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Q&As (General): NPs prescribing controlled substances
On April 19, 2017, government approved regulations to expand NPs’ scope of practice to include prescribing controlled substances.
What are controlled substances and why are they restricted?
A controlled substance is one that is included in Schedule I, II, III, IV or V of the federal Controlled Drugs and Substances Act. Controlled substances are used in healthcare to treat a wide variety of conditions including, but not limited to, pain, anxiety, epilepsy and sleep disorders. They include opioids, benzodiazepines, amphetamines, sedatives, anti-emetics and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential misuse, addiction and diversion.
Can NPs prescribe controlled substances?
Only NPs who have successfully completed College approved controlled substances education are authorized to prescribe controlled substances in Ontario. For more information about the education, read Q&As: Controlled Substances Education Requirement.
Are there any controlled substances that NPs can’t prescribe?
Yes, regulations under the federal law prohibit NPs from prescribing the following controlled substances:
- diacetylmorphine (heroin)
- opium (such as opium and belladonna suppository)
- coca leaves (such as cocaine) and
- anabolic steroids except testosterone (NPs are authorized to prescribe testosterone.)
Also, NPs in Ontario can only prescribe methadone with a Health Canada exemption (see next question for details).
Can NPs prescribe methadone?
Methadone is regulated more rigorously than other controlled substances. A Health Canada exemption is required to prescribe it. At this time, there is no process for individual NPs to obtain this Health Canada exemption.
However, there is one exception. If specific terms and conditions are met, there’s an exemption that allows prescribers (such as physicians and NPs) working in hospitals to prescribe methadone to clients who are admitted to hospital and who have a prior methadone prescription. If an NP is prohibited from prescribing controlled substances, they cannot prescribe methadone under this exemption.
Details of the mandatory terms and conditions are on Health Canada's website.
Not meeting these terms and conditions may result in a contravention of the Controlled Drugs and Substances Act and its regulations.
In addition to the terms and conditions, NPs are expected to meet the accountabilities outlined in the Nurse Practitioner practice standard and ensure they have the competence to prescribe methadone.
- Health Canada’s web resource on the Methadone Program
- Centre for Addiction and Mental Health’s methadone treatment resource for professionals
How can I tell if an NP is authorized to prescribe controlled substances?
You can use the College’s register Find a Nurse to check whether an NP is authorized to prescribe controlled substances. NPs who are not authorized to prescribe controlled substances are identified on the register as “Entitled to Practise with Restrictions” with a description that states: "This member cannot prescribe controlled substances. They have not completed the education needed to do so."
What evidence supported the changes to NP scope of practice?
A significant amount of policy work was done to inform decision-making, including:
- an analysis of relevant legislation
- literature reviews
- a review of other regulators’ policies
A national working group under the Canadian Council of Registered Nurse Regulators established a national approach to regulating this new area of practice. Joint work included a literature review, identifying education competencies and courses, as well as next steps to be taken within each jurisdiction (for example, integrating into program approval).
In 2013, the College conducted a survey of Ontario NPs to better understand practice realities associated with the use of controlled substances (for example, relevance of specific controlled substances to their practice setting/client population, learning needs, existing supports, and attitudes and concerns about the risks associated with controlled substances). In addition, in 2014 and 2016, the College consulted on proposed core competency indicators and practice expectations with several key stakeholders.
Isn’t prescribing controlled substances a risky activity? Why give NPs this authority now?
Yes. Activities associated with controlled substances are high risk (e.g., potential for misuse, addiction, diversion). Yet these risks need to be balanced with ensuring clients have access to appropriate treatment. Ontario NPs frequently assess clients with conditions that may require controlled substances for treatment. If NPs can’t prescribe controlled substances, clients may not get the treatment they need or their treatment may be delayed.
Safe, effective and ethical prescribing includes practitioners being able to assess and identify potential and actual medication misuse, addiction and diversion. Education and other regulatory mechanism will address the risks associated with controlled substances so NPs can prescribe safely, effectively and ethically.
Can I phone in a prescription for a controlled substances to a pharmacy?
Telephone orders and other verbal orders should only be used in limited circumstances as there are inherent risks with using verbal orders. Under federal law, certain controlled substances (most narcotic medications) cannot be ordered without a written prescription. If phoning prescriptions to a pharmacy, NPs should ensure that the medication can be prescribed by phone and should document the rationale for why they needed to do so by telephone.
The Ontario College of Pharmacists provides a resource that may be helpful: Prescription Regulation Summary Chart (Summary of Laws) or visit their website – http://www.ocpinfo.com/.
Am I allowed to order controlled substances with refills?
