What are controlled substances and why are they restricted?
A controlled substance is one that is included in Schedule I, II, III, IV or V of the federal Controlled Drugs and Substances Act. Controlled substances are used in healthcare to treat a wide variety of conditions including, but not limited to, pain, anxiety, epilepsy and sleep disorders. They include opioids, benzodiazepines, amphetamines, sedatives, anti-emetics and hormonal therapies, among others. Controlled substances are restricted because they present a high risk for potential misuse, addiction and diversion.
Can NPs prescribe controlled substances?
Only NPs who have successfully completed College approved controlled substances education are authorized to prescribe controlled substances in Ontario. For more information about the education, read Q&As: Controlled Substances Education Requirement.
Is controlled substances content part of NP program curriculum?
“Yes. Controlled substances content is integrated in the curriculum for all Ontario NP programs. Students enrolled in Ontario NP programs will meet the required controlled substances content and do not have to complete a standalone course.
Members and applicants who don’t have this content in their NP program can take Council-approved controlled substances courses to gain the foundational competencies that are unique to controlled substances, and meet their education requirement set out in regulation.
Are there any controlled substances that NPs can’t prescribe?
Yes, regulations under the federal law prohibit NPs from prescribing the following controlled substances:
- opium (such as opium and belladonna suppository)
- coca leaves (such as cocaine) and
- anabolic steroids except testosterone (NPs are authorized to prescribe testosterone.)
How can I tell if an NP is authorized to prescribe controlled substances?
You can use the College’s register “Find a Nurse” to check whether an NP is authorized to prescribe controlled substances. NPs who are not authorized to prescribe controlled substances are identified on the register as “Entitled to practice. Cannot prescribe controlled substances until specialized education is completed.”
Can NPs prescribe methadone and diacetylmorphine?
Under the Controlled Drug and Substances Act (CDSA) NPs have the authority to prescribe and administer methadone without an exemption. NPs also have the authority to prescribe diacetylmorphine.
Only NPs who have successfully completed CNO approved controlled substances education are authorized to prescribe controlled substances in Ontario, this includes methadone, buprenorphine and diacetylmorphine. Additional resources are also available to support NPs continuing competence and clinical decision making.
Activities associated with controlled substances are high risk. As with any other activity or procedure NPs engage in, they are expected to have the knowledge, skill and judgment to prescribe methadone and diacetylmorphine in a safe, competent and ethical manner. NPs are expected to understand the unique risks associated with prescribing any controlled substance and incorporate relevant evidence-informed strategies to mitigate these risks.
NPs are also expected to meet the accountabilities outlined in the Nurse Practitioner practice standard and ensure they have the competence to prescribe methadone, buprenorphine and diacetylmorphine.
Additional resources:
Controlled Substances – Resources and References
You must meet the expectations for prescribing controlled substances outlined in the Nurse Practitioner practice standard. These include prescribing a quantity of controlled substances to be dispensed that balances the need to reassess and monitor the client with the risk of harm that may result if the client runs out of medication. NPs providing episodic care should prescribe the minimum amount necessary until the client can be assessed by their regular care provider.
I’m involved in procuring medications for my practice setting. Are there any legal requirements around reporting theft of controlled substances?
There are legal requirements under the Controlled Drugs and Substances Act related to record-keeping and reporting theft of these medications. You must report the loss or theft of controlled substances to Health Canada’s Office of Controlled Substances within 10 days.
I’m an NP that is not authorized to prescribe controlled substances. What do I do if I determine a client requires a prescription for a controlled substance?
NPs can expect to encounter clients requiring prescriptions for controlled substances, since many medications are controlled substances. You should plan for this anticipated client care need by establishing strategies consistent with College standards and guidelines. You should also work with your employer to ensure you have access to resources for meeting client needs. In this case, the resource you need is the ability to refer to a health professional such as an NP or physician authorized to prescribe controlled substances. The client’s prescription must be filled out by the authorized prescriber in a manner that is consistent with their regulatory obligations.
NPs who are not authorized to prescribe controlled substances must not taper a controlled substance or renew a prescription for a controlled substance as these are considered prescribing.
If you commonly encounter clients in your practice that require controlled substances you should consider completing the education requirement that would authorize you to prescribe controlled substances. As expected for any activity, you may have additional learning needs you have to meet, relevant to your setting and client population.
I’m an NP who is not authorized to prescribe controlled substances. I assessed a client and determined that she needs treatment with a controlled substance. The physician I work with agreed with my findings and proposed a treatment plan. Can I complete this prescription based on the outcome of my consultation with the physician?
No. Consulting with a physician does not give you the legal authority to prescribe any medication. The authority to prescribe medication comes from the legislation. Therefore, in this case the physician should be asked to prescribe the controlled substance. Physicians have their own professional accountabilities, which may also require them to personally assess the client.
I’m an NP interested in developing a policy related to weaning clients off high doses of narcotics. Does CNO have guidelines to support this?
CNO does not have guidelines related to weaning patients off high doses of narcotics. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. When determining what sources of information are most appropriate to inform your nursing practice, use your clinical judgment to assess the individual care needs of each patient, the appropriateness of the nursing practice and the practice environment you are working in.
CNO's controlled substances resources and references page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or patient population. You are accountable for using the best evidence to inform your clinical decisions.
NPs are accountable for taking appropriate action to resolve or minimize the risk of harm to a patient from a medication adverse reaction (from the Medication practice standard). Implementing a policy that supports weaning patients of high doses of narcotics is one example of meeting this expectation. With patient interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.
I’m an NP and I work in a walk-in clinic. I’m concerned that patients are drug-shopping to divert controlled substances. How do I spot this behaviour and manage any increased patient pressure?
