Legislative Alchemy

Legislative Alchemy

Naturopathy has been legal in Connecticut for almost 90 years, but with a scope of practice limited to counseling and a few treatments like physiotherapy, colonic hydrotherapy and “natural substances.” There was no specific authority to diagnose and treat. All of that changed on October 1, 2014, courtesy of the Connecticut legislature, which, in the words of the American Association of Naturopathic Physicians (AANP), “modernized” the naturopathic scope of practice.

Actually, the legislature did nothing of the sort. Naturopathy is based on the prescientific concept of vitalism, and we find it right there in the very first paragraph of the new law. Naturopathy is defined as:

diagnosis, prevention and treatment of disease and health optimization by stimulation and support of the body’s natural healing processes, as approved by the State Board of Natureopathic [sic] Examiners, with the consent of the Commissioner of Public Health. . .

Also included in the expanded scope of practice are:

ordering diagnostic tests and other diagnostic procedures, . . . ordering medical devices, including continuous glucose monitors, glucose meters, glucose test strips, barrier contraceptives and durable medical equipment; and . . . removing ear wax, removing foreign bodies from the ear, nose and skin, shaving corns and calluses, spirometry, tuberculosis testing, vaccine administration, venipuncture for blood testing and minor wound repair, including suturing.

So, they will be measuring lung function with spirometry (and presumably treating lung diseases) and diagnosing and treating diabetes, as well as removing ear wax and shaving corns and callouses. What an odd hodgepodge! “Vaccine administration” obviously includes advice on whether to vaccinate, a disturbing thought given naturopaths’ anti-vaccination ideology. And I do have to wonder exactly how much suturing naturopaths have had the opportunity to do in their residency-free education and training.

The Connecticut Naturopathic Physicians Association (CNPA) appears to be unaware of their legislative success. (Yes, they will be able to call themselves “physicians.”) As of October 15, 2014, their website is still asking for support for practice expansion.

Naturopaths wanted, but were not given, the authority to “prescribe, dispense and administer legend and non-legend drugs in all routes of administration.” They vow to come back next year to ask again in accordance with the AANP’s strategy of naturopaths having full primary care physician scope of practice in all states.

In promoting this legislation, the naturopaths made the same arguments they always make. First, they that their education and training prepares them for full primary care scope of practice, which will help ease the primary care physicians shortage. This is what we call a “conclusory allegation” in the legal trade. There are no facts to back it up. It’s like saying “the defendant was negligent” in a personal injury case without presenting any facts to support that conclusion. You can’t get away with it in court and they shouldn’t get away with it before the state legislatures, but they do.

On the other hand, there is quite a bit of evidence that their education and training is wanting. As we know, the naturopathic educational system is virtually self-contained. Their schools are stand-alone, not part of any public or private university system. No objective evaluation of these schools by third parties has ever taken place and there are no studies to support this imagined equivalency.

Or you could just look at their practices: whether treatment of allergies or infertility, vaccination, pre-natal vitamins, women’s health, or the many other ways SBM posts have demonstrated that naturopathic practice is not science-based, or evidence-based or even reality-based. Or the fact that what little data there is shows that seeing a naturopath is associated with worse care. And if that doesn’t convince you, Orac’s posts last week (here and here), revealing some recently-discovered discussions among naturopathic practitioners, should leave no doubt.

Naturopaths contend they can safely prescribe drugs because there have been few malpractice and disciplinary claims made against them arising from prescribing medications. Of course, for those figures to be relevant, one would have to first show that there is a connection between provider negligence and malpractice claims. In fact, no such relationship has been established. (Also here.)

One good argument against their having prescription privileges is right there on the CNPA website. After the recent contaminated compounded drug debacle, Congress wanted to clean up the industry. The FDA is enacting new rules governing compounding pharmacies, and the naturopaths are terrified that their in-office compounding privileges might be taken away. The AANP is making a pitch on the CNPA’s website for everyone to rally to the cause. They want to pump their patients’ bodies with questionable treatments such as injectable vitamins and IV solutions and herbal suppositories, from which patients, according to the AANP, “derive tremendous benefit” and they want to do it in the privacy of their own offices.

The naturopaths also touted the enhanced ability to collaborate with other health care professionals. That hasn’t worked out so well elsewhere. One MD, the “Physician Lead for Integrative Medicine at Kaiser Permanente Northwest,” (KPNW) who is quite sympathetic to CAM, reported on the difficulties of managing patients with naturopaths.

