and limits for the amount of supply. Due to the complexities and ever-changing regulations of each state's NP prescriptive authority, all NPs need to be current and familiar with their state’s statutes, including prescribing weight loss medications.
21. Can An NP Prescribe Steroids?
Steroids can be categorized as a glucocorticoid such as methylprednisolone or an anabolic steroid, which is a synthetic variation of the male sex hormone testosterone.
are frequently used by athletes to help build muscles and strength. They are commonly overused and abused by teens and professional athletes for performance enhancement. Teens and non-professional athletes usually acquire anabolic steroids illegally from the gym, friends, or online.
Anabolic steroids have legal medical indications also. They are used to treat testosterone deficiency, delayed male puberty, breast cancer, AIDS treatments, and low red blood count. Medical providers judiciously prescribe anabolic steroids for the above conditions as there is a slight tendency for addictive behavior associated with steroid use.
Glucocorticoids are legal and are not controlled substances. An NP can write prescriptions for glucocorticoids.
On the other hand, anabolic steroids are listed as Schedule III controlled substances. Anabolic steroids are typically prescribed in specific sub-specialty practices, such as oncology. NPs who can prescribe Schedule III-controlled substances may have additional limitations or criteria necessary for prescribing anabolic steroids.
22. Can An NP Prescribe Suboxone?
Suboxone is a narcotic analgesic combination used to treat opioid addiction. It is a combination of buprenorphine and naloxone. Buprenorphine is an opioid. Interestingly, naloxone blocks the feelings of well-being and pain relief that are associated with buprenorphine. Suboxone is available in sublingual tablets and film and buccal film form.
Suboxone needs to be prescribed judiciously as it is habit-forming and can cause many side effects, including respiratory depression. Also, careful monitoring is necessary due to the need to titrate the dosage over time.
If patients request nurse practitioners to prescribe Suboxone, what should an NP do? As a result of the Comprehensive Addiction and Recovery Act of July 2016
(CARA), nurse practitioners can be granted privileges to prescribe Suboxone after completing a free training program. Per CARA
, “NPs and PAs who completed the required training and application were authorized to prescribe buprenorphine for up to 30 patients concurrently in the first year, subject to applicable state laws”.
After completing 24 hours of training to prescribe buprenorphine for medication-assisted treatment (MAT) nurse practitioners can prescribe Suboxone. Additionally, NPs need to obtain a Drug Enforcement Administration waiver
for Suboxone treatment.
Although the majority of the states now allow NPs to prescribe Suboxone due to CARA, individual state practice authority is still in place when prescribing. Therefore, physician oversight is still necessary in states where NPs do not have full prescriptive authority.
Up until recently, Tennessee, Wyoming, and Oklahoma did not allow NPs to prescribe Suboxone
. Currently, all states now allow NPs to prescribe the drug but many have restrictions listed. Most recently, new Tennessee laws
now allow NPs to prescribe Suboxone. Refer to individual state criteria for prescribing.
23. Can An NP Prescribe Viagra?
Viagra is a fairly new medication used to correct erectile dysfunction. Viagra is in the drug class of impotence agents. The generic name for Viagra is sildenafil. Viagra works by relaxing muscles to certain areas of the body, increasing blood flow. Viagra is in pill form and is only to be taken prior to sexual activity. Viagra is not a controlled substance.
Can a nurse practitioner prescribe medication for erectile dysfunction? The answer is yes. A nurse practitioner can prescribe Viagra. Although an NP can prescribe Viagra, it is prudent that a practitioner specializing in men’s health, such as an adult or family nurse practitioner
, do the prescribing. Please refer to your state's criteria for any additional directives for prescribing this medication.
As with all medications, there are side effects. NPs prescribing Viagra need to carefully screen patients taking Viagra before treatment is initiated and monitor for side effects, especially in patients with high blood pressure or cardiac conditions.
24. Can An NP Prescribe Vyvanse?
Vyvanse or the generic name Lisdexamfetamine is a CNS stimulant used to treat attention deficit disorder. Vyvanse is also used to treat binge eating disorders in adults. As one of the newer ADHD drugs, Vyvanse is listed as a schedule II-controlled substance due to the potential for abuse.
