One of the main, but perhaps underappreciated, reasons quackery thrives in the United States is that the states legalize it by licensing practitioners of pseudoscience as health care providers. These practitioners are placed under the regulatory jurisdiction of, well, themselves. I call the whole deplorable process Legislative Alchemy, and you can see all posts on the topic here. It gives practitioners an underserved imprimatur of state authority and leaves public protection from harmful practices to the oversight of those who are themselves engaging in the very same conduct. Each year, dozens of bills are brought before the state legislatures to establish initial licensure or, once that goal is achieved, scope of practice expansion.
Most attempts fail, but CAM practitioners are a dogged bunch, and they will come back each year until they get what they want. It took chiropractors about 60 years to become licensed in all 50 states. Acupuncturists are almost there. Naturopaths lag far behind, but are slowly gaining ground each year, even if it is only via practice expansion in states where they are already licensed. 2015 was a losing season for all, but not without advancement toward larger goals.
In 2015, naturopaths didn’t come any closer to their goal of licensing as primary care physicians in all 50 states. In fact, in what was undoubtedly a major embarrassment, they lost ground when naturopaths were delicensed in one state, Idaho. And this on the heels of a licensing bill’s failure in that same state. In other words, Idaho said, “not only no, but hell no” to naturopathy.
Elsewhere, licensing bills failed in Iowa, Mississippi, Nevada (a state that otherwise wholeheartedly embraced quackery in 2015), North Carolina, and Rhode Island. While, technically, the 2-year legislature doesn’t adjourn in New Jersey until January 11, naturopathic licensing bills there never even made it to committee hearing, guaranteeing their failure at this point. All told, naturopaths failed in their attempt to gain licensure in 7 states.
Licensing bills are still pending in 5 states, all carryovers from the 2015 sessions of a two-year legislature in Illinois, Massachusetts, Michigan, New York and Pennsylvania. (Britt Hermes has a post on the Massachusetts bill on her blog, Naturopathic Diaries.) In Pennsylvania, a bill passed in the House and is now before the Senate Committee on Consumer Protection and Professional Licensure. During 2013-14, bills came perilously close to becoming law in Massachusetts and New York. Gov. Deval Patrick vetoed a bill that passed both houses (under dubious circumstances) in Massachusetts and a New York bill passed in the Senate, only to fail in the House.
Naturopathy: Licensing inadequacy
Reading these licensing bills always presents a frightening prospect: naturopaths, despite their woefully inadequate education and training, are regularly given the authority to diagnose and treat any patient with any disease or condition. This leaves patients open to the possibility that they will be diagnosed with fake diseases like adrenal fatigue, chronic Lyme, and chronic candidiasis, and imaginary malfunctioning thyroids. They can order diagnostic testing and prescribe and sell dietary supplements and homeopathic remedies; sometimes with the ability to administer these substances by IV. In addition to homeopathy, other quackery is specifically permitted in some bills, such as visceral manipulation, hair analysis, colonic hydrotherapy, and “electromagnetic energy” treatments. They often seek the right to refer to themselves as “physicians” and define naturopathy as a form of “primary care.”
When they don’t get their desired scope of practice initially, naturopaths will return to the state legislatures year after year pushing for expansion. 2015 was no exception.
These efforts failed in Connecticut, where they couldn’t even get the legislature to order the Department of Health to look into the matter of giving them prescription privileges; in Hawaii, where they wanted to corner the market on colon hydrotherapy by banning other practitioners from using it; and in Montana, where naturopaths went all out by seeking the essentially the same prescription privileges as MDs.
North Dakota was a particular victory for science-based medicine and a real nail-biter to boot. A bill would have permitted naturopaths to prescribe from a formulary established by a Board of “Integrative Medicine,” perform minor office surgeries, and practice naturopathic childbirth attendance. In February, the bill failed in the Senate by a vote of 22 yeas to 25 nays. The very next day, it was reconsidered and passed, 25-22. It then went to the House, where it was voted out of committee with a “do pass” recommendation. But, when it went to the House Floor, the bill failed by a wide margin, 35-56.
