Michael Stanley has worked as a physician assistant for the better part of two decades and seen around 65,000 patients during that time. But he has never written any of them a prescription for a controlled substance.

Anywhere else in the country, Stanley would be able to prescribe controlled medications if his supervising physician approved. Kentucky is the only state where PAs are prohibited from writing prescriptions for controlled substances.

That would change under House Bill 93.

“In Kentucky, we have a shortage of physicians and we also have very poor health care outcomes in many of our rural areas,” said Rep. Daniel Elliott (R-Danville), the bill’s sponsor. “We have three schools in Kentucky who train physician assistants and a lot of them unfortunately are leaving the state to practice elsewhere because of the fact their ability to practice is restricted in Kentucky.”

House Bill 93 would allow approved PAs to prescribe “non-narcotic Schedule II controlled substances and all Schedules III through V controlled substances.” It would also put in place requirements for continuing education and recertification every two years for PAs who prescribe.

What is a PA?

Stanley developed his interest in becoming a physician assistant while on active duty in the Coast Guard. It’s actually a profession that has its roots in the military — many of the graduates of the first ever PA program at Duke University in the 1960s were soldiers who had returned from the Vietnam War with skills in battlefield medicine, he explains.

“It’s a fantastic profession. It’s a job in which you have a direct impact on patients’ lives each day,” Stanley says. “You’re able to sit down with them, help figure out what’s wrong … make them feel better, get them back to work.”

Physician assistants always operate under the supervision and guidance of a physician — “it’s a team approach” that can be very beneficial for patients, he says.

To become a physician assistant, Stanley had to earn a bachelor’s of science degree and complete specific classes related to the field, including microbiology, chemistry, physiology and more. He then needed a physician assistant master’s degree, which involved a year and a half of classroom training and a year of clinical rotations. He graduated in 2000 with 2,000 hours of clinical supervised care under his belt.

Among his training — which he notes is standardized across the nation — was pharmacology. That’s because in every state except Kentucky, “you’re expected upon graduation” to be writing prescriptions, he says.

Potential benefits

Stanley works in the emergency room at T.J. Samson Community Hospital in Glasgow. He says if he could prescribe medications, especially for pain, it would “speed things along.”

“As it stands now, there’s a time delay,” he says, explaining how his physician may not always be available. The physician could be making rounds elsewhere in the hospital or dealing with another patient. If he has to track down the physician for a prescription, “it just stalls things.”

Sometimes, patients are left waiting until the physician returns, meaning others in the waiting room are also waiting.

Stanley says there are also times when paramedics dealing with an emergency call over the radio to get authorization to give someone a controlled substance. PAs cannot currently authorize that, so when the physician is somewhere else, the paramedics must wait to administer the medication until the physician returns.

“Every emergency room in Kentucky runs into that,” Stanley says.

If PAs could prescribe, it could also make health care cheaper for the public. Stanley says there are cases where a PA works with a patient and knows what they need, but because a physician has to see them to write a prescription, the patient is billed a higher rate.

The prohibition on PA prescriptions also limits PA’s job opportunities and drives many of them out of the state, he adds.

Stanley’s hospital has an urgent care clinic that he wanted to work at in the past, but he couldn’t because on days when no physician was working at the clinic, patients would have had no way of obtaining prescriptions.

“There are a lot of PAs throughout the state that have been denied jobs,” he says.

There are schools in Kentucky that train PAs, but many of those who graduate then move away “and we don’t see them again.”

Physician assistant is regularly ranked as one of the best compensated jobs out there, and it’s an “in-demand profession,” meaning if Kentucky could hold onto its PAs, its economy would stand to benefit, Stanley says.

“Each one that graduates, we desperately need to hang onto,” he says.

Third time trying

Rep. Elliott sponsored similar bills in 2017 and 2018, but they failed to pass. He said he’s “cautiously optimistic” that it could pass this time around.

In 2018, the bill didn’t go anywhere. House leadership learned the Senate would not be willing to consider Elliott’s bill, so “there really wasn’t a need to pass it in the state House if the state Senate wasn’t going to pass it.”

Elliott said opposition seems to stem from “the perception that we would somehow be expanding access to controlled medications. Clearly, we have an opioid problem and I think some don’t want that perception.”

But Elliott’s bill wouldn’t allow PAs to prescribe the opioids that have contributed most to the current epidemic, Stanley said. Those drugs — hydrocodone, oxycontin, fentanyl and others — are Schedule II narcotic medications; the bill would only allow PAs to prescribe Schedule II non-narcotic drugs, he explained.

“This will not contribute to the opioid crisis because we’re not going to be prescribing the opioids that have caused the problem,” Stanley said.

Among the non-narcotic Schedule II drugs the bill would enable PAs to prescribe are Ritalin and testosterone. Stanley said a PA prescribing Ritalin, which is used to treat attention deficit hyperactivity disorder, could reduce the cost of medical visits for children on government-funded health insurance, he said. And being able to prescribe testosterone would make it easier or cheaper for some women to get certain kinds of birth control.

Elliott and Stanley said the other 49 states that allow PAs to prescribe have not seen problems or had regrets.

“There isn’t a proliferation of excessive prescriptions for controlled substances when physician assistants are granted this prescriptive authority in other states,” Elliott said, not that “everything a physician assistant does is in consultation with a doctor.

“We’re kind of getting blamed for a problem that we did not create,” Stanley said. “… No state that has allowed PAs to prescribe controlled substances has ever repealed it. So we have lots of data on the fact that PAs are safe prescribers.”

Elliott noted his bill wouldn’t be a blanket approval for prescribing by any PA. Each PA that wanted to prescribe would have to go through an application process and be approved. Stanley said a PA’s supervising physician would also have to authorize a PA to write prescriptions by signing off on their confidence in the PA every two years.

Elliott said he doesn’t yet know what Senate leadership might think of his bill this time around.

“We’re getting closer, I hope, to a resolution of the issue,” he said. “I think they recognize the difficulty the law places on that profession and on patients who are in need of health care.”

This article has been corrected to reflect that physician assistants cannot currently prescribe controlled substances in Kentucky, and to correct the proper spelling of physician assistant.