A controlled substance is one that is included in Schedules I, II, III or IV, or part 1 of Schedule V of the federal Controlled Drugs and Substances Act. Controlled substances are used in health care to treat a wide variety of conditions including, but not limited to, pain, anxiety, epilepsy and sleep disorders. They include opioids, benzodiazepines, amphetamines, sedatives and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential misuse, addiction and diversion.

Effective October 1, 2026, NPs are no longer subject to any profession specific restrictions on prescribing under the Controlled Drugs and Substances Act, specifically those related to opium and coca leaves. Opium and coca leaves are not marketed drugs; so any authorized practitioner who wishes to prescribe these substances must apply for special access through the Health Canada’s Special Access Program.

All NPs who prescribe controlled substances remain accountable to the Nurse Practitioner practice standard when prescribing and dispensing controlled drugs and substances, along with all other CNO practice standards. NPs are expected to practice in compliance with all relevant legislation, the standards of practice of the profession and applicable employer policies.

Yes, you can dispense a controlled substance that you prescribed or that an authorized provider you work with has ordered. The Nurse Practitioner practice standards describe the practice expectations for public protection when dispensing medication.

Only NPs who have successfully completed CNO approved controlled substances education are authorized to prescribe controlled substances in Ontario. For more information about the education requirement, read Controlled Substances Education Requirement FAQs.

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 your 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.

You can use CNO’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 practice. Cannot prescribe controlled substances until specialized education is completed.”

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 CNO 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. 

No. Consulting with a physician does not give you the legal authority to prescribe any medication. The authority to prescribe medication comes from legislation. Therefore, in this case the physician should prescribe the controlled substance. Physicians have their own professional accountabilities, which may also require them to personally assess the client.

Under the Controlled Drug and Substances Act (CDSA), NPs have the authority to prescribe and administer methadone without an exemption. NPs also have the authority to prescribe diacetylmorphine.
Only NPs who have successfully completed CNO-approved controlled substances education are authorized to prescribe controlled substances in Ontario, and this includes methadone, buprenorphine and diacetylmorphine. 

Activities associated with controlled substances are high risk. As with any activity or procedure NPs engage in, they are expected to have the knowledge, skill and judgment to prescribe methadone and diacetylmorphine in a safe, competent and ethical manner. NPs are expected to understand the unique risks associated with prescribing any controlled substance and incorporate relevant evidence-informed strategies to mitigate these risks.

NPs must meet the expectations for prescribing controlled substances outlined in the Nurse Practitioner practice standard and ensure they have the competence to prescribe methadone, buprenorphine and diacetylmorphine. Expectations in the NP standard 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.

Please refer to the applicable legislation, the Controlled Substances Regulations (SOR/2025-242) for specific information that must be recorded.

The destruction of controlled substances (Section 139 of the Controlled Substances Regulations) may be performed by an NP only if the following conditions are met:

• the destruction is witnessed by another health professional 
• the destruction is carried out in accordance with a method that complies with all federal, provincial and municipal environmental protection legislation applicable to the place of destruction; and
• immediately following the destruction, the NP and the witness must write their name in printed letters, sign and date a joint declaration attesting that the controlled substance was destroyed

As an exception to the witness requirement, a nurse practitioner may destroy, without a witness, the remainder of a controlled substance contained in an open ampule that will not be administered.

If the destruction of the controlled substance is not carried out, the NP must provide the substance to a licensed dealer specialized in destruction of controlled substances. 

Yes, there are legal requirements in the Controlled Substances Regulation 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.

CNO does not have guidelines specific to treating clients who are addicted to controlled substances. Our role and expertise are to provide standards and harm reduction resources that are applicable to nurses who work in a broad range of roles, across various settings.

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.

You may need to seek out other sources of information, including information that is specific to your setting and/or patient population. You are accountable for using the best evidence to inform your clinical decisions. With patient 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.

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 Professional Boundaries and Nurse-Client Relationships practice standard, Nurse Practitioner practice standard, the Discontinuing or Declining to Provide Care practice standard, and Conflict Prevention and Management practice guideline.

Related link: 

Harm Reduction in Nursing Practice 

CNO 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.

CNO 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.

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.

When you are no longer employed at this clinic, you cannot access client health records, including diagnostic test results. You can only remain involved in the care of these clients if your employment is extended, or you are retained by the employer in some other way (for example, on contract), to provide health services to these clients.

You are accountable for working with the employer to facilitate continuity and transfer accountability of client care. This may include strategies such as: 

• notifying clients and giving them information about how their health care needs will be met 
• prioritizing high-risk clients for appointments
• ensuring the employer is aware of pending diagnostic test or lab results.