What happened to turn things around? Former naturopathic doctor Britt Hermes told the truth. She’s recounted her written testimony before the North Dakota Legislature on her blog, Naturopathic Diaries. There, she exposes the misrepresentations naturopaths make to the state legislatures: the subjects they actually study (homeopathy, botanicals), their medically useless textbooks and the lack of clinical training. She’s done her homework too: a chart compares the pharmacology training of naturopaths versus that of Physician Assistants and Nurse Practitioners, who must practice under the supervision of a physician, and convincingly demonstrates how naturopathic education pales in comparison.
Unfortunately, two practice expansion bills passed in Colorado. One allows naturopaths to inject vitamins and non-prescription drugs. The other is a textbook example (along with a California bill we’ll get to next) of the confusion and ambivalence legislators display over just how far they should go in letting naturopaths play real doctor. It’s as if they know they shouldn’t trust the song-and-dance they’re getting from the naturopaths, but aren’t quite sure what to do about it. (They appear especially concerned about naturopathic anti-vaccine ideology, and for good reason.) This usually results in the expansion (or initial scope of practice) granted in a bill’s original draft being chipped away until arriving at a suitable mishmash of naturopathic privileges and patient safeguards. It never seems to occur to legislators that, if a barricade of patient safety measures must be erected around naturopathic practice, perhaps they shouldn’t be allowed to practice in the first place.
Colorado passed a naturopathic registration (but not licensing) act in 2013, but with provisions protecting children by placing restrictions on naturopathic treatment of pediatric “clients,” including a complete ban on seeing clients under 2 years of age. (Those who see registered naturopaths are referred to as “clients,” not patients.) Naturopaths tried to get rid of these restrictions in 2014, but failed. In 2015, instead of lifting the restrictions altogether, they supported a bill that would allow them to see children under 2 with the same restrictions as apply to clients between 2 and 8 years old: providing parents with the recommended vaccination schedule, requiring 3 hours of yearly pediatric continuing education, informing parents that the naturopath is not a licensed physician, recommending that the child have a relationship with a licensed health care provider, and referring a child to a physician if no such relationship exits.
The bill passed and was signed by the Governor, but with even further limitations added along the way during the legislative process: more hours of training, including recognizing a sick infant (imagine that!) and when to refer an infant for more intensive care, and requiring a collaborative agreement with a licensed physician to “ensure safety” of clients under 2.
See what I mean? Another example, as promised, comes to us from California.
Via Senate Bill 538, California naturopaths wanted to remove MD/DO oversight of their prescribing Schedule III – V drugs, including routes of administration and patient-specific protocols in certain cases. They also wanted the right to use parenteral therapy, to perform minor surgical procedures and to perform, review and interpret results of diagnostic procedures, including venipuncture, lab tests, electrocardiograms, diagnostic imaging and biopsies. Disappointingly, the AARP supports the bill.
This major practice expansion was trimmed considerably as the bill moved through the Senate, where it passed. It was then voted down in the Assembly Appropriations Committee, only to be resurrected when reconsideration was granted, and there the bill sits. Even then, Assembly committees pulled back even further on the proposed expansion. In its current form, naturopaths must still have MD/DO oversight for Schedule III- IV controlled substances prescribing. Pharmacists insisted on a provision allowing them to see a standardized protocol when “there is uncertainty about the naturopathic doctor furnishing the order.” Parenteral therapy and minor surgeries and biopsies are out, as well as performing and interpreting diagnostic imaging, although they can order these.
The California Naturopathic Doctors Association (CNDA) is worried that the bill’s chances might be endangered by naturopaths practicing outside their legal scope of practice. In a recent email, the CNDA warned that naturopathic websites with the terms homeopathic, ozone therapy, ultraviolet radiation therapy, alternative cancer care, biotherapeutic drainage, and electrodermal screening are “being targeted.” It urged members to review their websites to ensure that what they offer is within their legal scope of practice. Not to make sure that what they offer is safe and effective, only legal.
This vigilance was prompted by a complaint filed against a Vermont naturopath for using ozone therapy and auto-hemotherapy combined with UV light treatment, a quack procedure involving taking a few ounces of blood and mixing it to ozone gas, then injecting it back into the body via an IV drip, exposing it to UV light on the return trip. According to one naturopath:
Now your blood has been cleansed of UV-sensitive pathogens. If you give that blood a clean slate, and your body can now “see” the antigen structure of those organisms. It knows that those organisms are there, but the organisms happen to be dead, so they’re not going to hurt you. Your body can then see those organisms and mount a much more efficient immune response.
