“I’ve been administering controlled substances since 1985,” says Dee Dee Gardner, DNP, CRNP, a nurse practitioner at Cullman Regional Orthopedics and Sports Medicine. “Now I can prescribe them.”
Gardner represents one of the first certified registered nurse practitioners (CRNP) in Alabama to be granted that privilege. Passed in April 2013 by the state legislature, Act 223 allows qualified nurse practitioners to apply for a Qualified Alabama Controlled Substances Certificate (QACSC), which empowers them to prescribe Schedules III, IV and V drugs. They are still prohibited from prescribing morphine or other drugs classified as Level I and II.
Until the Act passed, Alabama and Florida had been the only two states to prohibit nurse practitioners from prescribing controlled substances. “As NPs, we can inject joints, put in central lines—we can do all sorts of advanced things to patients. But we couldn’t give you something for your pain,” Gardner says. “This is a real advancement in Alabama healthcare.”
Administered under the Alabama Board of Medical Examiners, the certificate requires CRNPs and Certified Nurse Midwives to be in a collaborative agreement with a physician who holds a valid, unrestricted Alabama Controlled Substances Certificate (ACSC). They must also attend the initial 12-hour education course on advanced pharmacology—the same one physicians attend—and have at least 12 months of active clinical practice.
“You also have to work 1,000 hours per year as an NP,” Gardner says. “You can’t work one day a month and stay current in prescribing.”
Gardner attended the required three-day seminar on controlled substances last October. About 500 attended, including the physicians maintaining their own ACSC. “Once I finished that, I started writing all the required quality assurance processes and procedures for our practice,” she says. It took her five months. “When you’re seeing 30 to 35 patients a day, it takes awhile.”
Susan Alexander, DNP, ANP-BC, ADM-BC, attended the November seminar along with about 250 attendees. Alexander, who serves as the president of the Nurse Practitioner Alliance of Alabama and is a clinical associate professor at the College of Nursing at University of Alabama Huntsville, says about 1,200 NPs have attended the seminars so far.
“This is going to be a lot better for the patient, because you can hand them the prescription and instruct them at the same time,” Alexander says.
After obtaining the state certificate, NPs must apply to the DEA for a controlled substance license. In April, Gardner received her DEA number and could start prescribing controlled substances without a collaborating physician’s review or signature.
“I work in an orthopedic practice, and our patients don’t seek treatment because they’re sick, it’s because they’re hurt in some way,” Gardner says. “So prescribing controlled substances has resulted in an immediate improvement in the efficiency in our clinic.”
Before the certification, Gardner had to consult a physician about ten times a day on pain medications. “Now I’m not spending countless hours a week waiting for a physician to come out of a room or get off the phone to say I’ve got a patient with a fracture that needs something for pain,” Gardner says.
The collaboration means physicians must review the NPs narcotic prescriptions monthly. “We still have to have collaborative physician oversight, but we just want to be productive and have greater outcomes,” Gardner says. “We’re an augment to their practice, and as a result of more privileges, we expand the practice and generate income.”
The cost to attain the advanced privilege proved an eye-opener. The initial qualifying costs included $110 for the QACSC, $200 for the seminar, and $731 for the three-year DEA license. “It’s a ‘welcome to the real world’ for nurse practitioners,” Alexander says about the fees. “This is what it costs to practice at an advanced level.”
The DEA license opens access for NPs to the Prescription Drug Monitoring Program (PDMP) run by the Alabama Department of Public Health. “So I can find out whether the patient in front of me has gotten a prescription for this drug in the last month,” Alexander says. “Before this legislation, I had to call a doctor or talk to the doctor’s nurse, so she could get the doctor to access the database. It was an incredibly inefficient way to prescribe high-risk medications.”
Alabama still lags far behind most every state in privileges granted to NPs, including allowing them to sign handicap parking permits, perform sports physicals or sign death certificates.
The most freeing privilege for the nurse practitioner community would be independent practice. 30 states already allow it, clearing NPs to serve in areas where physician access is remote, making the currently required collaboration impossible. “Especially in rural areas where people don’t seek healthcare now, because there’s often no one to seek,” Gardner says.
Alabama CRNPs have a master’s degree in nursing and pass a national certification exam. On average, they also come with an average of 11.7 years of clinical practice experience, according to the American Association of Nurse Practitioners “They’re not new to this,” Alexander says, adding that this new privilege marks an opening to greater recognition for NPs as advanced healthcare professionals.
“If you’re in practice seeing and treating patients who need management of controlled substances, strongly consider applying for the certification,” Alexander says. “Because this is what you do as a professional.”