Legislative Alchemy, the process by which the state and federal governments transform quackery and pseudoscience into legal health care practices, continued apace in 2017. Today we look at state bills (some of which I previewed earlier this year) bestowing undeserved legitimacy on naturopathic “doctors” (NDs) who have degrees from naturopathic “medical” schools, by making them licensed or registered health care professionals. We also look at bills that attempted to expand naturopathic scope of practice, including two hard-fought instances where an attempted power grab backfired spectacularly.
NDs advertise themselves to legislators as being all about health promotion and disease prevention, skilled at treating chronic disease, and capable of addressing the shortage of primary care physicians. Their efforts are boosted by dietary supplement companies, which fund their lobbying.
Unfortunately, these talking points are sometimes parroted in legislation, like pending New York Senate Bill 4297 and Assembly Bill 5913 (read the laughable “Legislative intent” here and here), which would license naturopaths and give them an extremely broad scope of practice. In fact, naturopathic education and training is far inferior to that of primary care physicians (also here) and their patients receive substandard care. Their practices are filled with dubious modalities like homeopathy, unvalidated diagnostic tests, high-dose vitamin and herbal injections, detoxification, and ozone gas therapies. They get away with this because credulous legislators allow it.
With that sobering reminder of the lack of scientific acumen among our state legislators, let’s turn to the 2017 bills and see how they fared.
Step 1: Licensing, Registration or Certification
Bills legalizing naturopathic practice were introduced in six states in 2017: Illinois, Indiana, Mississippi, New York, North Carolina and Rhode Island. A bill carried over from 2016 remains pending in New Jersey. Bills in Indiana and Mississippi failed and, with New Jersey’s current legislative session adjourning in early January, it appears unlikely naturopaths will succeed in that state either.
NDs were successful in gaining licensure in Rhode Island but the legislature significantly narrowed their desired scope of practice. As originally introduced, bills would have allowed NDs to call themselves naturopathic “physicians,” prescribe drugs according to a formulary, perform minor office surgery, order diagnostic imaging studies, prescribe and dispense medical devices (including therapeutic devices, barrier contraception, and durable medical equipment), and use all routes of administration for the substances they can prescribe (e.g., minerals, vitamins, homeopathic remedies and prescription drugs on their formulary), including intramuscular and intravenous injections. Fortunately, none of those provisions survived.
The legislation that did pass makes it abundantly clear that, claims to the contrary notwithstanding, NDs are not primary care physicians. They cannot:
. . . practice or claim to practice as a medical doctor or physician, . . . a primary care doctor, a primary care practitioner, a primary care provider [or] a primary care naturopath . . .
In addition, Rhode Island NDs must have a written collaboration and consultation agreement with a licensed physician. Patients must read and sign a consent form that includes this information:
- Rhode Island does not recognize doctors of naturopathy as primary care providers and a doctor of naturopathy is not responsible for the overall medical care of any patient.
- Naturopathic care is intended only as an adjunct to, and not a substitute for, medical care . . . and doctors of naturopathy shall coordinate patient care with physicians and other health care providers.
- Patients are urged to have a primary care provider and to have all specialty care provided by a properly credentialed physician specialist.
- All questions regarding prescription medications should be directed to the prescriber or the patient’s primary care provider or licensed registered pharmacist.
Because vaccines are prescription drugs, the last provision should prevent NDs from misinforming patients with their anti-vaccination rhetoric or advising them to forego prescription hormone therapy in favor of desiccated animal glands.
The bad news is that they will still be able to diagnose and treat any patient of any age with any disease or condition using quack tests and “natural” remedies like colon hydrotherapy, homeopathy, and dietary supplements. And they will be under the jurisdiction of a Board of Naturopathy, not the state medical board.
Interestingly, acts deemed “unprofessional conduct” for Rhode Island physicians are not listed in the new law as unprofessional for NDs: They are not prohibited from taking kickbacks, falsifying records, performing unnecessary procedures, refusing to turn over medical records, deceptive advertising, or offering to treat a disease with a secret method (a red flag for quackery).