Nurse practitioners can prescribe Vyvanse in states that allow NPs to prescribe Schedule II-controlled substances. Check with your state's guidelines as many states require additional training or set forth criteria for prescribing Schedule II controlled substances. Arkansas, Georgia, and Missouri do not permit NPs to prescribe any schedule II-controlled medications.
25. Can An NP Prescribe Xanax?
Xanax or alprazolam (generic) is a drug used to treat anxiety and panic disorder. Xanax affects the central nervous system and is classified as a benzodiazepine. Xanax is a schedule IV drug due to the potential for abuse and addiction.
Xanax is highly addictive and in demand as a street drug due to the “high” that it produces. The street name for Xanax is benzos, purple footballs, bars or blues, to name a few.
If patients request nurse practitioners to prescribe Xanax, she needs to carefully assess the necessity for treatment and monitor to avoid abuse. Xanax needs to be prescribed for short-term only and a weaning schedule needs to be established when discontinuing.
An NP can prescribe Xanax in states that allow them to prescribe Schedule IV-controlled substances. Check with your individual state prescribing criteria as many differ on exact practice for prescribing Schedule IV-controlled substances such as Xanax. For example, Michigan NPs
may autonomously prescribe non-scheduled medications without physician delegation. However, for controlled substances, they must be delegated by a physician before prescribing.
How To Safely Prescribe Medications? – Step-By-Step Process Every Nurse Practitioner Must Follow
When prescribing medication, a safe and correct procedure is essential. Although a nurse practitioner can write prescriptions for almost all drugs, a quick review of the details of how to prescribe medications safely can’t hurt.
As we all learned the steps to administering medication safely in nursing school, providers also have guidelines for prescribing medications safely. The World Health Organization
(WHO) has developed a booklet to assist providers in safely prescribing and administering medicines to reduce medication errors and harm to patients.
American Family Physician describes a systematic 8 step approach
advocated by WHO to safely prescribing medication.
In summary, the approach is as follows:
1. Assess and state the patient’s problem clearly.
2. Indicate the patient objective (goal for treatment).
3. Select appropriate medication, taking into consideration cost, patient’s age, medical condition, and other medications taken.
4. Prescribe clear, appropriate therapy in English without using abbreviations (prn, qid, etc). This will help to reduce prescribing errors. Include the anticipated length of treatment with additional detailed instructions as needed. Consider nonpharmacological therapies as well for treatment.
5. Provide adequate patient education regarding medication, including how to take medication, side effects, refills, and when to return for follow-up.
6. Continue to monitor therapy and follow-up regularly—review medication at every visit.
7. Take into consideration drug cost. Assess if your patient has access to insurance for medications or other medical prescription benefits.
8. Consider using computer software for prescribing. With the ever-changing landscape of medications, utilizing a prescribing program on a computer or hand-held device will make work easier, keep you up-to-date on the latest drugs and help to decrease medication errors caused by poor handwriting.
Although it is becoming rare, if you choose to write a paper script, there are a few guidelines for safely filling out the script pad.
Of note, prescriptions for controlled substances must be written on a counterfeit-proof pad produced by a reputable distributor or electronically prescribed.
When prescribing, nurse practitioners must follow the guidelines set forth by the state where she is practicing.
For example, Florida statutes dictate, “A written prescription for a medicinal drug issued by a health care practitioner licensed by law to prescribe such drug must be legibly printed or typed so as to be capable of being understood by the pharmacist filling the prescription; must contain the name of the prescribing practitioner, the name and strength of the drug prescribed, the quantity of the drug prescribed, and the directions for use of the drug; must be dated; and must be signed by the prescribing practitioner on the day when issued. However, a prescription that is electronically generated and transmitted must contain the name of the prescribing practitioner, the name and strength of the drug prescribed, the quantity of the drug prescribed in numerical format, and the directions for use of the drug and must contain the date and an electronic signature, as defined in s. 668.003(4), by the prescribing practitioner only on the day issued.”
In general, prescriptions written by nurse practitioners should include the following information:
◦ Prescriber information- Depending on which state you work in, your name and supervising physician's name and DEA number, if you have one.
