Pharmacy Practice in Focus: Health Systems
Pharmacists describe their experiences using DEA certificates for controlled substance prescribing in different practice settings, as well as barriers and opportunities for future expansion.
Tristan Tyger, PharmD, is a palliative medicine clinical pharmacist at The Ohio State University Wexner Medical Center in Columbus.
Jeff Boyer, PharmD, MS, BCPS, is a pharmacist at Southern Arizona VA Healthcare System.
Jessica Geiger PharmD, MS, FPPCP, is the director of clinical services at EdLogics and adjunct faculty at University of Findlay College of Pharmacy in Ohio.
No funding was used for the creation of this article. The views and opinions expressed in this interview are those of the authors and do not necessarily reflect the official policy or position of any agency of the US government.
Pharmacist prescriptive authority has progressed significantly since the first collaborative practice legislation was passed in Washington state in 1979.1 Now, states continue to expand pharmacist prescriptive authority for controlled substances by permitting pharmacists to apply for Drug Enforcement Administration (DEA) controlled-substance licenses.
Several studies have shown the positive impacts of pharmacist-controlled substance prescribing. For instance, a 2016 study in an outpatient oncology clinic found that pharmacist-controlled prescribing of substances for cancer-related symptom management improved medication dosing, consistency of medication management, quality of care, and saved time for providers.2 Another study reviewed the use of pharmacist-controlled substance prescribing in a Veterans Affairs (VA) chronic pain clinic setting, demonstrating efficacy with opioid tapering, monitoring, optimization, and overall increased use of opioid risk mitigation strategies.3
These studies offer a small window into how pharmacist-controlled prescriptive authority for substances can benefit different practice types. This article aims to describe individual experiences of pharmacists obtaining and implementing DEA licensure for controlled substance prescribing in practice settings of chronic pain, palliative care, and substance use disorder treatment.
Jessica Geiger PharmD, MS, FPPCP: I remember being so excited when the laws in Ohio changed to allow pharmacists to obtain a DEA license. At the time, I worked in a hospital and did not have a collaborative practice agreement, so I could not apply for one. Fast-forward many years, and I worked in a chronic pain clinic in [Veterans Affairs] in a telehealth capacity. The clinic was interdisciplinary (physician, physician assistant, pharmacists, pain psychologist, and nurse) and my role within the team was to manage medications, focusing on multimodal therapies. If there was no previous pain workup, the veteran was scheduled with either the physician or the physician assistant to receive a full assessment and diagnosis. During that appointment, they may also start a medication regimen. If there was already a pain workup and diagnosis, the veteran would be scheduled with a pharmacist first for medication management. The pharmacists on the team would also help field medication-related phone calls from our clinic population.
Prior to obtaining a DEA license, I was able to initiate and adjust noncontrolled medications. [To] manage controlled substances, I needed to collaborate with the referring provider to obtain an order for the suggested controlled substance. I wanted to be able to act on patient needs in real time, rather than asking them to wait while I made recommendations to either their primary care physician or the pain clinic providers on whether they agreed with the medication change. This could take a few days, which delayed care for the veterans. Obtaining a DEA license allowed me to handle many care needs in real time, which I hoped would lead to increased satisfaction for the veterans.
As I worked in telehealth, there were still restrictions on how I could use my DEA license. I was able to initiate [Schedule III through V] medications via telehealth; I was not allowed to prescribe [Schedule II] medications. The DEA licensure allowed me to practice at the highest level the laws in the state of Ohio for pharmacists would allow and gave me professional satisfaction in the process. Additionally, it allowed me to carry more of the responsibility for prescribing, which took some work off the plates of other members of the team, as well as the primary care physician.
Tristan Tyger, PharmD: [At my health system,] the interdisciplinary team takes care of primarily an oncology population, and managing patients’ symptoms in a timely and effective manner is a priority. The patients are seen in the clinic by physicians and advanced practice providers, with pharmacists primarily available as clinical consultants during clinic visits. Some of the ways pharmacists assist during visits include helping to formulate a medication plan for symptom management, providing recommendations for safe and effective medication use, evaluating lab results such as urine drug tests, and educating patients and caregivers on medication-related topics. Obtaining DEA licenses among our palliative pharmacist team gave us the opportunity to help both our patients and our providers to the fullest extent.
