Can Physician Assistants (PAs) prescribe opioids?

PA Opioid Prescribing Authority

Physician Assistants can prescribe opioids in most U.S. states, but prescribing authority varies significantly by state and is governed by state-specific scope of practice laws, not federal regulations alone. 1

Federal vs. State Authority Framework

The ability of PAs to prescribe controlled substances, including opioids, is determined primarily at the state level through scope of practice regulations, not by federal law. 1, 2 While federal DEA registration allows PAs to prescribe controlled substances once they meet requirements, each state independently regulates:

• Whether PAs can prescribe controlled substances at all 1
• What level of physician supervision or collaboration is required 2, 3
• Whether there are specific restrictions on opioid prescribing beyond general scope of practice laws 2

State-Specific Variations You Must Verify

Critical point: You cannot assume PA prescribing authority is uniform across states. State laws create substantial variation in three key areas:

Supervision Requirements

• Some states grant full practice authority with minimal physician oversight 3
• Others require direct physician supervision for all prescribing 2, 3
• Supervision requirements may be more restrictive for controlled substances than for other medications 2

Special Opioid-Specific Restrictions

Beyond general scope of practice laws, some states have enacted additional regulations specifically for opioid prescribing by PAs:

• At least one state prohibits all advanced practice clinicians from prescribing buprenorphine for opioid use disorder, even when general scope of practice laws would otherwise permit it 2
• Five states require PA supervision by a federally waivered physician specifically for buprenorphine prescribing 2
• These restrictions exist in addition to and separate from general scope of practice laws 2

Prescription Monitoring Requirements

Regardless of prescribing authority, PAs prescribing opioids must:

• Check state Prescription Drug Monitoring Programs (PDMPs) before prescribing, ideally before every prescription or at minimum every 3 months 4
• Perform urine drug testing before initiating opioid therapy and at least annually during continuation 4
• Calculate total morphine milligram equivalents when multiple prescriptions are identified 4

Practical Steps to Determine PA Authority in Your State

To determine if a PA can prescribe opioids in a specific state, you must:

1. Check the state medical board or PA licensing board regulations for general controlled substance prescribing authority 1

2. Search for opioid-specific statutes beyond general scope of practice laws, as these may impose additional restrictions not apparent from general PA practice regulations 2

3. Verify current supervision requirements, as these may differ for controlled substances versus other medications 2, 3

4. Confirm DEA registration requirements and any state-specific controlled substance registration 1

Common Pitfall to Avoid

Do not assume that because a PA has general prescribing authority in a state, they automatically have full opioid prescribing privileges. States may have created separate statutory frameworks specifically regulating opioid prescribing by advanced practice clinicians that exist outside of and in addition to general scope of practice laws. 2 These laws are not always apparent from reviewing general PA practice regulations and require specific legal research.

Clinical Practice Standards When PAs Do Prescribe Opioids

When PAs have legal authority to prescribe opioids, they must follow the same clinical guidelines as physicians:

• Prescribe ≤3 days of immediate-release opioids for acute pain; more than 7 days is rarely needed 5
• Avoid dosages ≥90 MME/day or carefully justify decisions to reach this level 4
• Exercise increased caution at ≥50 MME/day 4
• Avoid concurrent opioid and benzodiazepine prescribing whenever possible 4
• Establish treatment goals and written agreements before initiating therapy 5, 6

The answer to whether PAs can prescribe opioids in your specific state requires verification of current state statutes and regulations, as this authority is not federally standardized and varies significantly by jurisdiction. 1, 2