The employer is responsible for ensuring strategies are in place to meet client-care needs while they recruit your replacement. This may include making arrangements with other service providers or using other strategies that fit the clients’ needs.
Additional Resource: Discontinuing or Declining to Provide Care – Guidance for NPs

You must sign as either Nurse Practitioner (NP) or Registered Nurse, Extended Class [RN(EC)].

No other variations of the NP title may be used.

Most NPs are salaried employees. To reduce the risk of conflict of interest, ensure there are clear parameters about whether these services are offered during regular work hours and how the revenue generated from these fees will be managed. You should work with your employer to develop a clear workplace policy about charging clients fees. Policies should be consistent with the standards and regulations governing affected health professionals. Decisions should be made in the best interest of clients and the policy should address ethical considerations, including the process for clients who cannot afford to pay a fee.

Refer to CNO’s Professional Misconduct reference document for information about nurses’ professional accountabilities when charging fees.

No. The regulations under the Mental Health Act specify that an Application by Physician for Psychiatric Assessment (Form 1) be completed by a physician.

A Certificate of Involuntary Admission (Form 3) also requires a physician’s assessment and the examining physician’s signature. For this reason, an NP cannot admit involuntary clients under the Mental Health Act.

For more information on NP accountabilities, read theNurse Practitioner practice standard.

No. CNO 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 must not prescribe a particular medication simply because it is available for sale in the practice setting.

The practice expectations for public protection are described in the Nurse Practitioner practice standard.

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.

Yes, NPs can sell medication with the exception of controlled substances. NPs are prohibited from selling controlled substances. Before you sell a medication, you are accountable for assessing the client to determine that at least one of the following circumstances exists:

• 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.

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.

Subsection 272(1) of the Cannabis Regulations indicates that when an individual is under the professional treatment of an NP and cannabis is required for the condition for which the individual is receiving treatment, NPs are authorized to: 

• provide clients with a “medical document”
  
  
  • Part 14 of the Cannabis Regulations defines “medical document” as a document provided by a health care practitioner to support the use of cannabis for medical purposes.
• issue “written orders” while practicing in a “hospital”
  
  
  • The Cannabis Regulations defines “hospital” as a facility that is (a) licensed, approved or designated by a province under the laws of the province to provide care or treatment to individuals suffering from any form of disease or illness; or (b) that is owned or operated by the Government of Canada or the government of a province and that provides health services. NPs must determine if their facility would satisfy the definition of “hospital” within the Cannabis Regulations.
  • Part 14 of the Cannabis Regulations defines “written order” as a written authorization given by a health care practitioner that a stated amount of cannabis be dispensed for the individual named in the authorization. 
• administer cannabis product to clients, other than cannabis plants or cannabis seeds.
  
  
  • The Cannabis Regulations defines “cannabis product” as cannabis of only one of the classes set out in Schedule 4 to the Act— or a cannabis accessory that contains such cannabis — after it has been packaged and labeled for sale to a consumer at the retail level, but does not include a drug containing cannabis
• transfer a cannabis product to clients, other than cannabis plants or cannabis plant seeds (subject to certain restrictions)

NPs who have a therapeutic relationship with the client are authorized to provide medical documents or written orders for cannabis to treat or relieve their condition. NPs are accountable for ensuring that medical cannabis is an appropriate, evidence-based treatment and meets the accountabilities outlined under therapeutic management in the Nurse Practitioner practice standard. 

NPs completing a medical document or written order to authorize the use of cannabis for medical purposes must review the risks, side effects, drug interactions with other medications, cannabis-related conditions, poisonings, safe storage and the importance of obtaining cannabis from a legal source. 

Under section 273 of the Cannabis Regulations, a medical document must indicate the following:

• the NP’s full name, professional designation, business address and phone number (fax and email, if applicable)
• the address of the location where the client consulted with the NP
• the province in which the NP is authorized to practice their profession and the registration number assigned by the province to that authorization
• the client’s full name and date of birth
• the daily quantity of dried cannabis, expressed in grams, that the NP authorizes for the client
• the period of use (maximum one year), specified as a number of days, weeks or months.

The NP must sign and date the medical document and include a statement confirming that the information in the document is correct and complete. The medical document is valid only for the period of use specified within it, which must not exceed one year. NPs are recommended to keep a copy of the completed medical document for their records.

Health Canada monitors misuse of the medical cannabis system in Canada. NPs who authorize medical cannabis may be subject to review and follow-up. NPs must be prepared to provide supporting information such as peer-reviewed data, references, or resources to support their clinical reasoning such as their documentation record. If the NP does not respond to the Health Canada request or cannot provide information to substantiate the authorized amount, the client’s application may be refused.

