Ingrid Hein

June 27, 2016

SAN ANTONIO — Nurse practitioners who have the authority to prescribe controlled substances in the form of mental health drugs have prescribing patterns similar to physicians, new research shows.

"This demonstrates that nurse practitioners who have had unrestricted authority for prescribing controlled substances do not prescribe them in greater quantity or differently than their peers," said Tracy Klein, PhD, FNP, ARNP, from the Washington State University College of Nursing in Spokane.

Dr Klein and her colleagues assessed the prescribing patterns of generalists (family, pediatrics) and specialists (psychiatry) who treated Medicaid patients in Oregon with attention-deficit and hyperactivity disorder (ADHD) in 2012.

Data from Oregon were used because the state has a history of broad-scope prescribing authority for nurse practitioners dating back to the late 1970s, Dr Klein told Medscape Medical News. And since 2000, nurse practitioners in Oregon have had the authority to prescribe Schedule II drugs, which include ADHD medications.

The researchers evaluated the prescription of controlled substances — such as methylphenidate, amphetamine and dextroamphetamine mixed salts, lisdexamfetamine, dexmethylphenidate, and dextroamphetamine — and uncontrolled substances — such as guanfacine, clonidine, and atomoxetine.

The results were presented here at the American Association of Nurse Practitioners (AANP) 2016 National Conference.

The study involved 1785 prescribers. Of the 381 nurse practitioners, 303 (80%) were generalists and 78 (20%) were specialists. Of the 1404 physicians, 1242 (86%) were generalists and 162 (14%) were specialists.

For 10,753 unique children 3 to 18 years of age, there were 82,754 prescriptions for 30-day supplies of medication.

Prescribing patterns for controlled and uncontrolled medications were similar for nurse practitioners and physicians.

Table 1. Breakdown of the 82,754 Prescriptions Evaluated

Age Range Nurse Practitioners Physicians
  n % n %
Generalists        
   3 to 5 years 180 2.9 2092 4.3
   6 to 11 years 3440 55.7 29,077 59.1
   12 to 18 years 2555 41.4 18,044 36.6
Specialists        
   3 to 5 years 374 4.1 601 3.3
   6 to 11 years 5044 54.6 9797 54.0
   12 to 18 years 3815 41.3 7735 42.7

 

Prescribing patterns by age range were similar for nurse practitioners and physicians. Overall, children 3 to 5 years of age received less than 5% of the prescriptions, children 6 to 11 years received slightly more than half, and adolescents 12 to 18 years received about 40%.

Adolescents were most likely to be prescribed controlled drugs by nurses, physicians, generalists, and specialists. And overall, generalists wrote the highest number of these prescriptions.

Prescriptions for uncontrolled medications were written more often by specialists than generalists, regardless of whether the prescribers were nurse practitioners (48.5% vs 38.5%) or physicians (51.2% vs 28.3%).

Table 2. Prescription of Uncontrolled Substances

Specific Prescriptions Nurse Practitioners, % Physicians, %
Guanfacine    
   Generalists 16.1 11.8
   Specialists 25.2 26.4
Clonidine    
   Generalists 9.8 9.0
   Specialists 13.4 12.7
Atomoxetine    
   Generalists 12.6 7.5
   Specialists 9.9 12.1

 

The only variation in prescribing patterns was that generalist physicians prescribed controlled medications more often to children 3 to 5 years of age than nurse practitioners.

That is likely because "we included pediatricians in the generalist physicians group," Dr Klein explained. And nurse practitioners were more likely to defer to a specialist when it came to prescribing for very young children.

"I can't speak for all nurse practitioners, but most would consider a very young child with a mental condition at really high risk," and most generalists "would not feel as comfortable making a diagnosis for that child," she said.

Discrepancies in Prescribing Authority Not Justified

There are extensive disparities between states with respect to the prescriptive authority of nurse practitioners, as previously reported by Medscape Nurses. In some states, authority is granted at the time of APRN licensure; in others, the APRN must apply separately for the privilege, and in still others, there is variation in authority for controlled and uncontrolled substances.

 
We really don't see any logical reason to restrict nurse practitioners from prescribing.
 

Restrictions on the prescription of type or quantity of drug are not justified, Dr Klein said. "We really don't see any logical reason to restrict nurse practitioners from prescribing," she pointed out.

"There is a lot of interest in qualified pediatric nurse practitioners who do prescribe for children to provide more mental health services," said Catherine Haut, DNP, outgoing president of the National Association of Pediatric Nurse Practitioners.

"The data are not surprising to me. There's a need for nurse practitioners to do this," she told Medscape Medical News.

"If there was more consistency between state boards to allow nurse practitioners to prescribe controlled substances, there may be more benefit for children because there are many primary care nurse practitioners who care for children," she explained.

There are fewer than 7500 practicing child and adolescent psychiatrists in the United States, and fewer than 600 developmental behavioral pediatricians. The Council of Pediatric Subspecialties calls this "a huge shortage."

"I work in rural area where there aren't psychiatrists available. Too many kids go unnoticed and untreated," said Dr Haut. Behavioral therapy always comes first, but prescribing is an important option because "there's more evidence that supports the use of meds."

Parents she works with really see a difference in their children, she reported. "I had a child who had a hard time learning to read; the parents thought she had dyslexia."

Dr Klein and Dr Haut have disclosed no relevant financial relationships.

American Association of Nurse Practitioners (AANP) 2016 National Conference. Presented June 24, 2016.

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