November 1st, 2010

Prescription authority comes with risks, uncertainties

Forces are in the health care system changing its landscape. The greatest changes seem to revolve around the payments of insurance, including who will provide particular services. One of the services that has become part of the discussion is which professionals will be permitted to have prescription-writing privileges for controlled substances.

Traditionally, Doctors of Medicine (MDs) and Doctors of Osteopathic Medicine (DOs) could write prescriptions for medications. Dentists (DDS and DMD) also can prescribe. In some areas, Advanced Practice Registered Nurses (APRN), known in some places as Psychiatric Mental Health Nurse Practitioners (PMHNP), with a master’s degree in psychiatric/mental health nursing, once licensed, may prescribe.

There may be areas where nurse practitioners, physicians’ assistants and pharmacists and others may prescribe.

Most recently, psychologists have been seeking the authority to write prescriptions. In recent history, patients of psychologists who needed access to medication received prescriptions from psychiatrists. Some of the reasons put forth regarding expanding the authority to write prescriptions to psychologists are that there are not enough or any, psychiatrists in a particular geographic area, that the patient is already seeing the psychologist, that there may be courses or qualifications available to provide psychologists with necessary background and that there are safety precautions that are already provided some places for APRNs which could be expanded to psychologists. The arguments appear to revolve around convenience for patients, lower cost for society and limiting possible redundancy.

Little history supports that giving psychologists prescribing authority will alleviate these issues at this time. However, there may be data available soon. Presently, Louisiana, New Mexico, and the Armed Services allow psychologists to prescribe. Oregon’s legislature passed a law allowing psychologists to prescribe, but the governor vetoed the bill. It may be appropriate to watch what happens in Louisiana, New Mexico and the Armed Services and collect data on usage and possible problems before expanding the authority to prescribe into other jurisdictions.

Questions and risks occur with regard to the authority to prescribe. The training of some disciplines (MD and DO) is different from the training for other disciplines (Ph.D. and Psy.D.). There are programs such as the Massachusetts School of Professional Psychology’s Masters Program in Clinical Pharmacology or the program out of the California School of Professional Psychology that are making efforts to provide the necessary background information and safety assurances for the possible risks.

What are the risks? Some of them include prescribing the wrong medication, prescribing the wrong amount, the possibility of certain allergies, the possibilities of negative side effects, other mixing or interactions of medications and overdoses. The psychotropic drugs used in the treating of patients are not benign. If there is liability in a particular case, the awards vary a great deal. The awards can run into the millions. Some psychologists will be treating children and this may raise the risk to the prescriber, particularly in the minds of jurors in a malpractice case. And some juries award punitive damages under certain circumstances. These jury awards can be in the tens of millions.

If there is risk, and particularly if there are lawsuits, then professional liability insurance will increase accordingly. If you are ever sued, with the cost of time and money to defend yourself, you can feel you have lost, even if you ultimately win the lawsuit. Be careful what you wish for, you might get it.

Another argument is that the psychologists’ authority to prescribe medications will further a reliance or use of these medications rather than using the unique skills and methodologies of psychologists.

If psychologists get the authority to prescribe, there will probably be restrictions. The authority will probably be limited to certain drugs related to the field. There will need to be a curriculum that is accepted to the power and the risks involved here. There will probably need to be some oversight, although this may be complicated. If psychologists obtain this authority along with some nurses, physician’s assistants and others, who are the others?

By Edward Stern J.D.

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