Between scheduled appointments with the palliative team, patients may call into the clinic with new or changing symptoms, necessitating a change to their medication regimen. The pharmacist team assists the providers in managing these telephone encounters during clinic hours, making appropriate medication adjustments based on a palliative nurse’s symptom assessment. The pharmacist team is able to make medication adjustments independently pursuant to our consult agreement, which was initially limited to noncontrolled medications prior to DEA certifications being available to pharmacists in our state. Oftentimes, symptom management encounters led to recommendations for adjusting controlled substances as well, but these changes had a lag time related to needing the providers to sign the new prescriptions.
By obtaining DEA licensure, the pharmacists are now able to implement controlled-substance medication changes instantly using our own credentials, which helps us provide timely changes to maximize symptom management for our patients. From a professional standpoint, it also allows us to practice at the top of our licensure and training as true medication experts, in the sense that the pharmacist is able to take ownership of medication decisions and implementation, seeing the medication adjustments through to completion with a signed prescription.
Jeff Boyer, PharmD, MS, BCPS: Becoming involved in a newly established pain clinic in the midst of the opioid epidemic, I realized quickly the variance between the judicious use of opioid therapy for pain management and when this approach had failed or resulted in a substance use disorder. I often found myself as the intermediary between the provider when making controlled substance medication recommendations and the patient after shared decision-making. This, unfortunately, often led to interruptions in care and disengagement by the patient if recommendations were not implemented.
As a clinical pharmacist working under a pain management scope of practice, working to the top of my license means the prescribing and management of controlled substances frequently encountered in this specialty; however, without a DEA license, I was unable to provide the continuity needed in a timely manner or the appropriate treatment for an evident or emerging opioid use disorder. An overwhelmed primary care and pain clinic desired the ability to have a clinical pharmacist complete follow-up assessment and medication changes to improve their ability to address the multiple alerts or consults occurring daily, thus improving access and patient care. With DEA licensure and later the implementation of the Mainstreaming Addiction Treatment Act, I desired the ability to fill that crucial role in closely navigating the gray area of pain and opioid dependence and order the medication changes to improve safety and quality of life.
Geiger:In chronic pain, I was able to prescribe CIII-CV medications, mostly buprenorphine products, during the visit and assist in transitioning veterans off full mu opioid agonists as appropriate. This was helpful as waiting for orders to be approved by a different prescriber could cause delays, and there was a chance that someone would change their mind (which is fine). I experienced fewer veterans changing their minds about transitions to buprenorphine when I was able to prescribe the medication and then follow up quickly to talk them through how to use it. Additionally, having my DEA license allowed me to help decompress the schedules of the other providers and members of the pain team.
Tyger: For a palliative care pharmacist team, using DEA licenses to prescribe controlled substances has significantly streamlined interdisciplinary clinic workflows, reduced delays in patient care, minimized communication errors, and enabled providers to more effectively focus on clinic duties. In our practice setting, the pharmacists are primarily managing cancer-related symptoms via telephone calls from patients who are already established with the palliative clinic providers when they experience a change in symptoms that needs to be addressed before the next scheduled appointment.
All patient calls are initially routed to a triage nurse for review and assessment. Then, calls related to symptom management or medication questions are escalated to a pharmacist, while other concerns are directed to a provider. By managing calls within pharmacist scope, pharmacists allow providers to dedicate more time to in-clinic visits and complex cases. In an initial quality analysis after implementing controlled substance prescribing within the palliative pharmacist team, it was discovered that the turnaround time between initial intake of a symptom-related phone call and signing of a controlled substance prescription decreased from an average of 178 minutes to 101 minutes. That demonstrates a decrease of 77 minutes.