◦ Prescribing number and contact information (usually found at the top of prescription pad)
◦ Patient information to include full name, age, and date of birth
◦ Prescription details- to include medication prescribed, its dose, and its dosage form
◦ Patient instructions describing how to take medication
◦ Dispensing instructions- Indicate medication quantity by checking the box for an amount (if offered) and number of refills
◦ Provider Signature at the bottom of pad- follow your state's guidelines as to who needs to sign the prescription (you alone or you and your supervising physician)
7 Common Prescription Errors Every Nurse Practitioner Must Avoid
1. Incorrect diagnosis or patient
When prescriptions are dictated orally, confusion can happen with sound-alike names. This can result in a grievous medication error if another patient happens to be on the receiving end of the incorrect prescription. Clearly spell out the patient's full name when dictating.
A mix-up can also occur if an incorrect diagnosis is attached to a patient’s chart. When looking for treatment and medication for your patient, a wrong diagnosis most likely will change the course of treatment.
2. Incorrect dose
Always double-check the dose that you are prescribing to prevent incorrect dosing errors. Check the patient’s age and weight. Make sure that your writing is legible and write out all measurements instead of using abbreviations.
3. Illegible handwritten prescriptions
Illegible handwritten prescriptions have been the source of medication errors in years past. With the introduction of electronic prescribing, this problem has lessened. However, if you must handwrite a prescription, do so carefully, keeping in mind that others may not be familiar with your handwriting. Carefully handwritten wording in English that has no abbreviations is a safe approach to handwritten prescriptions.
4. Delays or omissions in writing prescriptions
Obviously, an oversight such as delaying or forgetting to send out a prescription can worsen a patient’s symptoms. Many patients, especially older adults, may not call to remind the provider that they are still waiting on their prescription to be called in.
5. Not checking allergies
A simple yet often forgotten element of safe medication prescribing is to double-check any allergies your patient may have. Incorporating this double-check standard into your daily practice will save you and your patient much angst.
6. Drug interactions
Like checking for drug allergies, make sure that you double-check your patient’s list of medications they are taking. This would include supplements also. This simple step will save you countless medication interaction errors.
7. Lack of patient education about medication
Nurse practitioners are renowned for their excellent patient education. So, when prescribing medication, your teaching expertise is needed in this area to prevent drug errors on the part of your patient.
Points to discuss are:
◦ Name of the medication
◦ What the medication is for
◦ How to take the medication- what route and discuss if need to take with food, etc
◦ How much to take
◦ When to take medication
◦ Refills if there are any
◦ Side effects
◦ When to call for medical questions or concerns
Ethical And Legal Implications Nurse Practitioners Must Be Aware Of While Prescribing Medications
Nurse practitioners are expected to perform in a highly knowledgeable and professional fashion. These high standards transfer to ethical and legal implications that are within an NPs scope of practice. In addition, an NP needs to adhere to the state and federal laws for practice and licensure. That is a big responsibility for a nurse practitioner to live up to each day.
To prescribe medication, each nurse practitioner needs to be intimately aware of the scope of practice for prescriptive authority for the state she is practicing in. By adhering to the state prescription criteria for NPs, a nurse practitioner can safely and legally prescribe medication to patients.
All nurse practitioners must provide free access to care for all patients of all cultures, races, and diversity. Equitable care must be given in accordance to acceptable standards of treatment. The American Nurses Association (ANA) lists a code of ethics
for nursing standards that is helpful for nurses of all backgrounds. NPs can apply these basic nursing principles to their everyday practice to help ensure that they are treating all patients ethically.
Although there are standards of practice for nurse practitioners
to adhere to for safe prescribing practices, they do not have their own code of ethics. A code of ethics for NPs was proposed
in 2004 but never came to fruition. However, some states, such as California, have NP standards that touch on ethics and safe prescribing practices.
Writing scripts for controlled substances to friends and family members that are not in your practice or prescribing outside of your area of expertise has the potential to get an NP into trouble. With all of the ongoing changes to directives, nurse practitioners need to be highly aware of their state's scope of practice
and current guidelines for prescribing. When in doubt, it is best to research every grey area when it comes to prescribing legally.
Recent Changes To Practice Authority Laws Post The COVID-19 Pandemic
The COVID pandemic has undoubtedly highlighted the need for more nurses, advanced practice nurses included. The push for full practice authority
for NPs from all of the states has never been so critical. Legislative changes in response to pandemic needs have enabled nurse practitioners to (temporarily) operate to the full extent of their education. Hopefully, once the pandemic subsides, NPs will have provided enough proof that they merit full practice authority post-pandemic.
