This paper examines the regulatory frameworks governing APRN prescriptive authority in New Hampshire and Massachusetts, two neighboring states with markedly different approaches. New Hampshire grants board-certified APRNs plenary prescriptive authority equivalent to physicians, requiring only a Master's degree in nursing and DEA registration. Massachusetts, by contrast, implements a specialty-specific system with five recognized APRN roles, offering plenary authority only to certified nurse midwives while requiring supervising physician agreements for other specialties. The paper analyzes how each state's geographic and demographic context shapes regulatory policy, concluding that New Hampshire's permissive framework prioritizes rural healthcare access while Massachusetts's restrictive model emphasizes controlled oversight of Schedule II–V drug prescribing.
Massachusetts is the 44th largest state in the United States with 7,838 square miles of land (Netstate.com, 2014). By comparison, New Hampshire (NH) is the 45th largest state with 8,969 square miles of land. These statistics reveal that NH is the larger of the two states in terms of land mass, yet in 2014 had less than one-fifth the population of neighboring Massachusetts (U.S. Census Bureau, 2014). Accordingly, NH residents are more likely to live in a rural setting and receive healthcare services from advanced practice registered nurses (APRNs) (Buerhaus, DesRoches, Dittus, & Donelan, 2014). Physicians, on the other hand, are more likely to practice in suburban areas.
Given the logistical constraints associated with providing primary, acute, and long-term care in rural settings, it may come as no surprise that APRNs practicing in NH have plenary authority to prescribe medications (New Hampshire Board of Nursing, 2013a). In other words, board-certified APRNs practicing in NH have the same prescriptive authority as licensed physicians. This stands in stark contrast to a number of other states that require physician oversight of prescriptive authority, in addition to limiting the classes of drugs that can be prescribed by APRNs (Gadbois, Miller, Tyler, & Intrator, 2014). All that is needed to prescribe FDA-approved drugs in NH is a valid individual or group registration number from the U.S. Drug Enforcement Agency (DEA) (New Hampshire Board of Nursing, 2013b).
New Hampshire's approach to APRN prescriptive authority is streamlined and permissive. Board-certified APRNs in the state obtain plenary prescriptive authority, meaning they can prescribe any FDA-approved medication without requiring physician approval or oversight. The regulatory requirements are minimal: an APRN must hold current board certification and maintain a valid individual or group DEA registration number. This framework reflects New Hampshire's acknowledgment that many APRNs practice in rural areas where physician supervision may be geographically impractical or impossible to arrange.
The simplicity of New Hampshire's system stands in sharp contrast to states with more restrictive models. Rather than limiting prescriptive authority by drug class or requiring ongoing supervision agreements, New Hampshire has chosen to increase educational entry requirements. APRNs practicing in the state must hold a Master of Science in Nursing (MSN) or advanced practice nursing degree, a requirement implemented in 2004 (Gadbois, Miller, Tyler, & Intrator, 2014). The logic underlying this approach is that rigorous graduate training, combined with board certification, adequately prepares APRNs to practice independently with full prescriptive authority.
"Five specialties with varying authority levels"
The Department of Public Health, after determining that an APRN has met the requirements for prescriptive authority in that specialty, will confer a Massachusetts Controlled Substance Registration (MCSR) number to the APRN. The APRN can then request an individual or group registration number from the DEA. However, prescriptive authority varies significantly across specialties. CNMs have plenary prescriptive authority in the state of Massachusetts, while CNSs have none (Department of Public Health, 2014). The remaining APRN specialties—CNP, CRNA, and PCNS—require an ongoing prescriptive agreement with a supervising physician.
Massachusetts imposes strict requirements on physicians who supervise APRNs with prescriptive authority. The supervising physician must hold an unrestricted full license in Massachusetts, have completed training in an accredited school in the United States or Canada, be board-certified, and be practicing in a specialty area similar to that of the supervised APRN (Board of Registration in Nursing, 2014). For physicians supervising PCNSs, training must have been completed in psychiatry at an accredited institution of higher learning. If the supervising physician has hospital admitting privileges for the specialty area, board certification is not required for CNPs and CRNAs. The supervising physician must also maintain valid controlled-substance registrations through both the Massachusetts Department of Public Health and the DEA.
The written agreement between the Massachusetts APRN and supervising physician must define the nature and scope of the APRN's prescriptive authority and be renewed every two years (Board of Registration in Nursing, 2014). The agreement should describe how supervision can be delegated to another physician, along with any limitations in the duration and scope of the delegation. The agreement must state the circumstances that trigger physician consultation or referral, define the mechanism and duration for monitoring prescribing practices, and require review of Schedule II drug administration within 96 hours. Even though medical marijuana is still categorized as a Schedule I drug by the DEA (Silverman, 2015), CNPs are authorized by the state of Massachusetts to prescribe this drug under appropriate physician supervision (Board of Registration in Nursing, 2014).
The prescriptive agreement between the APRN and supervising physician is a public document and must be provided to anyone requesting a copy (Mass.gov, 2015b). If the APRN needs prescriptive authority in multiple settings but a supervising physician is not available who practices in all settings, then a supervising agreement must be created with a physician for each additional setting. Other restrictions include physician oversight of APRN patient diagnosis and treatment in Massachusetts (Gadbois, Miller, Tyler, & Intrator, 2014).
APRNs requesting prescriptive authority in Massachusetts are only required to have a general Master of Science degree, while in NH, APRNs must have a Master of Science in Nursing (or advanced practice nursing degree) to enter the workforce (Gadbois, Miller, Tyler, & Intrator, 2014). The increased training requirement for APRNs in NH is somewhat recent and was implemented in 2004. Both states require practicing APRNs to keep their national credentials in good standing and allow APRNs to prescribe Schedule II through V drugs after obtaining the necessary approval from the state and DEA. This contrasts with several other states that prohibit administration of Schedule II drugs by APRNs.
Schedule II drugs encompass narcotic painkillers, which have been blamed for a dramatic increase in opioid-related overdoses and deaths (U.S. Centers for Disease Control and Prevention, 2015). The regulatory approaches of New Hampshire and Massachusetts to Schedule II drug prescribing reflect broader policy trade-offs between facilitating healthcare access and controlling medication misuse risk.
Massachusetts is by far the more restrictive state of the two when it comes to regulating the prescriptive authority of APRNs. The relatively strict regulatory environment in Massachusetts may seem extreme when compared to NH, but NH requires a Master of Science in Nursing before an APRN can practice in the state. Rather than impose a complex system of prescriptive authority regulation on APRNs, NH has instead chosen to increase the training requirement and then confer the same prescriptive authority to APRNs that is enjoyed by licensed physicians. This makes sense given that many NH APRNs practice in rural settings, where it may be difficult or impossible to establish oversight agreements with nearby physicians. New Hampshire's regulatory environment therefore allows APRNs to practice without restrictions, which in turn increases access to healthcare services in rural settings.
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