Licensing bills will remain pending in Illinois and New York (for the ninth consecutive legislative session) in 2018 because these states have two-year legislative sessions. In North Carolina (Senate Bill 258, House Bill 692), perhaps to make the idea of naturopaths practicing medicine more palatable to opponents, a bill will carry over to 2018 that would allow “certification” of NDs. No one should be fooled, however. As in other states, North Carolina NDs would be able to diagnose and treat any patient of any age with any disease or condition, no matter how complex. They could order and perform diagnostic testing, dispense (i.e., sell to patents) “natural” remedies like dietary supplements, “neutraceuticals” and homeopathic remedies, using, among others, rectal and vaginal routes of administration. They would be regulated by a Naturopathic Doctors Certification Board and NDs would comprise a majority on the Board.
As an insurance policy against failing to gain recognition for the eighth consecutive legislative session, N.C. House Bill 277 would create a work group to study “the appropriate oversight and regulation” of naturopathic practice in that state. The bill seems rigged to guarantee a specific outcome. The work group would consist of one public member, two naturopathic “physicians” appointed by the North Carolina Association of Naturopathic Physicians, and two (real) physicians, one of whom must have experience working with naturopaths, a typical requirement in pro-naturopathy bills designed to tip the scales in favor of an “integrative”-type physician sympathetic to pseudoscience. The work group is to “identify an approved study of naturopathic medicine” but defines this phrase so that only one outcome can be reached: The current system of naturopathic education created and run by and for naturopaths.
Step 2: Come back for more
Once they are licensed or registered in a state, naturopaths always come back for more. In 2017, NDs sought practice expansion in 11 states: Alaska, California (2 bills), Colorado, Connecticut, Hawaii, Maine, Minnesota, North Dakota, Oregon (5 bills), Pennsylvania, and Washington.
In the 2015-2016 legislative session, NDs fought a bruising, and losing, battle in California to greatly expand their scope of practice. Their original bill removed state-required physician supervision over naturopathic prescribing and allowed NDs to conduct and interpret diagnostic studies, perform biopsies, and administer parenteral therapy, among other liberalizations. Fortunately, the bill didn’t pass.
This year, they had an even bigger fight over the right to practice at all, resulting in a bill (Senate Bill 796) that went through a whopping 8 versions, as competing interests duked it out in the halls of the California Senate and Assembly.
State law automatically repealed the naturopathic practice act in 2018 unless the legislature acted. (I argued, unsuccessfully, that this would be the perfect opportunity for California to rid itself of naturopaths.) Not content with merely sustaining their right to be licensed health care professionals, naturopaths with degrees from naturopathic “medical” schools used the opportunity to try to kill off traditional naturopaths by making their practice illegal. Although they managed to kick the can for further review of their own practice act down the road (until 2022), they not only failed to rid themselves of competition from traditional naturopaths (who can still practice under California’s “health freedom” law), the legislature added new requirements aimed at preventing conflict of interest in continuing education (CE) courses. CE must also:
provide balance, independence, objectivity and scientific rigor,
although this standard is watered down by a provision requiring patient care recommendations in CE courses:
be based on evidence accepted by naturopathic doctors,
Another California bill attempting a practice expansion, in the form of NDs and chiropractors being allowed to perform school physicals for athletic participation, appears dead, having missed a legislative deadline for further consideration, although the legislature’s website reports the bill is “active.”
Like California, Colorado’s naturopathic registration act would automatically “sunset” in September of this year without legislative action. And, like their brethren in California, Colorado’s registered NDs exploited the opportunity presented by legislative review to attempt a vast scope-of-practice expansion. The resulting imbroglio, including a nasty attack on one Senator by the former head of the Colorado Association of Naturopathic Doctors (CAND), ended in a major defeat for Colorado naturopaths.
We’ll begin at the beginning, because the fight over practice expansion in Colorado is a perfect exemplar of the way the naturopathic lobbying machine pumps unsuspecting legislators with misinformation, naturopathic allies in state government turn a blind eye to evidence of naturopathic misdeeds, and allowing NDs into the regulated health professions fold simply legitimizes their harmful practices.