Some of the recent changes to practice authority due to the pandemic are:
According to NIH.gov, “On March 30, 2020, the Centers for Medicare and Medicaid Services authorized an emergency declaration to allow NPs to practice to the full extent of their license. Governors across the country including in Massachusetts, New York, Pennsylvania, and New Jersey among others issued executive orders to temporarily loosen the SOP restrictions on NPs and allow full practice authority for NPs.” Now nurse practitioners can prescribe from these states without supervision from a collaborating physician.
Delaware granted full practice authority for nurse practitioners during the first half of the pandemic.
AANP has established a webpage and map of temporarily suspended and waived practice agreement requirements
for NPs. Due to the ever-changing climate of the pandemic needs, this map is updated frequently. Some agreements are expiring but there are hopes of re-instating full practice agreements as the demand for providers continues.
Future Outlook Of Prescriptive Authority For Nurse Practitioners
Although some states are digging in their heels to prevent full prescriptive authority for all nurse practitioners, there is hope for progress to continue.
The recent addition of Delaware and the onboarding of California soon have helped to bolster the fight for full practice authority for nurse practitioners across the U.S.
Additionally, there is a bill in place (S. 800/H.R. 4870) that would authorize nurse practitioners (NPs) to certify therapeutic shoes for their diabetic patients. Hopefully, this simple provision will pass to allow nurse practitioners to support their diabetic patients further.
Another bill in congress is designed to give NPs more access to patient care. H.R. 1956/S. 1986, the Increasing Access to Quality Cardiac Rehabilitation Care Act of 2021
would “authorize N.P.s to order and provide supervision of cardiac and pulmonary rehabilitation services beginning in 2022”.
Although the American Medical Association (AMA) is against FPA for NPs in general, many states' medical authorities favor it.
In addition, NPs continue with their grassroots efforts to gain favor with the community, physicians, and organizations across the U.S. One win is the department of Veterans Affairs who has adopted FPA for all of its facilities across the U.S. In addition, AARP, the Bipartisan Policy Center, the National Academy of Medicine, and over 40 nursing organizations support FPA.
Each state association of nurse practitioners is fighting hard at the state level to gain leverage in the fight for FPA. Many are frustrated as they are not making headway. But they continue to provide clear reasoning as to the benefits for their state by granting FPA to nurse practitioners.
AANP lists an advocacy page
on their website with all of the latest updates regarding what is happening nationally and locally pertaining to the fight for full practice authority.
My Final Thoughts
The struggle to gain full prescriptive authority for nurse practitioners has been long and, at times, disheartening. To be clear, nurse practitioners are not trying to be doctors. We are proud of our individualized skills that are based on holistic and patient-centered medicine. We have had the training to safely and knowledgeably prescribe medication. For now, NPs need to be aware of what medications a nurse practitioner can prescribe to work within the scope of practice for your state legally. At present, the criteria for prescribing for nurse practitioners is very diversified and at times complex. I hope that this article has helped answer the evolving question of what medications can a nurse practitioner prescribe.
FREQUENTLY ASKED QUESTIONS ANSWERED BY OUR EXPERT
1. Are There Any Additional Educational Requirements For NPs In Order To Obtain Prescriptive Authority?
This varies according to state. Many states require some type of medication course, especially for controlled substances. An example is Alaska which requires 15 hours of advanced pharmacology and clinical management of drug therapy before being authorized to prescribe medication. In addition, training is necessary to prescribe Suboxone in any state.
2. Can A Nurse Practitioner Prescribe Medication To Family And Friends?
All sources state that prescribing to friends and family not in your practice is a major “grey area” that is not recommended for best practice standards. Controlled substances are not allowed to be prescribed to friends and family if not within your practice. Careful consideration and documentation will still need to be given to those within your practice due to the potential for unethical administration of controlled substances.
3. Can Nurse Practitioners Prescribe Medication For Themselves?
No state laws prohibit NPs from prescribing medication
to themselves. The one exception to this is controlled substances, where a provider is forbidden to prescribe to themselves.
4. Can A Psychiatric Nurse Practitioner Prescribe Medication?
Psychiatric nurse practitioners can most certainly prescribe medication. Psychiatric nurse practitioners
should follow their state prescribing criteria for nurse practitioners. It is prudent for NPs in this specialty to prescribe within the realm of their expertise.