Under federal law, there are specific requirements about refills for controlled substances.
- Refills are not permitted for narcotics
- Refills are permitted for benzodiazepines and targeted substances by either a written or telephone prescription that specifies the number of refills
- Prescriptions (including any refills authorized) for benzodiazepines and targeted substances expire within a year
- Refills for part I controlled drugs (e.g., amphetamines) are permitted by a written prescription only, and must specify the number of refills and refill dates (or intervals between refills)
- Refills for part II controlled drugs (e.g., barbiturates) and part III controlled drugs (e.g., testosterone) are permitted by either a written or telephone prescription, and must specify the number of refills and refill dates (or intervals between refills)
The Ontario College of Pharmacists provides a resource that may be helpful: Prescription Regulation Summary Chart (Summary of Laws).
You must meet the expectations for prescribing controlled substances outlined in the Nurse Practitioner practice standard. These include prescribing a quantity of controlled substances to be dispensed that balances the need to reassess and monitor the client with the risk of harm that may result if the client runs out of medication. NPs providing episodic care should prescribe the minimum amount necessary until the client can be assessed by their regular care provider.
I’m involved in procuring medications for my practice setting. Are there any legal requirements around reporting theft of controlled substances?
There are legal requirements under the Controlled Drugs and Substances Act related to record-keeping and reporting theft of these medications. You must report the loss or theft of controlled substances to Health Canada’s Office of Controlled Substances within 10 days.
I’ve heard that federal law allows NPs to prescribe marijuana. Can I sign a medical document stating that my client is eligible for medical marijuana?
Yes. NPs are authorized to sign a medical document stating that their client is eligible for medical marijuana. You are accountable for ensuring that medical marijuana is an appropriate evidence-based treatment for your client. You are also accountable for meeting the accountabilities around therapeutic management outlined in the Nurse Practitioner practice standard.
NPs completing a medical document authorizing a client to access medical marijuana should counsel the client about risks, side effects, safe storage and the importance of obtaining the marijuana from a legal source. NPs must comply with requirements under the Access to Cannabis for Medical Purposes Regulations. As outlined in the regulations, NPs may only provide medical documents for clients under their professional treatment. NPs must provide specific information on the medical document, including:
- the NP’s full name, professional designation, registration number, contact information (business address, phone, fax and email, if applicable), address of the location at which the client consulted with them
- the client’s full name and date of birth
- daily dose of marijuana in grams that a client can take, and
- the period of use (maximum 1 year), which begins on the day on which the medical document is signed by the practitioner.
The NP must sign and date the medical document.
- Sample Medical Document for the Access to Cannabis for Medical Purposes Regulations
- Information on new Access to Cannabis for Medical Purposes Regulation
- Health Canada’s information for health care professionals
I’m an NP that is not authorized to prescribe controlled substances. What do I do if I determine a client requires a prescription for a controlled substance?
NPs can expect to encounter clients requiring prescriptions for controlled substances, since many medications are controlled substances. You should plan for this anticipated client care need by establishing strategies consistent with College standards and guidelines. You should also work with your employer to ensure you have access to resources for meeting client needs. In this case, the resource you need is the ability to refer to a health professional such as an NP or physician authorized to prescribe controlled substances. The client’s prescription must be filled out by the authorized prescriber in a manner that is consistent with their regulatory obligations.
NPs who are not authorized to prescribe controlled substances must not taper a controlled substance or renew a prescription for a controlled substance as these are considered prescribing.
If you commonly encounter clients in your practice that require controlled substances you should consider completing the education requirement that would authorize you to prescribe controlled substances. As expected for any activity, you may have additional learning needs you have to meet, relevant to your setting and client population.
I’m an NP who is not authorized to prescribe controlled substances. I assessed a client and determined that she needs treatment with a controlled substance. The physician I work with agreed with my findings and proposed a treatment plan. Can I complete this prescription based on the outcome of my consultation with the physician?
No. Consulting with a physician does not give you the legal authority to prescribe any medication. The authority to prescribe medication comes from the legislation. Therefore, in this case the physician should be asked to prescribe the controlled substance. Physicians have their own professional accountabilities, which may also require them to personally assess the client.
I’m an NP interested in developing a policy related to weaning clients off high doses of narcotics. Does the College have guidelines to support this?
The College does not have guidelines related to weaning clients off high doses of narcotics. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. That being said, the College recognizes the need for NPs to have resources about this new area of NP practice. We have developed a page that points NPs to a variety of resources related to controlled substances, including content about weaning (tapering) controlled substances.
The controlled substances resource page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or client population. You are accountable for using the best evidence to inform your clinical decisions.