As required by law, in 2016 the Colorado Department of Regulatory Affairs (DORA) issued its Sunset Review of the Naturopathic Doctor Act (passed in 2013). As part of the review process, Colorado Citizens for Science in Medicine arranged a conference call with a DORA representative to present concerns about naturopathic practice. I, on behalf of the Society for Science-Based Medicine, participated in the call, along with former licensed naturopath Britt Hermes, pediatric infectious disease physician Paul Offit, MD, noted biomedical expert Arthur Caplan, Ph.D., as well as a Colorado physician and a pharmacist who is an expert on nonprescription products, including dietary supplements and homeopathic remedies. We presented testimony, supported by studies and other documentation provided to DORA, that:
- Naturopathy is not based on scientific principles, but rather on tradition and pseudoscience, and lacks evidence of safety and efficacy.
- Some naturopathic practices (like homeopathic nosodes as a substitute for vaccination and quirky diets for cancer treatment) are dangerous, yet are part of the naturopathic school curriculum.
- Naturopathic education and training are insufficient for competent diagnosis and treatment and are filled with pseudoscience.
- Naturopathic practices, like selling supplements to patients and misrepresenting the efficacy of therapies, are unethical under well-established biomedical ethics principles.
- Seeing an ND can incur unnecessary expense and delay in effective treatment.
DORA, without explanation, failed to address our concerns, and its Review simply parroted naturopathic talking points, such as:
Naturopathic doctors treat acute and chronic conditions, but the emphasis of naturopathy is to prevent disease.
(DORA cites the University of Maryland’s wholly uncritical description of naturopathy for this proposition, one more example of how quackademic medicine promotes pseudoscience to the public’s detriment.)
By omitting our critique, DORA prevented lawmakers from learning that naturopathic doctors are trained to use treatments with extremely poor evidence for safety and effectiveness and can lead patients to delay or avoid credible medical care.
DORA recommended that the state continue naturopathic registration with a few minor changes in the statute because:
The laws that govern naturopathic doctors ensure competent and qualified practitioners.
Which DORA could confidently assert only by ignoring both the Colorado Science for Citizens in Medicine and other available evidence that registered Colorado NDs are freely using quack treatments with no interference from the state.
A bill was filed and passed in the Colorado Senate (SB 106), which extended the sunset date until 2020 (when there will be another review), and, following DORA’s recommendations, made minor changes, such as making registered NDs mandatory reporters of child and elder abuse.
But when SB 106 arrived in the House, NDs and their allies radically amended it. It morphed from the drafters’ original intent – to implement DORA’s recommendations – into a giant practice expansion bill, allowing NDs to prescribe hormones and IV vitamins, minerals, chelating agents and amino acids. The House version stripped the bill of a requirement that NDs used the initials “R.N.D.” (Registered Naturopathic Doctor) to avoid public confusion as to their status.
Why hormones? NDs love to prescribe hormones. DORA’s Review revealed that, in a survey of Colorado registered naturopaths, being able to prescribe hormones was “important” to “very important” to 75% of them. This far outranked the importance of being able to prescribe antibacterial, antifungal and antiviral meds.
The CAND was worried that the Senate wouldn’t buy the House’s overhaul of SB 106, so they sent out an SOS asking proponents to contact their Senators with this propaganda:
Naturopathic doctors are well trained on the use of hormone therapy and its dangers. I would like greater choice in my health care provider and the option of using natural hormone therapy if I would ever need it. Intravenous, nutritional therapy has many health benefits, including helping those with a compromised digestive system and those with chronic and acute infections. A recent article showed that IV Vitamin C performed better than IV antibiotics in treating sepsis, a life-threatening illness, and another showed its potential benefits in treating cancer alongside chemotherapy. NDs teach the use of IV Nutritional therapy and are well trained on its efficacy and risks. Since few MDs and DOs offer this therapy in Colorado [I wonder why?] it would be a significant public health benefit for NDs to be able to provide it.