The CNDA noted that, while Vermont naturopaths enjoy a broad scope of practice, ozone therapy is in a “gray area.” According to the FDA, ozone has no useful medical purpose, but when that did that ever stop a naturopath? The CNDA expressed no concern whatsoever that ozone therapy is total nonsense. In fact, it offers its own course in the subject, although an ad for the course was taken down after the Vermont ozone kerfuffle became known. (Fortunately, we have a screen shot here.) Now that’s the kind of unimpeachable ethics and keen knowledge of pharmacology you want in a regulatory board supervising poorly educated and trained people who prescribe drugs.
A Washington bill authorized naturopaths to prescribe and administer legend (prescription) drugs, hydrocodone products contained in Schedule II of the controlled substances act, as well as all controlled substances in Schedules III – V. That bill failed but naturopaths were not deterred for long. A new bill was recently filed that would do essentially the same thing. No additional education or training would be required for these expanded privileges, nor would any regulatory supervision be provided other than the usual oversight of the Washington State Board of Naturopathy. (If you’d like to see this particular Board’s scientific IQ in action, take a look at my SFSBM post on its approval of two quack blood tests. I have to say, given these antics on the part of the California and Washington naturopathic boards, naturopathic education must be sorely lacking in hematology.)
Much to the chagrin of my SBM and SFSBM colleague, Mark Crislip, a new Oregon law forces insurers to allow naturopathic “physicians” to choose whether they’d like to be credentialed as a primary care provider or specialty provider (they are currently limited to the latter). Naturopathy is redefined as “primary care” under state law.
But don’t lose hope!
I see a potential silver lining here. It will be interesting to find out how many naturopaths take advantage of this new option and, of those who do, how many patients use them as PCPs. And, as Dr. Crislip himself recently discovered, the integration of naturopaths into the health care system will provide an opportunity to see what they are up to via the magic of EHRs (electronic health records). As Dr. Crislip recounts, another Oregon doctor was reviewing the EHR of a patient who had seen a naturopath. All that was in the patient’s assessment and plan was “Phelgm Misting Orifice.” (I’ll let him tell you the rest of the story.)
Because chiropractors are already licensed in all 50 states, their legislative efforts are directed at expanding their scope of practice and increasing insurance coverage of their services.
One practice-expansion tactic they use is getting a bill passed defining their scope by reference to what they are taught in chiropractic school. For example, in Hawaii, chiropractic practice is limited to “adjustments” of the spine, with some exceptions allowing them to treat certain extra-spinal neuromuscular conditions. A bill was introduced eliminating those restrictions and allowing chiropractors to diagnose and treat any disease or condition (except through the use of legend drugs or surgery) as long as the diagnostic methods and treatments were taught by an accredited chiropractic college. Fortunately, the bill failed.
Now you can see why the intra-fraternal wars over the Council on Chiropractic Education and its accreditation standards aren’t just academic. It’s all part of a strategy to refashion chiropractors into primary care physicians, or at least substantially increase their income potential by allowing chiropractors do to more types of procedures. If the states default to the schools to decide the chiropractic scope of practice, and the CCE controls school curricula, what the CCE says the schools must teach becomes very, very important.
New Mexico gives chiropractors the most liberal scope of practice in the country, including the right to prescribe certain drugs if they have 90 hours of additional training, making them “advanced practice” chiropractors. A bill was introduced to expand that scope even further by allowing chiropractors to diagnose and treat any condition for which they have been “educated and trained.” Another “advanced practice” chiropractic tier was added (“Level Two”), allowing the prescription, injection, and dispensing of all dangerous drugs (as defined by state law) except Schedule I and II controlled substances, as long as they are drugs used in standard primary care practice. The chiropractic board was given the authority to add other drugs to the formulary “in consultation with” (but not approval of) the pharmacy board. The pharmacy board had gotten in the way of the chiropractic board’s previous efforts to expand the formulary, thus the need to neutralize its ability to interfere. Fortunately, this expansion effort didn’t pass.
A more modest attempt to add limited prescription rights to chiropractic scope of practice failed in Arizona as well, as did a bill establishing a certification in “animal chiropractic.” In Ohio, chiropractors want to recommend, distribute, administer, and sell non-prescription drugs, vitamins, minerals, antioxidents, other dietary supplements, homeopathic products, glandulars, and medical equipment. All real money-makers, especially where bogus tests for “deficiencies” will reliably detect a need for these products. That bill is still in committee.
