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Kentucky Nurse Practitioners Push For More Prescribing Power

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Kentucky nurse practitioners want the authority prescribe controlled substances — like opioids — without physician oversight. A House committee next week is likely to consider a new measure that could allow advanced practice nurses to do just that.

The physician oversight comes in the form of a "collaborative prescriptive agreement," a form that doctors sign off on. Without the form, advanced nurses can’t prescribe controlled drugs. Under the new legislation, the requirement would be lifted after a four years.

“We are now finding that [advanced practice registered nurses] are finding difficulty securing a collaborator,” said Jessica Estes, president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives. “And it’s creating some barriers.”

Estes, a nurse practitioner near Owensboro, said she wants to prescribe bupherphrione, a drug often given to patients who struggle with addiction to help curb their cravings. She completed the required training to prescribe the controlled substance last year,  but Estes said she can’t find a doctor to sign off on her collaborative agreement.

“I’d love to be able to offer that in Hancock County and Ohio County, but because I’m not able to secure a collaborator to sign this piece of paper, I’m unable to offer that service,” Estes said. “So I could be a helper, but I can't do that because I don’t have this piece of paper.”

Kentucky advance practice nurses got a big legislative win in 2014. For the first time, they were able to prescribe routine drugs — like antibiotics and blood pressure medications — to patients on their own after spending four years collaborating with a doctor. Kentucky nurse practitioners can now basically set up their own shops — without having to work with a doctor — but only if they don't prescribe controlled substances, like opiates.

An Argument For Oversight

The bill introduced recently in the General Assembly makes some doctors nervous. Boyd Buser, the dean of the Kentucky College of Osteopathic Medicine at the University of Pikeville, said collaborative agreements are important.

“At least there is some relationship,” Buser said. “It’s not like there’s direct oversight, where there’s a doctor having to stand over them. So to me, the [agreement] is not a hugely onerous issue but still provides some level of collaboration and oversight. Another layer, so to speak.”

Buser said giving nurses the authority to prescribe controlled substances without oversight from a doctor would potentially increase the number of opioids being prescribed.

“I just think that expanding the number of prescribers for opioids is not the direction to go to help the opioid problem,” Buser said.

Buser also said doctors have more training than advanced practice nurses.

“The mid-level providers, you know, it’s not remotely comparatively close to the amount of training that a physician has before they go into independent practice,” Buser said.

But Estes said nurse practitioners are properly trained to prescribe controlled substances. She said the real issue is the required paperwork. Estes said the document is meaningless because doctors and nurses don’t have to meet to go over prescribing patterns or have a real "collaboration." Often, she said, nurse practitioners have a hard time finding a physician to sign off on the prescription. She said some advanced nurses even pay doctors just to get their signatures on the agreement.

“You’re simply removing a piece of paper that sits in a file,” Estes said.

The Kentucky Medical Association and the Greater Louisville Medical Society declined to be interviewed for this story. But the two organizations issued a joint statement:
“With the ongoing issue of prescription drug abuse and the discussions in Frankfort about the issue, we would oppose any changes to the current law."
Kentucky isn’t the first state to grapple with this issue. Utah, Colorado, West Virginia and Connecticut all have laws that create pathways for advanced nurses to eventually prescribe some or all controlled substances on their own.

Lisa Gillespie is WFPL's Health and Innovation Reporter.