To assist NPs who authorize cannabis for their clients, Health Canada has published documents on its website that provides important information on research into the medicinal use of cannabis, dosing and administration, and client information. This includes information on reporting of adverse reactions from the use of cannabis

Under section 274 of the Cannabis Regulations, a written order must be signed and dated by the NP and include the following:

• the NP’s full name and professional designation
• the client’s full name who is under the professional treatment of the NP, and
• the daily amount of dried cannabis, expressed in grams, that the NP authorizes for the client. 

As with all medication orders, NPs are accountable to the Medication and Nurse Practitioner practice standards. 

• Information for Health Care Professionals: Cannabis and the cannabinoids
• Health Canada: Medical use of cannabis
• Canadian Nurses Protective Society: Access to Cannabis for Medical Purposes, what every nurse should know
• Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations
• Institute for Safe Medication Practices Canada (ISMP): Navigating Cannabis Conversations
• Practice Support FAQ: Medical Cannabis 

As the health professional who ordered the test, you are also accountable for following up or ensuring there is a reliable system in place for appropriate follow-up. This means that you and the hospital should have a process for reviewing the test results you have ordered and following up with clients.

You can facilitate the safe transfer of accountability by providing a timely discharge summary, including information about tests ordered. To promote continuity of care, you can make sure laboratory and diagnostic requisitions include a request to have test results sent to both yourself and the client’s primary health care provider.

You are accountable for communicating and documenting the following information with clients:

• the significance of the tests being ordered,
• potential implications of not taking the test,
• what type of follow-up to expect, and
• how they will receive the test results.

You may also want to give a copy of the discharge summary to clients. Your accountabilities when ordering tests are outlined in the Nurse Practitioner practice standard.

There is a shared accountability. Ultimately, clients make their own decision about whether to undergo a test. You are accountable for ensuring clients have the necessary information to make an informed decision about taking the test. In addition, you are expected to ensure systems are in place to track that you have ordered the test. This enables you to follow up with the client if required. If you learn that your client has not taken the test, you have an opportunity to explore the client’s reasons and engage in additional health teaching. You should document your follow-up with the client, including any unsuccessful follow-up attempts if the client does not respond.

Whether an NP can order restraints depends on the setting.

The Patient Restraints Minimization Act, 2001 specifies that only a physician or a person specified by regulation can order a restraint.

Only physicians are authorized to order restraints for patients in hospital because there are no regulations under the Patient Restraints Minimization Act that list other persons.

In long-term care, NPs are authorized to order restraints as they are specifically listed in regulations under the Fixing Long-Term Care Act, 2021.

There is no longer a legal requirement for NPs to establish and maintain a consultative relationship with a physician, so you do not require a “consulting” physician. However, the consultation standards have not changed:

ou are expected to consult physicians and other health professionals when you encounter client care needs beyond the legal scope of NP practice or your individual competence. Also, some employers require NPs to have a consulting physician. 

To make consulting possible, you would establish a network of other health professionals, as appropriate, to meet client care needs. If your current consulting arrangements with physicians meet this objective, then you should continue with those arrangements.

The practice expectations for public protection when providing interprofessional care and consultation are described in the Nurse Practitioner practice standard.

These changes mean different things, depending on your employer, practice setting and the care needs of your client population.

NPs have an accountability to determine how these changes affect their current practice processes in delivering safe client care. NPs are encouraged to work with their employers, including their radiology department, to determine how these changes impact their practice.

Here are some guiding questions to ask your employer to support these discussions:

• How does this impact my role and responsibilities as an NP?
• What policies support the performance of this activity?
• Do you foresee any barriers to NPs ordering CTs and MRIs in this practice setting? If so, how can these be managed?

The specialist (that is, staff in the radiology department) determines whether the investigation requires the use of contrast media, according to our colleagues at the College of Medical Radiation and Imaging Technologists of Ontario (CMRITO). This determination by the specialist includes identifying the type of contrast, dosage and contraindications. This process provides the necessary authorization to the medical radiation and imaging technologists (MRITs) performing the procedure on the client.

The specialist’s decision regarding the use of contrast media is informed by the clinical information provided by the ordering NP, such as client history, the clinical reason for the CT or MRI examination and the differential diagnosis. It is important that the NP include as much relevant clinical information as possible in the imaging requisition to help the specialist make an informed decision to support safe and efficient client care delivery.

For further insight, NPs are encouraged to discuss their setting-specific process to order contrast media with their radiology department, including the physicians and imaging and radiation technologists.

