Kentucky advance practice nurses got a big win in 2014. For the first time, they were able to prescribe routine medications, like antibiotics and blood pressure meds, to patients after spending four years collaborating with a doctor. This applied to…“nurse practitioners, nurse midwives and clinical nurse specialist…”
That was Jessica Estes , a nurse practitioner near Owensboro. She’s also the president of the Kentucky Coalition of Nurse Practitioners & Nurse-Midwives.
So this was a big win for these nurses. Nurse practitioners could basically set up their own shops - free from having to work with a doctor - but only if they didn’t prescribe controlled drugs, like opiates. They still have to have an agreement with a doctor indefinitely to prescribe those controlled drugs.
“We are now finding that APRNs are finding difficulty securing a collaborator , and they have to be of the same or a similar specialty, and licensed in Kentucky. And it’s creating some barriers.”
This ‘collaborative prescriptive agreement’ is a piece of paper, a form if you will. Doctors sign off on it. And every year, those doctors have the option of renewing that collaborative agreement.
But the bill introduced recently in the General Assembly would change that. It would allow advanced nurses to prescribe controlled substances on their own, as long as they’ve been under a collaborative agreement with a doctor for four years.
This change makes doctors nervous, and it was hard to find someone who would talk about it. The Kentucky Medical Association and the Greater Louisville Medical Society wouldn’t get on the phone, and instead, both groups sent the same statement. They oppose any changes to current law. They cited ongoing issue of prescription drug abuse.
Boyd Buser (Bue-ser) is the dean of the Kentucky College of Osteopathic Medicine at the University of Pikeville. He says the piece of paper--referred to by abbreviation as a “capa-cs”--is important.
“At least there is some relationship and it’s not like there’s direct oversight where there’s a doctor having having to stand over them. So to me, the capa-cs is not a hugely onerous issue but still provides some level of collaboration and oversight. Another layer, so to speak.”
Buser and other doctors say they don’t want nurses to prescribe controlled drugs without this oversight. One reason is - it would create more potential prescribers of opioids.
“I just think that expanding the number of prescribers for opioids is not the direction to go to help the opioid problem.”
But Estes says nurse practitioners get the training to prescribe these drugs. And often, the real problem is when a nurse practitioner can’t find a physician to sign this piece of paper. That’s the situation she’s in right now. She wants to prescribe buprenorphine, which helps patients who struggle with addiction stop having cravings.
“I’ve completed the training, 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. So I could be a helper, but I can't do that because I don’t have this piece of paper.”
Buser argues doctors are the most trained and best providers to give those services, and Estes [S-tis] needs some type of oversight.
“It’s s a huge amount of training , whereas the midlevel providers, you know, it’s not remotely comparatively close to the amount of training that a physician has before they go into independent practice.”
But to nurse practitioner Estes, removing the collaborative agreement after four years means...
“you’re simply removing a piece of paper that sits in a file.”
While the doctors generally do have more medical training, Estes argues the paper is meaningless - doctors and nurses don’t have to meet to go over prescribing patterns, or have a real ‘collaboration.’ Some advanced nurses even pay doctors just to get their signatures on this agreement.
Meanwhile, 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.