House passes bill to allow APRNs to prescribe controlled substances after a four-year collaborative agreement with doctor

American Association of Nurse Practitioners map, adapted by Kentucky Health News

By Melissa Patrick
Kentucky Health News

A bill to create a path for Kentucky's advanced practice registered nurses to prescribe controlled substances independently has passed the state House with only eight members voting against it. 

“We are always talking about encouraging folks to enter the health-care field; we hear discussion about a shortage of nurses that we have,” Rep. Russell Webber said while presenting the bill on the House floor. “This bill will help with that.”

House Bill 354, sponsored by Webber, would allow an APRN to prescribe controlled substances without a collaborative agreement with a physician, after practicing under such an agreement for four years and getting approval from the Kentucky Board of Nursing.

If the board decides an APRN is abusing this authority, it can require them to go back under a collaborative agreement, or it can take further action.

The latest version of the bill would hold independently prescribing APRNs to the same standard of care as other prescribers, and create a Controlled Substance Prescribing Review Panel to monitor them.

"This component adds teeth to this bill. It adds strength," said Webber, a Shepherdsville Republican. "It  may very well help us get to the bottom of some problems that are existing out there, if they are existing, but the data will certainly be worthwhile for us to have. Problems that may surface will be worthwhile for us to know."

Rep. Russell Webber

Webber was alluding to the implicit contention of the doctors' lobby, the Kentucky Medical Association, that APRNs haven't been responsible enough with their prescribing of Schedule II drugs, those with high potential for abuse, to prescribe them independently.

In Kentucky, APRNs have been able to prescribe controlled substances since 2006 under a "collaborative agreement for prescriptive authority-controlled substances," or CAPA-CS. They are allowed to prescribe a 72-hour supply of a Schedule II drug; HB 354 wouldn't change that.

The bill's primary co-sponsor, Rep. Patti Minter, a Democrat from Bowling Green, told the House that it is needed to increase health-care access in a state that has only 57 percent of the primary-care practitioners it needs and 25% of needed mental-health personnel. 

"Nurse practitioners are for many people the primary-care providers," Minter said. "They're the family doctors of the community."

Rep. Jerry Miller, R-Eastwood, said the bill would improve access to health care. "This is a good bill for the people," he said. "It may not be a good bill for the doctors, but it's a good bill for the people of Kentucky." 

House health committee Chair Kim Moser, R-Taylor Mill, a former nurse and a doctor's wife, voted no. Moser said she liked the amendments because "It's critical that all prescribers play by the same rules" but cautioned, "The only thing that we are doing by passing this bill is increasing controlled substances."

The House voted against suspending its rules to let Moser offer a floor amendment to reinstate the requirement that an APRN be licensed to practice for a year before being prescribing controlled substances, to obtain a registration certificate from the Drug Enforcement Administration and pass each component of the federal licensing exam in three attempts, just as physicians must do before prescribing controlled substances. 

Rep. Mary Lou Marzian, D-Louisville, a nurse, said the bill is needed because APRNs need a DEA number to order some diabetic and psychiatric medication, durable medical equipment, and flu and antibiotic shots.

APRNs were allowed to prescribe controlled substances without a collaborative agreement in the pandemic through an executive order that the General Assembly approved, but that ended in January when lawmakers extended the state of emergency but did not extend the APRNs' expanded authority.

Dueling numbers

A before-and-after comparison by the Kentucky Association of Nurse Practitioners & Nurse-Midwives, said there were "no significant differences in the average number of opioid prescriptions by APRNs without the CAPA-CS in place" before the emergency order was implemented and the six quarters it was in place. Similar findings were also noted for dentists and physicians. 

The data came from the state's Kentucky All Schedule Prescription Electronic Reporting system. Other KASPER data provided by the APRN association shows that the average number of Schedule II prescriptions per APRN prescriber dropped 34.9% between 2015 and 2021. 

Webber said, "Nurse practitioners were not writing prescriptions hand over fist for controlled substances and flooding the state with opioids." 

The KMA disputed those figures before the House Licensing, Occupations and Administrative Regulations Committee on March 9.

Cory Meadows, KMA's deputy executive vice president and director of advocacy, said "We have KASPER numbers that show that they are consistently up, way up over the course of a lot of years."

KASPER data provided by the KMA, comparing the total number of prescriptions for Schedule II opioids prescribed by APRNs shows an increase in all but one year since since 2011, the year before lawmakers passed what is called the "pill-mill bill" that placed restrictions on opioid prescribing.

There are some discrepancies, many of them slight, in the year-to-year numbers provided to Kentucky Health News by the two organizations, and they measure different things. 

For example, the APRN group provided the average number of Schedule II opioid prescriptions per the number of prescribers since 2015 and for seven recent quarters, while the KMA provided year-to-year percentage changes for the total number of such prescriptions. 

KMA data shows that Schedule II opioid prescribing by APRNs went up 8.2% between 2020 and 2021, years that the CAPA-CS were no longer required, under the executive order.

The APRN data shows that the average number of Schedule II opioid prescriptions per APRN dropped from 100.68 in 2020 to 99.28 in 2021 and that their quarterly average in 2021 was 25 prescriptions. The average was 50 for physicians and 22 for dentists.

The bill passed the House 84-8 and moves to the Senate, where it will be carried by Sen. Julie Raque Adams, R-Louisville. 

The "no" votes were all Republican: Moser, Joe Fischer of Fort Thomas, Kim King of Harrodsburg, Mathew Koch of Paris, Adam Koenig of Erlanger, Sal Santoro of Union, Nancy Tate of Brandenburg and Killian Timoney of Lexington.