First, you should read the Nurse Practitioner practice standard to know your accountabilities when faced with this types of situation. For example, the practice standard says NPs are accountable for incorporating evidence-informed strategies for assessing, managing and monitoring the risks of misuse, addiction and diversion.
Additional resources are also available on CNO's Controlled Substances: Resources and References page to support NPs continuing competence and clinical decision making.
The Nurse Practitioner practice standard says NPs need to identify when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care. So, you may want to consult another healthcare professional to benefit from their expertise.
I’m an NP and I have patients who are addicted to controlled substances. I want to help. Does CNO have guidelines to support my practice?
The Nurse Practitioner practice standard states that NPs are accountable for using strategies to reduce risk of harm involving controlled substances, including medication misuse, addiction and diversion.
CNO does not have guidelines specific to treating patients who are addicted to controlled substances. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings.
CNO's Controlled Substances: Resources and References page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or patient population. You are accountable for using the best evidence to inform your clinical decisions. With patient interest and safety in mind, you are expected to work with your interdisciplinary colleagues to identify gaps in available policies, procedures and processes, and if needed, develop them.
I’m a new NP working in an emergency department and I treat a variety of clients. I would like information for my prescribing practice (e.g., information related to cancer pain, chronic pain, managing withdrawal symptoms, dealing with opioid tolerant clients). Does the College have guidelines to support this?
NPs are accountable for implementing evidence-informed therapeutic interventions (from the NP practice standard).
CNO does not have guidelines related to the clinical areas you are inquiring about. Our role and expertise is to provide standards and resources that are applicable to nurses who work in a broad range of roles, across various settings. However, we recognize that to meet the expectation in the Nurse Practitioner practice standard that says NPs are accountable for implementing evidence-informed therapeutic intervention, NPs need resources to inform this area of their practice. We have developed a page that points NPs to a variety of resources related to controlled substances, including content that will support the areas you mentioned in your question.
The controlled substances resource page is one source of information. You may need to seek out other sources of information, including information that is specific to your setting and/or client population.
My client is not compliant with the plan of care and is refusing urine screening to monitor medication compliance. I am concerned about prescribing controlled substances in light of this. What should I do?
As an NP, you are responsible for monitoring the client’s response to the prescribed substance and for assessing, managing and monitoring the risks of misuse, addiction and diversion. You are also responsible for implementing strategies to mitigate these risks, and should only perform procedures or activities when you have access to the appropriate client information.
Several factors can contribute to conflict between an NP and a client. For example, this can occur if an NP judges or misunderstands a client (e.g., the client may feel the NP is not listening to, or respecting, their values, opinions or beliefs). NPs may need to reflect on and modify their communication style to meet the needs of the client and find the best possible solution in any complex nurse-client situation.
Ultimately, if the challenges with your client continue and place the client at risk, then you are accountable for acknowledging when there is a diminished therapeutic relationship and for requesting a transfer of care.
For more information on the accountabilities mentioned above, read the Therapeutic Nurse Client Relationship practice standard, Nurse Practitioner practice standard and Conflict Prevention and Management practice guideline.
I have been managing a client with complex addiction issues. My client is pushing for prescriptions that are not in their best interest and I’ve grown increasingly concerned about my personal safety. How do I manage this?
The College does not expect nurses to put their lives or personal safety at risk when caring for clients. As the primary NP, consider if you are the most appropriate care provider for that client and/or whether you need to refer to, or consult, an expert such as an addictions specialist or psychiatrist. For example, consider if you have the knowledge, skill and judgment to continue treating this client. Also, NPs are accountable for identifying when collaboration, consultation and referral are necessary for safe, competent and comprehensive client care.
Employers also have accountabilities under the Occupational Health and Safety Act – they are accountable for establishing a safe work environment and minimizing real or potential risk to employees and clients alike.
The College encourages nurses to work collaboratively with their employers, as well as colleagues, to mitigate real or potential threats. If needed, they should develop policies, procedures and processes that are specific to the practice setting and driven by client interests and safety.
For more information on maintaining a quality practice setting and guidelines for decision-making, read Refusing Assignments and Discontinuing Nursing Services and Ethics.
Where can I find information about Ontario’s Narcotics Strategy, and the Narcotics Monitoring System?
Information about Ontario's Narcotics Strategy and the Narcotics Safety and Awareness Act, 2010 can be found on the Ministry of Health's website. As part of the Narcotics Strategy, the province has established the Narcotics Monitoring System (NMS) to monitor the prescribing and dispensing of controlled substances. Although its name implies the monitoring of narcotics, the NMS monitors all controlled substances as well as opioids that are not controlled substances (such as medications containing Tramadol). The main purpose of the NMS is to examine drug-use patterns to inform harm reduction strategies and education initiatives, and improve prescribing and dispensing practices related to monitored drugs. If illegal activity or professional misconduct is suspected, the Ministry may report information from the NMS to law enforcement bodies and regulatory colleges.
Can I dispense medications that are controlled drugs and substances?
Yes, you can dispense a controlled substance that you prescribed or that was ordered by a physician or dentist with whom you work. The Nurse Practitioner and the Medication practice standards describe the practice expectations for public protection when dispensing medication.
How will this authority affect medical assistance in dying?
Medical assistance in dying protocols may require controlled substances. This regulation change may enable NPs to provide medical assistance in dying protocols (in accordance with legal requirements). See Guidance on Nurses’ Role in Medical Assistance in Dying for a description of legal and professional requirements.
How often am I required to complete approved controlled substances education?
This is a one-time requirement to gain foundational competencies that are unique to controlled substances. You may have other learning needs related to controlled substances. As part of commitment to continuing competence and quality improvement, you are expected to engage in practice reflection to identify learning needs, and set and achieve learning goals.