What controlled substances can a Physician Assistant (PA) order?

Controlled Substances Prescribing Authority for Physician Assistants

Physician Assistants (PAs) can prescribe Schedule II-V controlled substances, but their authority varies by state law and may require physician supervision, delegation, or collaboration depending on the state's regulations. 1

Federal Classification of Controlled Substances

Controlled substances are categorized into schedules based on their potential for abuse:

• Schedule II: High potential for abuse with severe psychological or physical dependence

  • Examples: Morphine, oxycodone, hydromorphone, fentanyl, methadone, hydrocodone
  • Requires DEA registration and appropriate state authority

• Schedule III: Moderate to low potential for abuse

  • Examples: Combination products containing ≤15mg hydrocodone with acetaminophen 2
  • Buprenorphine (requires special DEA waiver)

• Schedule IV: Low potential for abuse

  • Examples: Benzodiazepines, tramadol, zolpidem

• Schedule V: Lowest potential for abuse

  • Examples: Certain cough preparations with limited amounts of codeine

State-Specific Considerations

The ability of PAs to prescribe controlled substances is determined by:

1. State laws and regulations: Each state has different requirements regarding:

   • Level of physician supervision required
   • Types of controlled substances PAs can prescribe
   • Quantity limitations
   • Refill restrictions

2. DEA registration: PAs must obtain their own DEA registration to prescribe controlled substances

3. Practice agreements: Many states require formal agreements with supervising physicians that may specify:

   • Which controlled substances can be prescribed
   • Circumstances under which they can be prescribed
   • Documentation and consultation requirements

Common Limitations and Requirements

1. Supervision requirements:

   • Some states require direct supervision
   • Others allow more autonomous practice with collaborative agreements
   • A few states grant independent prescribing authority

2. Schedule II restrictions:

   • Some states limit the duration of Schedule II prescriptions by PAs
   • May require more frequent physician consultation for Schedule II medications
   • Some states prohibit PA prescribing of certain Schedule II medications

3. Special circumstances:

   • Buprenorphine for opioid use disorder requires additional DEA waiver (X-waiver) 3
   • Some states have additional restrictions for prescribing to patients with chronic pain

Best Practices for PA Prescribing

1. Know your state laws: Maintain current knowledge of state-specific regulations

2. Maintain proper documentation:

   • Document medical necessity
   • Record assessment of risk for abuse
   • Document informed consent discussions

3. Follow evidence-based guidelines:

   • Use appropriate screening tools
   • Implement risk mitigation strategies
   • Consider non-opioid alternatives when appropriate

4. Monitoring requirements:

   • Use prescription drug monitoring programs (PDMPs)
   • Conduct urine drug testing when appropriate
   • Schedule regular follow-up visits

Common Pitfalls to Avoid

1. Exceeding state-authorized scope: Prescribing beyond what state law permits

2. Inadequate documentation: Failing to document medical necessity and risk assessment

3. Ignoring red flags: Missing signs of medication misuse or diversion

4. Failing to check PDMPs: Not utilizing state prescription monitoring databases

5. Inappropriate prescribing patterns: PAs should be aware that studies have identified some concerning patterns of higher-frequency, high-dose opioid prescribing among a small subset of NPs and PAs compared to physicians 4

PAs must stay current with both federal and state regulations regarding their prescribing authority, as these laws frequently change and vary significantly between states. Maintaining proper documentation and following evidence-based guidelines are essential for appropriate prescribing of controlled substances.