By

Thirty million prescriptions for narcotic painkillers were written nationwide in 2013 by non-doctors, according to data obtained by the Milwaukee Journal Sentinel and MedPage Today.

Those prescriptions — written by physician assistants, nurse practitioners and others — amounted to about a third of the 92 million written by primary care doctors that year, according to data provided by IMS Health, a drug market research firm.

Over the last few decades, so-called "mid-levels" have been granted wider prescribing authority. The idea was that they could handle less complicated cases like colds and routine blood work, allowing doctors to spend more time with patients.

But the groups have since lobbied for wider prescribing authority and now can use their prescription pads almost as completely as primary care doctors can, depending on the state.

In many states, physician assistants and nurse practitioners are allowed to prescribe opioids such as OxyContin, which is classified as a narcotic under the federal Controlled Substances Act. Indeed, they can write prescriptions for all but the most powerful and restricted narcotics, such as morphine.

In some states, even optometrists are allowed to prescribe opioids.

It is not clear whether the increase in prescribers has contributed to the nation's growing problem with opioid addiction and overdoses, said Richard Cook, a U.S.-trained anesthesiologist and patient safety expert at the Royal Institute of Technology in Stockholm.

"There's been a shift in the way we provide care to patients, and it's been going on now for well over a decade with no signs of halting," Cook said.

He called it an "area of controversy" with "very little strong evidence that we could point to saying this is either harming or advancing care."

Non-doctors also were among the top prescribers for benzodiazepine tranquilizers, which have been turning up in an increasing number of opioid overdose deaths.

In 2010, the most recent year for which data was available, 30% of the 16,651 people who died of an opioid overdose also had taken a benzodiazepine, according to the U.S. Centers for Disease Control and Prevention.

In 2013, primary care doctors wrote about 53 million benzodiazepine prescriptions, followed by psychiatrists at 13 million. Nurse practitioners and physician assistants were close behind with 11 million prescriptions for the drugs such as Xanax and Valium.

Authority challenged

Some groups have challenged that broader prescribing authority. In 2012, the American Society of Anesthesiologists decried a Centers for Medicare & Medicaid Services rule that enabled nurse anesthetists — nurses who specialize in anesthesiology and pain medicine — to be paid for diagnosing and treating chronic pain.

"Authorizing numerous new nurse anesthetists to prescribe potentially highly addictive drugs is of great concern to the ASA," a statement from the organization said. "Prescribing controlled substances is a serious and complex medical matter that requires a physician's education and training."

In an interview, Jane Fitch, a physician and president of the society, said the group's concern had a lot to do with rising rates of opioid abuse and overprescribing.

"We thought with all the players already in that arena, to create a whole other group of providers to write more scripts for pain patients might not be in anyone's best interest," Fitch said.

The setting in which a non-doctor practices also can have an impact on prescribing: A nurse anesthetist in an operating room will have vastly different duties than one hired at a pain clinic.

"There are some instances in which their prescribing is fully warranted, but where it gets questionable is in the clinic and outpatient setting," said Lewis Nelson, a physician and professor of emergency medicine with NYU Langone Medical Center who has been tracking the prescription painkiller epidemic.

Overdose deaths

Last year, a Journal Sentinel/MedPage Today investigation revealed that one of the country's top experts on how to safely prescribe opioids was under investigation by U.S. Drug Enforcement Administration for overdose deaths at his former clinic in Salt Lake City, Utah.

Lynn Webster, now president of the American Academy of Pain Medicine, acknowledged at the time that as many as 20 former patients of the clinic had died of overdoses. He said he believed that many of those probably were suicides.

He said he did not think that any of the deaths were from prescriptions he wrote, but rather from his staff. In Utah, nurse practitioners and physician assistants can write prescriptions if they are supervised by a doctor.

At the time, Perry Fine, a Salt Lake City pain specialist who was hired by Webster to review some of the overdose cases, said any questionable prescribing was done by nurse practitioners or physician assistants.

In an email this week, Fine said he believes that the prescribing of any drugs that have appreciable risk such as opioids, should be limited to those with specific education and demonstrated expertise in the field.

The one exception would be low-dose, low-volume opioids for short-term pain, he said.

"There is no reason that certain PAs and NPs cannot meet that threshold, and conversely, there are many physicians who do not meet that threshold," he said.

Webster declined to comment for this story.

Petros Levounis, a New Jersey addiction specialist, said he thought it was "crazy" that under federal law only physicians, and not nurse practitioners and physicians' assistants, could prescribe a drug that is known to help treat opioid addiction, buprenorphine.

"Here we have an army of NPs and PAs who can prescribe the cause of the problem, but they are not allowed to prescribe the solution to the problem," said Levounis, chairman of psychiatry at New Jersey Medical School.

Specialists have made the argument that even primary care providers don't have enough training when it comes to treating pain and prescribing powerful narcotics appropriately.

Nelson, of NYU, said there has been overprescribing by nurse practitioners and physician assistants.

"But that being said, there are more than enough physicians who overprescribe," he said. "NPs and PAs are no more or less guilty (for America's prescription drug problems) than physicians. There is enough blame to go around."

John Fauber is a reporter for the Milwaukee Journal Sentinel. Kristina Fiore is a reporter for MedPage Today. Data analysis was done by Elbert Chu of MedPage Today.

This story was reported as a joint project of the Journal Sentinel and MedPage Today, which provides a clinical perspective for physicians on breaking medical news at medpagetoday.com.