In Mississippi and Louisiana, bills were introduced to remove restrictions on chiropractors’ use of diagnostic tests and imaging. Those didn’t pass either. Chiropractors in Texas were unsuccessful with a bill that would have enlarged their scope from analyzing and treating a “biomechanical condition of the spine and musculoskeletal system” by adding the phrase “or the condition of another system of the human body that is affected by the musculoskeletal system.” One can well imagine that a creative interpretation of this additional phrase would have made their scope practically limitless.
A different sort of prescription issue remains pending in Michigan, where chiropractors want the authority to prescribe physical therapy. PTs, as well as MDs and insurance and business interests, oppose the bill. Under state law, patients have direct access to PTs in limited cases. PTs take the position that chiropractors can already refer patients who are eligible for this direct access. However, for more complicated cases, only an MD, DO, DPM, or DDS/DMD is properly educated and trained to fully assess the patient’s biomedical issues and determine whether physical therapy, drugs, surgery or some other treatment is appropriate. Chiropractors have neither the education nor scope of practice to properly assess all of these treatment options.
Another money maker is the authority to perform physical and eye exams. Attempts to gain both in Nebraska and the right to perform commercial driver’s license exams in Virginia didn’t pass. Finally, Wyoming chiropractors wanted to call themselves “chiropractic physicians.” That one didn’t make it either.
In case you weren’t counting, all told there were a dozen attempts to improve the chiropractic lot in 2015 via the state legislatures. All failed except the two, in Ohio and Michigan. Those remain pending during the 2016 session.
Acupuncture, traditional Chinese medicine and oriental medicine
Acupuncturists fared somewhat better in 2015 than their fellow practitioners of pseudoscience. North Dakota passed an acupuncture practice act, although their scope of practice is fairly narrow. It includes botanical medicine and needle acupuncture, but without “electronic stimulation.” Rhode Island added the practice of “oriental medicine” to its acupuncture practice act, defined quite broadly as a form of “primary health care” using Chinese medical and acupuncture diagnosis, including “newer scientific models” for “assessment, treatment, prevention and cure of any disease.”
In Colorado, acupuncturists were successful in expanding their scope of practice to include injection therapy: the injection of sterile herbs, vitamins, minerals, homeopathic substances, sarapin, saline, glucose, procaine, and lidocaine into (the imaginary) acupuncture points. Amazing how the rationale for acupuncture and Oriental medicine – that it’s been used for “thousands of years” – conveniently falls by the wayside when they want to expand their practice.
Not all efforts were rewarded. In Iowa, acupuncturists tried unsuccessfully for a substantial practice expansion via adding oriental medicine, but Iowan oriental medicine is apparently different than Rhode Islander oriental medicine. The Iowa version would have included reflexology, magnets, dietary supplements, and “mind-body techniques,” among others. In Oklahoma, their effort to pass an initial licensing act failed, as it did in Wyoming. In Wyoming, acupuncturists wanted their practice to include stimulating “points on the body” with lancets. In other words, they wanted to bleed their patients. Not just metaphorically, via the wallet. They wanted real thing.
In Mississippi, acupuncturists again tried to get rid of the requirement that a patient have a physician referral for acupuncture treatment. They were again unsuccessful. Maine’s governor vetoed a bill that would have established a pilot project for treatment of substance abuse disorders with auricular acupuncture, a method that miniaturizes all the pseudoscience of whole body acupuncture and imposes it on the ear. A bill to expand the practice of acupuncturists in New York remains pending.
And here’s where you come in
Over on SFSBM, we follow the trail of Legislative Alchemy through all 50 state legislatures year-round. Many of the 2015 bills have been resolved, but 2016 is just getting underway. If you are wondering how to stem the tide of quackery, here’s an opportunity. Follow what is happening in your state and, when you see a bill you don’t like, contact your state legislator and tell him/her about it. Between SFSBM and SBM, you have plenty of raw material to compose a killer letter or, for those who want to try out their lobbying chops, in-person presentation. Check your state legislature’s website; some, like Washington, will take online comments on a particular bill from state residents. All will tell you how to contact your legislators.