5. What Factors Must A NP Consider When Prescribing Animal-Derived Medications?
An NP should be familiar with what medicines and vaccines contain animal-derived products. This is because some religions and cultures, such as the Islam religion and Jehovah's Witness, object to animal-derived drugs and vaccines. In addition, those with food allergies or moral objections may request that only non-animal derived medications
Examples of medication containing animal products are:
◦ Gelatin in capsules
◦ Certain vaccines such as Varivax and ProQaud
◦ Medication with milk products or dairy such as Benadryl Children’s Cough
6. Are There Any Medications A Nurse Practitioner Cannot Prescribe?
NPs cannot prescribe Schedule I controlled substances in any state as they are illegal and have no medical use in the U.S. Examples of Schedule I controlled substances are ecstasy, heroin, and LSD. As listed above, certain states do not allow NPs to prescribe some medications as listed per their state NP prescribing criteria, such as for controlled substances. Please refer to your individual state criteria for specific information on what you are allowed to prescribe.
7. Which States Do No Allow NPs To Prescribe Controlled Substances?
Georgia, Missouri, Ohio, Oklahoma, and West Virginia do not allow nurse practitioners to prescribe Schedule II-controlled substances.
8. Can A Nurse Practitioner Write An Emotional Support Animal Letter?
Once again, the answer to this topic is surprising. Mental health professionals such as psychologists and therapists and your family physician can write an emotional support animal letter
. NPs, including psychiatric nurse practitioners
, are listed as “not qualified
” to write this type of letter for a patient.
9. How Can I Help to Advocate for Full Prescriptive Authority for NPs?
Visit the AANP advocacy center on the AANP website for all updates and how to help in this fight. Please write to your local and state government officials and congress
and educate them about what NPs do and the high-quality care provided.
10. Why Would NP Full Prescriptive Authority Benefit the States That Do Not Allow NPs to Prescribe Methadone
Methadone is used to help withdrawal symptoms for people addicted to heroin. NPs in the states of Georgia, Missouri, Ohio, Oklahoma, West Virginia, and Arkansas cannot prescribe Methadone. All of these states with the exception of Georgia are ranked in the top half of the U.S. as the highest drug use states. West Virginia and Missouri are ranked #2 and #3 for the most troubled states for drug use problem areas. In addition, many of these states are rural with limited access to healthcare.
With the Covid pandemic, increased opioid use
and deaths have been on the increase. Obviously, more help is needed in the opioid crisis and NPs who can prescribe Methadone can certainly assist in the fight.
In addition, as many states have found, increasing access to healthcare in rural and provider shortage areas by allowing NPs full prescriptive authority, particularly for substance abuse, helps fill the provider gap.
11. Are Nurse Practitioners Allowed to Prescribe Physical Therapy to Their Patients?
According to the recently updated interactive NP scope of practice law guide
, NPs from Tennessee, Georgia, and Kentucky are not permitted to prescribe physical therapy. Check with your individual state for guidelines for prescribing P.T. as other states list additional limitations and criteria for prescribing.
12. Are there any guidelines for NPs when prescribing for the elderly population?
There are no official state criteria for prescribing to older adults. However, as many NPs are aware, increased diligence is needed when prescribing for the elderly. Therefore, it is wise to be familiar with potentially dangerous medication usage in older adults. A guide called The Beer’s List
was established to help improve safety for prescribing for older adults that is helpful in this area.
13. What can happen if I do not comply with the NP licensing and practice standards for my state?
State boards of nursing and the governing medical board do not take kindly to NPs who fail to follow the state criteria set up for individuals state NP guidelines. If you practice outside of the scope of practice for your state, you risk losing your license to practice. That is why it is crucial for you to stay current on your state's NP guidelines for practice and keep your licensing up-to-date.
14. Can nurse practitioners sign death certificates?
It varies from state to state as to whether or not nurse practitioners can sign death certificates. Only licensed physicians can sign death certificates in Louisiana, Mississippi, Oklahoma, Tennessee, California, Colorado, Illinois, Kansas, Michigan, Ohio, and Wisconsin. Several other states list certain limitations to this privilege, so check your state guidelines for signing death certificates.
Donna Reese MSN, RN, CSN
Donna Reese is a freelance nurse health content writer with 37 years nursing experience. She has worked as a Family Nurse Practitioner in her local community clinic and as an RN in home health, rehabilitation, hospital, and school nursing.