NPs are accountable for taking appropriate action to resolve or minimize the risk of harm to a client from a medication adverse reaction (from the Medication practice standard). Implementing a policy that supports weaning clients of high doses of narcotics is one example of meeting this expectation. With client interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.
I’m an NP and I work in a walk-in clinic. I’m concerned that clients are drug-shopping to divert controlled substances. How do I spot this behaviour and manage any increased client pressure?
First, you should read the Nurse Practitioner practice standard to know your accountabilities when faced with this types of situation. For example, the practice standard says NPs are accountable for incorporating evidence-informed strategies for assessing, managing and monitoring the risks of misuse, addiction and diversion.
A very helpful source of evidence-informed strategies is the College of Physicians and Surgeons of Ontario’s policy document entitled Prescribing Drugs. It contains practical steps to help prevent diversion, misuse and abuse, as well as identifying common aberrant drug-related behaviours. You should also consider if you are the most appropriate care provider for that client and/or whether you need to refer or consult an expert. For example, consider if you have the knowledge, skill and judgment to manage the situation. The Nurse Practitioner practice standard says NPs need to identify when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care. So, you may want to consult another healthcare professional to benefit from their expertise.
I’m an NP and I have clients who are addicted to controlled substances. I want to help. Does CNO have guidelines to support my practice?
The Nurse Practitioner practice standard states that NPs are accountable for using strategies to reduce risk of harm involving controlled substances, including medication misuse, addiction and diversion.
The College does not have guidelines specific to treating clients who are addicted to controlled substances. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. However, we recognize the need for NPs to have informed resources in this new area of NP practice. We have developed a page that points NPs to a variety of resources related to controlled substances, including some resources related to treating opioid dependence. There is also content about methadone and an existing methadone exemption in hospitals on the NPs prescribing controlled substances general Q&As page.
The controlled substances resource page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or client population. You are accountable for using the best evidence to inform your clinical decisions. With client interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.
I’m a new NP working in an emergency department and I treat a variety of clients. I would like information for my prescribing practice (e.g., information related to cancer pain, chronic pain, managing withdrawal symptoms, dealing with opioid tolerant clients). Does the College have guidelines to support this?
NPs are accountable for implementing evidence-informed therapeutic interventions (from the NP practice standard).
The College does not have guidelines related to the clinical areas you are inquiring about. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. However, we recognize that to meet the expectation in the Nurse Practitioner practice standard that says NPs are accountable for implementing evidence-informed therapeutic intervention, NPs need resources to inform this new area of their practice. We have developed a page that points NPs to a variety of resources related to controlled substances, including content that will support the areas you mentioned in your question.
The controlled substances resource page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or client population.
My patient is not compliant with the plan of care and is refusing urine screening to monitor medication compliance. I am concerned about prescribing controlled substances in light of this. What should I do?
As an NP, you are responsible for monitoring the client’s response to the prescribed substance and for assessing, managing and monitoring the risks of misuse, addiction and diversion. You are also responsible for implementing strategies to mitigate these risks, and should only perform procedures or activities when you have access to the appropriate client information.
Several factors can contribute to conflict between an NP and a client. For example, this can occur if an NP judges or misunderstands a client (e.g., the client may feel the NP is not listening to, or respecting, their values, opinions or beliefs). NPs may need to reflect on and modify their communication style to meet the needs of the client and find the best possible solution in any complex nurse-client situation.
Ultimately, if the challenges with your client continue and place the client at risk, then you are accountable for acknowledging when there is a diminished therapeutic relationship and for requesting a transfer of care.
For more information on the accountabilities mentioned above, read the Therapeutic Nurse Client Relationship practice standard, Nurse Practitioner practice standard and Conflict Prevention and Management practice guideline.
I have been managing a client with complex addiction issues. My client is pushing for prescriptions that are not in their best interest and I’ve grown increasingly concerned about my personal safety. How do I manage this?
The College does not expect nurses to put their lives or personal safety at risk when caring for clients. As the primary NP, consider if you are the most appropriate care provider for that client and/or whether you need to refer to, or consult, an expert such as an addictions specialist or psychiatrist. For example, consider if you have the knowledge, skill and judgment to continue treating this client. Also, NPs are accountable for identifying when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care.
Employers also have accountabilities under the Occupational Health and Safety Act – they are accountable for establishing a safe work environment and minimizing real or potential risk to employees and clients alike.
The College encourages nurses to work collaboratively with their employers, as well as colleagues, to mitigate real or potential threats. If needed, they should develop policies, procedures and processes that are specific to the practice setting and driven by client interests and safety.