At KPNW, medical physicians will refer patients “who have failed usual care” to naturopaths for a limited number of conditions based on an “evidence grid” developed by KPNW. (The grid is necessary due to the lack of adequate evidence for naturopathic treatments. If you don’t have much in the way of actual studies and such, you have to work something out, and they came up with a grid.) The article gives us a rare glimpse into the world of actual naturopathic practice and what we see is disturbing, although entirely consistent with what we might expect. (I’ve omitted citations in the interest of brevity.)

These problems included patients asking MDs to order tests recommended by naturopaths which “are either unrecognizable or seem inappropriate.”

The most frequent example relates to evaluation and management of thyroid disorders. Naturopathic physicians will commonly recommend multiple hormone studies, including T3 and T4 levels, in settings where, from a primary care internal medicine perspective, the sensitive thyroid stimulating hormone (TSH) test is the only appropriate test. The patient is understandably confused, having received contradictory advice from the naturopath on the one side and internist, or endocrinologist, on the other. Whom to believe? Many patients do not discriminate that endocrinologists, who are residency and fellowship trained, have five more years of training than the naturopathic physician in this area.

That five years hardly begins to describe the differences between a naturopath and an endocrinologist. Of course, you’d think the naturopath would defer to the endocrinologist, as an MD or DO PCP would do, but apparently not.

Patient management is an issue as well.

Naturopaths will typically advise patients to supplement with combination T3-T4 preparations, such as desiccated thyroid. This contradicts conventional endocrine guidelines for Levothroid T4 supplementation in the setting of hypothyroidism. Desiccated thyroid preparations may provide inconsistent levels of thyroid hormone from one batch to the next. T3-containing preparations may also provide for more fluctuation, and less steady state, of thyroid hormone levels because of the rapid gastrointestinal absorption and the relatively short half-life of T3. In addition, blinded RCT data have shown no benefit of combination T3-T4 preparations over T4 in terms of patients’ symptoms and quality of life. The naturopathic community’s failure to clearly articulate responses to these points severely aggravates negative perceptions of naturopathy within mainstream medicine. Some naturopaths will recommend thyroid supplementation for patients who are biochemically euthryoid (normal TSH). A subset of these patients will later present to the primary care internist or endocrinologist on inappropriate doses of thyroid hormone, with a suppressed TSH. In the worst-case scenario, the patient rejects the internist’s advice to change and reduce thyroid supplementation, and assumes a hostile stance to the internist’s refusal to order T4 and T3 levels. Yet such inappropriate thyroid supplementation will increase the patient’s risk for atrial fibrillation, osteoporosis, and other complications of hyperthyroidism.

Yes, I suppose a physician’s “negative perceptions of naturopathy” would be “severely aggravated” if some naturopath were endangering his patients’ health. Just imagine being a fellowship-trained endocrinologist and dealing with this folderol from folks who’ve never even done a residency and spent a good bit of time learning the finer points of homeopathy in “medical” school.

Beyond management of thyroid patients “there are numerous other sources of contention” such as:

Many patients with fatigue and other nonspecific complaints will be given the diagnosis of “systemic candidiasis” by their naturopathic physician. This naturopathic diagnosis presumably suggests some imbalance or irregularity of the indigenous microbial flora. These patients sometimes present to their internists for further evaluation and management of this condition. However, as the patients generally have no clinical or laboratory evidence of candidemia, the baffled internist cannot locate or reinforce the diagnosis, leaving all parties frustrated.

And then there are the dietary issues:

Although most allopathic primary care physicians welcome additional attention and counseling for the patient toward proper and healthy dietary habits, many in the naturopathic community seem to promote eating patterns that may appear faddish to the internist. For example, patients who visit naturopaths are almost universally advised to discontinue consumption of wheat and dairy products.

Also:

Similarly, prescribing a strict gluten-free diet in the absence of objective biopsy or serologic evidence of celiac disease imposes extremely severe restrictions on the patient’s cuisine which may be largely unnecessary.

Patients and medical physicians aren’t the only ones who are disadvantaged by these practices. The author reports that, of the funds spent on referrals to CAM practitioners over the first 8 months of 2012, 72% was paid to acupuncturists, 23% to chiropractors, but only 4% to naturopaths. They cause too many problems and medical doctors simply don’t want to refer to them.

Look out, Connecticut

Connecticut naturopaths have already established a beachhead in quackademic medical centers at Yale and the University of Connecticut. According to the CNPA, naturopaths:

are trained to serve as primary care general practitioners who are experts in the prevention, diagnosis, management, and treatment of both acute and chronic health conditions.

