Nurse practitioners' authority to prescribe controlled substances
Thank you for the opportunity to provide feedback on proposed changes to regulations and bylaws to enable nurse practitioners (NP) to prescribe controlled substances in Ontario.
Due to evidence that NPs working to their full scope of practice, including prescribing controlled substances, creates increased access to safe, high-quality health services, the Registered Nurses' Association of Ontario (RNAO) continues to view this as a priority.
The federal government made changes to regulations under the Controlled Drugs and Substances Act in November 2012 to enable NPs in Canada to prescribe controlled drugs and substances. It is now within the scope of practice for NPs to prescribe controlled drugs in British Columbia, Alberta, Saskatchewan, Manitoba, Quebec, Nova Scotia, Prince Edward Island, New Brunswick, Newfoundland and Labrador, Yukon, Northwest Territories and Nunavut. Ontario is the only jurisdiction lagging behind.
On Oct. 24, 2016, Minister of Health and Long-Term Care Eric Hoskins informed CNO he "would like to see nurse practitioners in a position to prescribe controlled drugs and substances as soon as possible and no later than March 2017." We are now approaching this deadline, and it is nearly five years since federal regulations changed. CNO must move urgently on this matter of great public interest.
Enabling NPs to prescribe controlled substances will increase access to comprehensive primary health care and key areas such as end-of-life care (including medical assistance in dying), pain management, addiction, mental health, harm reduction, and gender affirming hormone therapy for transgender people. In studies from the United States, increasing NP prescriptive authority to include controlled substances was associated with positive outcomes such as increased access to care, decreased costs, and the advancement of the NP role.
Evidence shows it can also help address Ontario's epidemic of opioid overdose, which claimed more than 700 lives in 2014. A 2007 report to the Ministry of Health and Long-Term Care (MOHLTC) from the Methadone Maintenance Treatment Practices Task Force recommended legislative amendments to allow NPs to prescribe methadone. A decade later, a similar MOHLTC-appointed body, the Methadone Treatment and Services Advisory Committee, recommended "amendments to provincial regulations that would enable nurse practitioners, with appropriate training, to prescribe and administer buprenorphine/naloxone and methadone for opioid use disorder.
In addition to these reports, the province's first comprehensive opioid strategy was released in October 2016, and it included specific action items to enable NPs to prescribe buprenorphine/naloxone; enhance integration of comprehensive primary care, mental health, and treatments such as buprenorphine/naloxone and methadone; as well as Indigenous mental health and addiction initiatives. Clearly, there is a public desire for NPs to do more for opioid addiction.
Once NPs are empowered to prescribe controlled substances, RNAO supports the principle of making information available to the public about whether an individual NP has met the education requirements as defined in the regulation, and if there is a relevant Health Canada notice.
Because other jurisdictions have already pursued this initiative, there are opportunities to learn from the experiences of other nursing regulatory bodies. The College of Registered Nurses of British Columbia (CRNBC), for example, provides information about class, status, NP category of practice, and whether the NP is PharmaNet eligible. The CRNBC public register is explicit that being PharmaNet eligible "means that the nurse practitioner is authorized to independently prescribe medications in accordance with the CRNBC Nurse Practitioner Standards, Limits, and Conditions and is assigned a PharmaNet number."
The College of Registered Nurses of Manitoba provides a fact sheet on prescribing controlled drugs and substances that clearly outlines NP education requirements to prescribe: controlled substances generally; methadone for analgesia; methadone for opioid use disorder; and buprenorphine/naloxone. Unlike CNO's assertion that "prescribing controlled substances as a risky activity," the College of Registered Nurses of Nova Scotia provides information that is factual, contextual, and trust-inspiring to nurses and the public.
Recommendation 1: RNAO supports the proposed regulation change that will enable NPs to prescribe controlled substances after successful completion of education requirements approved by CNO.
Recommendation 2: Consistent with federal law, NPs in Ontario must be enabled to prescribe methadone as well as other controlled substances. Instead of accepting CNO's rationale that "no exemption process exists for Ontario NPs," RNAO urges CNO to work with the MOHLTC and the provincial methadone program (administered by the College of Physicians and Surgeons of Ontario) so that NPs can access the same exemption process, education, and mentoring supports currently available to physicians.
Recommendation 3: As "prescribing controlled substances is a high risk activity" for all prescribers regardless of discipline, prescribing education should focus on interprofessional programs with common competencies. Education related to prescribing must be evidence-based, reflect best practices, and be safeguarded from conflict of interest, including industry marketing.
Recommendation 4: RNAO recommends that CNO implement lessons learned from regulatory bodies in other jurisdictions where NP prescribing of controlled substances has already been implemented. This would include, for example, equivalent treatment of controlled drug prescribers in British Columbia, NP prescription of methadone in Manitoba, and creating of informational materials about NP prescribing that is factual, contextual, and trust-inspiring as in Nova Scotia.
Recommendation 5: CNO must improve the quality and speed of its regulatory processes in order to improve public safety and increase access to health services.
Thank you once again for this opportunity to provide feedback on this critical initiative.
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT
Chief Executive Officer, RNAO
See the letter with references below