For more information on maintaining a quality practice setting and guidelines for decision-making, read Refusing Assignments and Discontinuing Nursing Services and Ethics.
Where can I find information about Ontario’s Narcotics Strategy, and the Narcotics Monitoring System?
Information about Ontario's Narcotics Strategy and the Narcotics Safety and Awareness Act, 2010 can be found on the Ministry of Health's website. As part of the Narcotics Strategy, the province has established the Narcotics Monitoring System (NMS) to monitor the prescribing and dispensing of controlled substances. Although its name implies the monitoring of narcotics, the NMS monitors all controlled substances as well as opioids that are not controlled substances (such as medications containing Tramadol). The main purpose of the NMS is to examine drug-use patterns to inform harm reduction strategies and education initiatives, and improve prescribing and dispensing practices related to monitored drugs. If illegal activity or professional misconduct is suspected, the Ministry may report information from the NMS to law enforcement bodies and regulatory colleges.
Can I dispense medications that are controlled drugs and substances?
Yes, you can dispense a controlled substance that you prescribed or that was ordered by a physician or dentist with whom you work. The Nurse Practitioner and the Medication practice standards describe the practice expectations for public protection when dispensing medication.
Is controlled substances content integrated into NP curriculum?
Yes. Now that prescribing controlled substances is part of NPs’ scope of practice, it has been integrated into Ontario NP program curriculum. Students starting in Ontario programs from September 2017 onwards will have the required controlled substances content and will not have to complete a standalone course.
Members and applicants who don’t have this content in their NP program can take Council-approved controlled substances courses to gain foundational competencies that are unique to controlled substances, and meet the education requirement set out in regulation.
How often am I required to complete approved controlled substances education?
This is a one-time requirement to gain foundational competencies that are unique to controlled substances. You may have other learning needs related to controlled substances. As part of commitment to continuing competence and quality improvement, you are expected to engage in practice reflection to identify learning needs, and set and achieve learning goals.
How will this new authority affect medical assistance in dying?
Medical assistance in dying protocols may require controlled substances. This regulation change may enable NPs to provide medical assistance in dying protocols (in accordance with legal requirements). See Guidance on Nurses’ Role in Medical Assistance in Dying for a description of legal and professional requirements.
Can I dispense medications that are controlled drugs and substances?
The identification number is assigned to track medications from the point of procurement to the point they are provided to a client. The purpose of an identification number is to trace a medication back to the manufacturer. In the event of safety concerns (e.g., a medication recall), the identification number enables health professionals to follow up with clients appropriately.
You should consult your employer about whether this tracking system exists in your practice setting and how to obtain the identification number. If such a system does not exist, you should advocate for measures to ensure safe medication practices. If you are self-employed, you are expected to establish your own tracking system. The practice expectations for public protection when dispensing medication are described in the Nurse Practitioner practice standard.
Why is the drug manufacturer’s name required on the label of a medication I dispense? What if this information is not available to me?
When an NP is compounding a cream for topical application, the NP is expected to have the manufacturer’s original packaging for the various substances used in the compound. Therefore, when compounding, you must include the manufacturer’s name on the label if the compound is being dispensed to a client.
Is it a conflict of interest for NPs who prescribe a medication to also dispense or sell that medication?
No. The College has developed specific conflict-of-interest provisions to reduce the risk of NPs finding themselves in a position of conflict. For example, NPs cannot charge “dispensing fees” or obtain a profit from the sale of a medication.
NPs cannot obtain any benefit as a result of prescribing, dispensing or selling medication. A “benefit” is defined as any financial or non-financial incentive, whether direct or indirect, that conflicts with an NP’s professional or ethical duty to a client. NPs are expected to base treatment decisions on best available evidence, clinical judgment and client needs. NPs do not prescribe a particular medication because it is available for sale in the practice setting.
The practice expectations for public protection are described in the Nurse Practitioner practice standard.
Can NPs sell medication? Can I ask an administrative assistant to conduct the financial transaction associated with selling medication?
- the client does not have reasonable access to a pharmacy
- the client would not otherwise receive the medication
- the client does not have the financial resources to otherwise obtain the medication, or
- the medication is sold as part of a health promotion initiative.
Yes, NPs can sell medication. Before you sell a medication, you are accountable for assessing the client to determine that at least one of the following circumstances exists:
NPs cannot charge more than the actual cost of the medication, neither for personal financial gain nor to account for overhead or any other expense incurred.
Although NPs cannot delegate the sale of medication, if the above circumstances are met, an administrative assistant may conduct the financial transaction, which is the only one aspect involved in a sale.
For further information about the practice expectations for public protection when selling medication, see the Nurse Practitioner practice standard.