Expanded prescription authority for nurse practitioners rejected

Louisiana State Capitol
Photo by Travis Gauthier

This story was first reported by Louisiana Illuminator and republished with permission.

A discussion Tuesday among Louisiana lawmakers over whether to let nurse practitioners write prescriptions for patients for chronic pain and obesity turned into a debate over whether the state is doing enough to address its health care disparities. It also touched on the opioid addiction crisis and whether the expanded authority for nurse practitioners would contribute to the problem or improve matters.   

The Senate Health and Welfare Committee rejected a request from the Louisiana State Board of Nursing to remove a restriction on nurse practitioners that’s been in place since 1995 when they were given authority to write prescriptions. Nurse practitioners can treat people who are obese or suffer from chronic pain, but they cannot prescribe them controlled substances like they do for other patients.  

The removal of these restrictions would open the door to allow nurse practitioners to recommend medical marijuana to patients with these two ailments. Gov. John Bel Edwards signed a law last year to permit them to do so, but it requires the prohibition on controlled substances be removed from the state’s nursing rules.

Karen Lyon, the board’s executive director, largely avoided discussion of medical marijuana as she explained to senators on the committee Tuesday how the expanded prescriptive authority for nurse practitioners would improve the quality of care for those suffering from chronic pain, which she said is often a subjective diagnosis. 

“Where does acute pain end and chronic pain begin? It’s a very nebulous, kind of gray area,” Lyon said.

In some instances, patients must wait weeks or months before they are referred to a physician who can treat them for chronic pain, said Lyon and nurse practitioners who attended the hearing. The current limitations affect patients with severe pain disorders such as diabetic necrosis and sickle cell disease.

Nurse practitioners are required to work under the supervision of a physician in Louisiana. Rather than changing prescriptive authority rules, committee chairman Sen. Fred Mills, R-New Iberia, said difficulties in obtaining proper patient care should be worked out between doctors and nurse practitioners.

State Rep. Dustin Miller, D-Opelousas, who is a nurse practitioner, appeared before the Senate committee and said it’s hard to find physicians who will take on chronic pain patients because they have legal limits on the amount of opioids they can prescribe. Miller said he personally does not treat chronic pain patients.

Lyon said opposition to the rule change from physician groups is unfounded, quoting letters sent to the nursing board that express concern over the “willy-nilly” prescription of opioids. 

“There’s no evidence to actually support that,” Lyon said.    

She shared statistics from the state’s prescription monitoring program with the committee that show some 9,400 Louisiana physicians prescribed roughly 95% of opioids such as hydrocodone, tramadol and oxycontin last year. Nearly 4,000 nurse practitioners who were monitored accounted for between 2% and 6% of those prescriptions.

But even with the best intentions, Dr. Jamie Kuo, a New Orleans emergency medicine physician, argued that any increase in opioid prescriptions would lead to a corresponding jump in overdoses. She cited state health department figures for the committee that counted 4,339 opiate-related visits to Louisiana emergency in 2021. Opioid overdoses resulted in 1,342 deaths two years ago, and prescription opioids accounted for 30% of unintended overdoses, she said.

“No matter how restrictive we are, we are going to increase those rates,” Kuo said.

Mills pressed Lyon for specifics on how nurse practitioners would treat obesity and chronic pain if the controlled substance restrictions were removed. Physicians have such protocols spelled out in their professional rules, Mills said, adding that the nursing board has no “guardrails” in place for nurse practitioners.

Lyons insisted existing regulations, such as prescription monitoring programs and professional licensing standards, dictate that nurse practitioners pursue less aggressive options to treat obesity and chronic pain before resorting to controlled substances.

Sens. Gerald Boudreaux, D-Lafayette, and Jay Luneau, D-Alexandria, brought up the shortage of doctors in their respective districts who accept Medicaid patients, implying that expanded authority for nurse practitioners could alleviate some of that need. Yet neither objected when Mills moved to reject the proposed rule change.

Gov. Edwards has 10 days to consider the committee’s decision before deciding whether he will reverse it or let it stand. Governor’s spokesman Eric Holl said the committee’s decision was received Wednesday and is under review.