Yes, NPs already order diagnostic tests including x-rays and ultrasound. As outlined in CNO’s Entry-to-Practice Competencies for Nurse Practitioners, entry-level competencies — which are the knowledge, skills and judgment required to support safe practice — include competencies related to ordering diagnostic testing. That includes diagnostic imaging such as CTs and MRIs. These competencies are integrated into foundational NP programs, which are approved by CNO.

For example, competencies include that NPs must:

• inform the client of the rationale for ordering diagnostic tests
• order and/or perform screening and diagnostic investigations using the best available evidence to support or rule out differential diagnoses
• integrate laboratory and diagnostic results with history and physical assessment findings
• analyze and interpret multiple sources of data, including results of diagnostic and screening tests, health history, and physical examination
• interpret the results of screening and diagnostic investigations using evidence-informed clinical reasoning

With any activity or procedure, nurses are accountable for maintaining and continually improving their competence. Depending on how NP orders for these tests are implemented in your practice setting, you may identify individual learning needs that you need to meet in order to safety carry out this or any other activity. Continuing competence and ongoing Quality Assurance is an accountability for all nurses. 

Related links:

• Entry-to-Practice Competencies for Nurse Practitioners

CNO asked the government this question and they shared the following on June 10, 2022: "physicians who submit claims to OHIP for services ordered by NPs will be paid for both the technical and professional components of the service. Independent Health Facilities that submit claims to OHIP for services ordered by nurse practitioners will be paid.”

NPs order and perform procedures when they have a therapeutic professional relationship with the client. When ordering or performing any procedure, including those involving the application of a form of energy, NPs are accountable to:

• determine that the procedure is warranted
• determine that the procedure is a safe and effective intervention for the client
• explain to clients the details of, and rationale for, the procedure as appropriate
• •explain to clients what they can expect from the procedure
• monitor the client’s responses during the procedure
• interpret the findings of the procedure accurately or consult if there are any questions about the accuracy of the interpretation of the findings/results
• incorporate findings or outcomes of the procedure into treatment plans
• communicate clinically significant results and findings, and the implications of those results, to clients and other health professionals as appropriate
• verify that there are reliable quality assurance mechanisms in place to ensure the proper and safe functioning of the equipment they use, and not use equipment when concerns have been identified

In addition, when performing any procedure themselves — including those that involve the application of a form of energy — NPs are accountable to:

• ensure they have the necessary resources available to perform the procedure appropriately and safely, and to manage potential outcomes associated with the procedure
• ensure that the client has been prepared appropriately
• ensure an appropriate environment for conducting the procedure

Note: NPs cannot order nuclear medicine testing.

Related links:

• Practice Support FAQ: Understanding Your Scope of Practice 
• Scope of Practice standard
• Nurse Practitioner practice standard
• Nurse Practitioners to order CTs and MRIs|Oral and Maxillofacial Surgeons to order MRIs · CMRITO Portal

There are different perspectives on providing virtual care that NPs should be aware of; CNO’s, regulatory bodies outside of Ontario and employers’ perspectives.

CNO would not prevent nurses registered in Ontario from providing virtual care to clients in other provinces or countries. In these instances, nurses are responsible for practicing according to the relevant laws in the jurisdiction where their client is located. If a nurse is providing care to a client in a different jurisdiction, the nurse must contact the regulator in that jurisdiction to make sure they are complying with their laws and requirements, including the provision of virtual care. 

The employer’s perspective is also very important. It is at the employer’s discretion to determine policies and procedures regarding the scope of roles and responsibilities of their employees. This includes whether nurses they employ can provide virtual care to clients in other jurisdictions, and the type of nursing care they may want their NPs to provide.

Another important consideration is the NP’s authority and competence to prescribe cannabis. NPs must ensure they have the authority to prescribe medical cannabis which may vary depending on where they are practicing. They are accountable for ensuring that medical cannabis is an appropriate evidence-based treatment for their clients. NPs must also have the knowledge, skill and judgment to prescribe safely and competently.
Here are some guiding questions to reflect on as you consider working in this practice environment:

• Do I have the knowledge, skill and judgment to perform these activities?
• Am I able to provide a comprehensive assessment of the client through virtual care?
• Have I consulted with other nursing regulatory bodies regarding their perspectives on virtual care?
• Have I consulted with my employer and reviewed relevant organizational policies?
• Can the client’s pharmacist accept a prescription from a nurse practitioner outside of their jurisdiction?
• Have I consulted with my liability protection provider?

As always, NPs are expected to apply the requirements outlined in CNO’s practice standards, including the Nurse Practitioner and Scope of Practice standard. You can also refer to the Practice Support FAQ: Understanding Your Scope of Practice.

For more information on virtual care, refer to CNO’s Virtual Care guideline.