What sort of “primary care” might Connecticut’s citizens expect from the state’s 228 licensed “naturopathic physicians” now that their scope of practice has been “modernized?” (By way of comparison, there are 17,294 physicians and surgeons and 9 homeopaths.)

Let’s visit the Connecticut Center for Health, a 5-member practice with offices in Middleton and West Hartford. One of their practitioners is a founding member of the AANP and another is the acting president of CNPA. All are graduates of naturopathic schools accredited by the Council on Naturopathic Medical Education. Some are holding positions at these schools. Certainly, we would not expect such leaders to deviate from the naturopathic standard of care. In fact, they seem to be regarded as exemplars of naturopathic practice by their peers.

Remember those problems Kaiser Permanente medical doctors were having with naturopaths? Apparently, Connecticut MDs and DOs will be confronting the same issues.

Thyroid disorder:

We thoroughly evaluate thyroid function by looking at T3 and T4 and determine if they are optimum and not just normal.

“Systemic candidiasis”:

Antibiotics, high sugar diet, steroids, and a low fiber diet may cause an imbalance in either the bacteria or fungi (yeast) in your intestines. Once an imbalance takes hold, it can cause significant problems with the intestines directly causing irritable bowel, gas, bloating, colitis, and a depressed immune function leading to chronic infections and/or allergies, asthma, hives, and fatigue. (For more information on this you can read The Yeast Connection by William Crook).

Three different lab tests help identify these underlying problems. Candida antibody blood panel, dysbiosis markers in urine, and stool culture.

Faddish diets (in this case for autism):

  • Diet of foods that are unrefined, free of additives, varied, fresh, little or no sugar. Focus on minimizing carbohydrate and make sure there is an adequate intake of protein and essential fatty acids (EFAs).
  • A gluten (no wheat, oats, rye, barley) and casein-free (no dairy) diet, avoiding both for at least 12 weeks.
  • A yeast- and mold-free diet for a minimum of 6 weeks.
  • A diagnostic trial of avoidance of all common allergenic foods for a minimum of 4 weeks, including: dairy products, wheat, baker’s yeast, brewer’s yeast, sugar, eggs, corn, peanuts, orange, lemon, lime, soy foods, shellfish, and tomato.
  • A trial removing the foods your child is allergic to, as identified through food allergy testing.

In their discussion of autism’s causes, they posit that:

immunizations, particularly measles, mumps, and rubella (MMR) vaccine, may precipitate autism. This is a very heated debate and research is still ongoing–no one knows for sure.

Well, I suppose if you are the vaccine-autism fraud perpetrator Andrew Wakefield there is a “heated debate.” Actually, we do know that the MMR vaccine never had any connection with autism and it doesn’t now. Remember, these folks can now administer immunizations. Wonder what they’ll tell parents about the MMR vaccine?

Unfortunately, their autism “treatments” are not limited to diet. They also recommend dietary supplements, non-fluoridated water and toothpaste, injections of secretin and IV gamma globulin, anti-fungal medication if intestinal “imbalances” are found, a trial of DMSA to chelate mercury if the child’s levels were high on testing (presumably the unvalidated and possibly harmful provoked urine test). As they don’t have the authority to prescribe, I am not sure how they are giving the injections and IV treatments. If the autistic child has “never been well” since being vaccinated, they say they can address this with homeopathy.

Autistic children are not the only victims of their pediatric quackery. They also claim they are “quite experienced in how to treat osteogenesis imperfecta.” Osteogenesis imperfecta is a rare genetic bone disorder characterized by fragile bones that break easily. It is also known as “brittle bone disease.” Specially trained medical professionals, such as pediatric orthopedists, supervise the management of a patient with OI. Notably, the OI Foundation does not count naturopaths among those professionals. But that doesn’t stop the naturopaths at Connecticut Center for Health, who promote herbal medicine, avoiding dairy, and (I kid you not) homeopathy for OI.

If you will permit me one more example from this target-rich website, just because naturopaths seem so enamored of the bowels:

The amount of stool that you eliminate each day has a tremendous impact on health and wellbeing. Stool volume eliminated in a 24-hour period should total 18 inches or more. If stool stays in the bowel longer than it should, the bowel reabsorbs a variety of potentially toxic chemicals into the blood. These chemicals cause the liver to overwork and may disorder the immune and nervous systems. . . Making sure you have daily adequate stool elimination is probably one of the most important things you can do to restore and maintain health.

Get out your rulers Connecticut! If you’re not producing 18 inches a day, you’re toast.

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.