A requestor from Washington state recently asked the Network for information on the conditions under which Nurse Practitioners (NPs) and Physician Assistants (PAs) can prescribe buprenorphine for treatment of opioid use disorder (OUD).
A recently enacted federal law, the Comprehensive Addiction and Recovery Act (CARA) permits these providers to prescribe buprenorphine if the following conditions are met:
1. The provider is licensed under State law to prescribe schedule III, IV, or V medications for the treatment of pain;
2. The provider has completed 24 hours of initial training or has such other training or experience as the Secretary of the Department of Health and Human Services determines; AND
3. The provider is supervised by, or works in collaboration with, a qualifying physician, if the provider is required by State law to prescribe medications for the treatment of opioid use disorder in collaboration with or under the supervision of a physician.
"Qualifying physician" is defined by the law as "a physician who is licensed under State law and who meets one or more" of several conditions, which are the same conditions for a physician to be permitted to prescribe buprenorphine for treatment of OUD.
Pursuant to Wash. Rev. Code Ann. § 18.79.050, advanced registered nurse practitioners may prescribe legend drugs and controlled substances in Schedules II-V upon approval of the Washington State Nursing Care Quality Assurance Commission. The statute does not specify that NPs must be under the supervision of a licensed physician in order to do so.
The Department of Health then enacted regulations to implement the statute. Wash. Admin. Code §§ 246-840-400 to 246-840-420 list the requirements for NPs to prescribe controlled substances. When prescribing, the following requirements apply:
Since there is no indication that NPs cannot prescribe unless they are under the supervision of a physician, the third CARA requirement would not apply.
Wash Rev. Code Ann. § 18.71A.030(2) defines the PA's scope of practice as follows:
"Physician assistants may provide services that they are competent to perform based on their education, training, and experience and that are consistent with their commission-approved delegation agreement. The supervising physician and the physician assistant shall determine which procedures may be performed and the degree of supervision under which the procedure is performed. Physician assistants may practice in any area of medicine or surgery as long as the practice is not beyond the supervising physician's own scope of expertise and practice."
The statute is silent with regard to the PA's prescriptive authority, but it is clear that a PA's scope of practice is always within the supervision of a licensed physician.
The Department of Health regulations give PAs the authority to prescribe controlled substances in Schedules II-V whenever such an action is consistent with the scope of practice in an "approved delegation agreement." Before prescribing, the PA must have an active DEA registration (Wash. Admin. Code § 246-918-035). That rule also provides that "If a supervising physician's prescribing privileges have been limited by state or federal actions, the PA will be similarly limited in his or her prescribing privileges, unless otherwise authorized in writing by the [Medical Quality Assurance Commission]."
Since PAs in Washington must practice (and, thus, prescribe) under the supervision of a physician and their practice must be within the scope of the delegation agreement,the third CARA requirement, mentioned above, would apply.
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