This is impactful because if symptoms are not addressed promptly, patients may end up seeking care in urgent care or emergency departments. The palliative clinic prioritizes timely follow-up on patient calls to ensure appropriate and efficient care. When medication changes are made for management of symptoms, patients often need to pick up the new prescriptions as soon as possible.
In addition to objective improvements for patient care, providers have perceived the heightened capabilities of the pharmacist team in a very positive way. Testimonials include mention of providers feeling like patient care is streamlined, interdisciplinary collaboration is increased, it has allowed them to focus on other responsibilities and reduced in-basket burden, and overall enhanced patient access to quality triage care.
Boyer: Substance use disorders frequently overlap with persistent pain, often complicating, confusing, and contraindicating treatment approaches. Having the ability to offer medications for opioid use disorder provides the ability to assist those patients who require higher levels of monitoring, stabilization, or risk mitigation, ultimately leading to improved quality of life. As a pharmacist, my position affords the ability to see patients in a timely manner, provide close and frequent follow-up, and spend the time to walk with the patient through a challenging process typically involving weekly or even daily follow-up.
Utilizing a DEA license, I can assist in improving access by being that accessible touchpoint where close monitoring and medication adjustments are implemented rather than requested. This can look like slowly tapering a high-dose opioid regimen or alleviating withdrawal from opioid use disorder by initiating buprenorphine. Providers request medication expertise from me to initiate or rotate controlled substance medications they are later more comfortable taking over. Facilitating this additionally allows sustainability and better access for me when providers feel more comfort continuing a stable regimen. The result is a patient who received the continuity needed to ensure safety and treatment success, and I am proud to say, more providers who are comfortable treating opioid dependence.
I chose to obtain a DEA license to be that team member to support my facility and give the patients the access, guidance, and options they needed. When additional time and action are no longer required to review my recommendations and order prescriptions by taking on that additional role as the controlled-substance prescriber, it enhances the medical providers’ efficiency operating as diagnosticians. This, in turn, leads to improved timeliness, access to care, and patient satisfaction. In substance use disorders, this can translate to a faster path in recovery and even mortality risk reduction.
For pharmacists who do not live in a state where obtaining a DEA license is currently permitted, writing letters to state legislators and partnering with state organizations to participate in legislative days can help promote awareness of what pharmacists can do, if only they are supported to do so. The Figure shows states that allow pharmacists to apply for DEA licenses.
Although these perspectives focus on the prescribing of opioids using DEA licenses, many more opportunities exist, including weight management and mental health clinical spaces, where other types of controlled substances are often used. Pharmacist-controlled substance prescribing can help fill care gaps due to physician shortages, improve health equity for underserved populations, and streamline patient care workflows by reducing delays in care and minimizing communication errors.
Continued barriers to the expansion of pharmacist-controlled substance prescribing include the cost of DEA registration, institutional support, fair and equitable payment models, payer recognition of pharmacist prescriptive authority, and pharmacist provider status. Advocacy within individual organizations is also critical to the successful implementation of DEA licenses for pharmacists.
Several national pharmacy organizations have advocacy efforts focused on pharmacist DEA certification. One example is a March 2025 call for the DEA to update its registration process to reflect state laws granting pharmacists prescriptive authority for controlled substances, specifically citing Colorado, Iowa, Nevada, North Dakota, and Oregon, but many other states permit pharmacists to obtain DEA certification. This was a collaboration between the American Pharmacists Association, American Association of Colleges of Pharmacy, American Association of Psychiatric Pharmacists, American College of Clinical Pharmacy, American Society of Consultant Pharmacists, American Society of Health-System Pharmacists, and many more organizations.4 More details are in the Figure.5-11
Special attention must be paid to state laws pertaining to additional requirements alongside opioid prescribing, for example, urine drug testing, signed medication agreements, opioid overdose reversal agent prescriptions, and prescription drug monitoring program review. It is recommended that all pharmacists defer to their state board of pharmacy for questions regarding pharmacist DEA licensure.
