Florida has the unfortunate distinction of being the only state that does not authorize advanced practice registered nurses (APRNs) to prescribe controlled substances. Florida's advanced registered nurse practitioners (ARNPs) are also required to have a written protocol with an MD, DO, or dentist, (yes, dentist) to diagnosis, order diagnostic tests, provide physical and occupational therapy, and treat patients (including prescribing medications). The protocol must list the medications or categories of medications that may be prescribed, none of which may be controlled substances.1 Change, however, is poised to occur with passage of House Bill (HB) 423 on March 11, 2016.

Eliminating restrictions

Florida ARNPs have been actively engaged in eliminating controlled substance prescribing restrictions for more than two decades. Recommendations in support of ARNP prescribing of controlled substances dates back to 1997. A task force appointed by the Agency for Health Care Administration (at the direction of the 1996 Florida Legislature) recommended changes to Florida law to allow ARNPs to prescribe controlled substances after completing certain approved courses and when meeting specified experience requirements.

Florida staff for the Senate Committee on Health Regulation again recommended in 2008 the Legislature extend controlled substance authority under protocols within the scope of practice of their specialty for nationally certified ARNPs.2 Fast-forward to 2016, and Florida ARNPs are actively engaged in advocacy efforts to enact these long-standing recommendations.

Florida has two NP groups: the Florida Association of Nurse Practitioners (FLANP; http://www.flanp.org) and the Florida Nurse Practitioner Network (https://fnpn.enpnetwork.com). These groups combine efforts with the Florida Nurses Association through the Florida Coalition of Advanced Practice Nurses (https://flcapn.enpnetwork.com).

In 2016, HB 423 has been a main focus of attention for the groups, which received a vote for final passage on March 11, 2016. Once signed by the governor, it will become law and allow ARNPs to prescribe controlled substances effective January 1, 2017.3 The bill allows ARNPs with a graduate degree (and physician assistants) to obtain Drug Enforcement Agency registration and prescribe controlled substances with certain conditions. This will be part of the established protocol the ARNP must have with a supervising physician.

Qualified to prescribe

HB 423 establishes a committee to recommend a formulary of controlled substances an ARNP may not prescribe or may prescribe only for specific purposes or in limited quantities. The committee will consist of 3 ARNPs, 3 physicians, and 1 pharmacist. At a minimum, the formulary must limit ARNP prescribing of Schedule II substances to a 7-day supply, except psychiatric medications prescribed by a psychiatric NP. The bill indicates that only psychiatric NPs may prescribe psychiatric mental health controlled substances to children under age 18.3

This bill had a companion in the Senate sponsored by Senator Denise Grimsley, Deputy Majority (Republican) Leader, an RN with an MBA and a staunch supporter of NP practice according to FLANP chairperson Stan Whittaker, ARNP, FNP-BC, and student member Alicia Craig-Rodriguez, MBA, BSN, RN, who were both interviewed for this article.4 NPs have also found an unusual ally in Representative Cary Pigman, an ED physician who believes NPs are qualified to prescribe controlled substances. He was one of the two co-introducers of HB 423. His support is in contrast to the opposition of the Florida Medical Association, which in 2010 declared, "There is no such thing as a nurse practitioner who is 'qualified' to prescribe controlled substances."5

Although some NPs have practice protocols with physicians who are not present at the work site and who support NP practice, other physicians are restrictive and even charge thousands of dollars to provide an NP with a protocol. Lack of controlled substance prescribing creates bottlenecks to care while NPs wait for physician signatures on prescriptions for medications the NP has selected. It also results in quasi-legal methods for obtaining controlled substance prescriptions for patients, something documented in Washington State. For example, NPs would call a pharmacy with a controlled substance prescription using a physician's name or use presigned prescriptions.6

The consequence of restricted practice in Florida is far more than an inconvenience. According to the FLANP, approximately 1 million Floridians lack adequate access to healthcare. More than 17,000 NPs can help meet the demand-especially in rural areas-if restrictions are eliminated.7 Controlled substance prescribing is one aspect of the much-needed change.

According to Craig-Rodriguez, a DNP student and Jonas Nurse Leader Scholar at Florida State University, Florida NPs were optimistic that 2016 will be the year controlled substance prescribing is authorized. Passage of SB 676 (the companion bill to HB 423) out of the Senate Health Policy Committee garnered a press release in which Senate President Andy Gardiner commented, "Florida is currently the only state that does not allow ARNPs to prescribe controlled substances... This legislation will help expand the availability of quality medical care by allowing skilled practitioners with advanced medical training to better meet the needs of their patients."8 Craig-Rodriguez was pleased to see her Senator, Bill Galvano, Majority (Republican) Leader, support the bill. He previously sponsored legislation to make it a felony for a nurse with a doctorate to introduce oneself using the title doctor.

Engaging the political process

Stan Whittaker, FLANP chairperson and a family NP in an ED in Blountstown, believes Florida NPs have become respected advocates for a variety of reasons. More NPs are learning the legislative and political process and are more engaged. FLANP has broken down barriers by educating legislators regarding the issues and competencies of NPs and linking NP practice to access to care. NPs are more strategically involved as citizen lobbyists and are more actively engaged in supporting candidates supportive of NP practice. Whittaker applauds Florida nurse educators who are instilling an understanding of professional involvement as a role component in NP students.

FLANP did not hire a lobbyist for the first 2 years after it organized in 2010. Whittaker himself tirelessly served as the organization's volunteer lobbyist until he recognized the difficulty of working and volunteering. Even though a paid lobbyist attends to the behind-the-scenes details, Whittaker still spends many days at the Florida Legislature providing legislators with information about NP practice and how bills will affect it and access to care. He feels his efforts to develop relationships with legislators are paying off. This year, 35 bills that affect NPs are being lobbied or monitored. Legislators are proactively including NPs in bills where previously only physicians would have been included.

While progress is being made, Whittaker urges more NPs to get involved by visiting or communicating in other ways with legislators. NPs also need to join and support NP and nursing organizations leading the effort to improve practice. Florida NPs have been unrelenting in efforts to advocate for changes in practice. NPs such as Whittaker stand as an enduring example to others engaged in similarly difficult legislative efforts to gain full practice authority. While incremental change is slow and tedious, the end result of advocacy is improved access to quality care.

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