Response to CNO NP Draft Practice Expectations
Thank you for the opportunity to respond to the request for feedback made by College of Nurses of Ontario (CNO) regarding Nurse Practitioner (NP) Draft Practice Expectations.
Given the evolving role of the NP and its demonstrated impact towards improving access to care, health outcomes and health system effectiveness, RNAO supports CNO’s inclusion of practice expectations specifically relating to prescribing, dispensing, procuring, administering and managing controlled substances as permitted federally in the New Classes of Practitioners Regulations (NCPR) which RNAO largely supported.
Historically, NPs’ inability to prescribe controlled substances has prevented NPs from practising to their full scope. This continues to result in unnecessary duplication and misallocation of resources in the health system, fragments continuity of care and caregiver and impedes access to timely care.
The NP Draft Practice Expectations includes prescribing controlled substances that allow NPs to provide a comprehensive treatment approach in providing chronic disease management, which includes pain and addiction. It will expand the authority of NPs to use their competencies, knowledge and skills to benefit patients through increased access to medication, which will have a positive impact on the patient experience and the health system.
RNAO strongly recommends that medical marijuana (‘dried marijuana’) and methadone be removed from the exclusion list.
The number of individuals enrolled in methadone maintenance treatment in Ontario has risen substantially over 10 years, from approximately 7,800 in 2001 to 35,228 in 2011, with these increases considered to be largely driven by individuals with problematic prescription opioid use.
RNAO has been a strong leader in advancing the prevention, treatment and recovery from mental health and addictions. One example of our efforts includes the Best Practice Guideline (BPG) Supporting Clients on Methadone Maintenance Treatment. This evidence-informed and internationally renowned resource is available at http://rnao.ca/bpg/guidelines/supporting-clients-methadone-maintenance-t....
Currently there are many northern community members whose lives are disrupted when they or their family members are confined to urban centres in order to access methadone. Many would like to transition to buprenorphine and naloxone (Suboxone) as their communities now have programs. If authorized, NPs could be instrumental in assisting clients to safely transition to Suboxone once they reach 40 ml. (or below) of methadone, thereby strengthening individual, family, and community health.
RNAO’s position is that NPs should not be subjected to exclusions that do not apply to other healthcare professionals, such as physicians. These restrictions continue to represent barriers to quality patient care in areas, such as chronic disease management, acute care, palliative care, long-term care and practice settings where NPs are involved in harm reduction strategies.
Removing the exclusions would align with the significant evolution and establishment of the NP role in Canada’s health system. It is noted, for example, that the College of Registered Nurses of British Columbia (CRNBC) are preparing provincial regulation for NPs to prescribe medical marijuana.
RNAO asserts that these exclusions, based on the rationale of potential risk of diversion and abuse, regulatory requirements and scope of practice, are not supported in the literature from a safety nor a health system perspective. NPs possess the capacity and expertise to effectively assess the risk for diversion and abuse and are able to effectively monitor for indications of diversion throughout the course of treatment.
Other Canadian jurisdictions are planning, in a step-wise approach, to regulate the prescribing of medical marijuana (‘dried marijuana’) and methadone that require NPs attending certification programs that become part of their provincial registration as a NP.
For example, the College of Registered Nurses of Manitoba (CRNM) directs NPs to complete the University of Ottawa Prescribing Narcotics and Controlled Substances Course or the Controlled Drugs and Substances Act (CDSA) Module for RN(NP)s at the Saskatchewan Institute of Science and Technology (SIAST) to fulfill additional regulatory requirements for prescribing. Athabasca University has a similar course for NPs that the College & Association of Registered Nurses of Alberta (CARNA) supports. COUPN provides Prescribing Narcotics and Controlled Substances as part of Continuing Professional Development for NPs and RNs.
In summary, RNAO is supportive of the Nurse Practitioner (NP) Draft Practice Expectations with the following amendment:
- Remove medical marijuana (‘dried marijuana’) and methadone from the exclusion list
With this amendment, this document will represent a significant step forward for NPs to provide equitable and coordinated access to quality health care for all Ontarians.
Once again, RNAO extends its appreciation to CNO for the opportunity to offer this response and will be pleased to discuss and/or offer clarification to any of the points included.
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer, RNAO