None of these assertions about health benefits and safety of naturopathic practices is true, except the part about there being an article touting the use IV vitamin C in treating sepsis, which was exposed as vastly overhyped and viewed with skepticism by responsible medical authorities, including SBM’s own Mark Crislip, MD. (Not that a naturopath should be allowed anywhere near a patient with sepsis.)
When the House version of SB 106 returned to the Senate, Senators refused to play along. The bill (which went through 7 versions) was stripped of the House’s practice expansion and the original provisions restored. Thankfully, NDs suffered a major defeat, but it wasn’t for lack of effort, which included Denise Clark, former head of the CAND, calling one of the bill’s Senate sponsors a liar, a move that probably didn’t help their cause.
Unfortunately, the Oregon legislature did not follow California’s and Colorado’s lead in pushing back against naturopathic overreach. A new state law will allow naturopathic “physicians,” as they can call themselves in Oregon, to put the life, liberty and health of patients at risk through vastly expanded powers previously reserved for MDs and DOs. Among other powers (which I covered more extensively in this post) NDs will be allowed to:
- Withdraw medical treatment, hydration and nutrition from a patient when the ND has determined that the patient has a terminal condition and would not likely benefit from further medical care or is at an advanced stage of illness and unlikely to improve, even in the absence of a patient’s having previously expressed his wishes on these issues.
- Order physical or chemical restraint, or psychotropic medication, for elderly and disabled persons.
- Sign standing medical orders directing or withholding specific medical treatment (for example, an order not to resuscitate the patient) for seriously ill or frail patients.
- Determine that a patient is not competent to give informed consent to mental health treatment, as well as consent to that treatment for the patient, including convulsive treatment, psychoactive medication, psychosurgery, and retention in a mental health care facility.
- Conduct medical examinations of sexual assault and child abuse victims; allows courts to order treatment of child abuse victim by an ND.
- Make diagnostic evaluations of persons alleged to have mental illness or developmental disability who are candidates for court-ordered commitment to a care facility, and provide medical care, including prescription medications, for mentally and developmentally disabled patients committed to care facilities.
As I said in the previous post:
Those are weighty matters to put into the hands of folks who think water has magical properties.
Naturopathic “physicians” weren’t as fortunate with other practice-expansion efforts in Oregon. Bills failed that would have allowed them (along with chiropractors) to return student athletes to play following a concussion and expanding NDs’ office surgery privileges. Efforts to expand prescribing privileges in North Dakota (again), Connecticut (also again) and Maine failed as well.
Again, because several states have two-year legislative sessions, practice expansion bills that didn’t pass this year an opportunity to get to the governor’s desk in 2018.
No sooner had Pennsylvania passed a naturopathic registration act last session than the NDs were back for more. The new Pennsylvania law did not specify a scope of practice or much of anything else, dumping the whole matter into the lap of the state medical board, which is charged with enacting rules governing their practice. (If you’d like to give the board your two cents worth, you can email the board at [email protected] and asked be added to the list of stakeholders who wish to be kept informed regarding the rule-making process and opportunities for public comment.) Apparently concerned that the medical board might not be as generous as they wished, naturopathic proponents engineered the introduction of a new licensing (as opposed to registration) act (Senate Bill 834) granting NDs a broad scope of practice. That bill remains pending.
Practice expansions are also pending in Alaska (prescription privileges, office surgery, order and perform diagnostic testing), Hawaii (authority to prescribe testosterone), Minnesota (companion bills in House and Senate grant authority to prescribe drugs, minor office surgery, perform speculum and orificial exams), and Washington (expands authority to prescribe controlled substances).
The naturopathic modus operandi is to convince legislators they are all about health and wellness, buoyed with a few anecdotes of supposedly successful treatments delivered via patient testimonials. That’s all your legislators will hear unless science-minded citizens like you show up armed with the facts. Fortunately, Britt Hermes has done the heavy lifting for you by creating a page on her blog, Naturopathic Diaries, devoted to legislative action, and a handy pdf you can print out or link and send to your legislators. You can follow naturopathic bills in your state over on SfSBM’s website. To find out how to contact your state legislators, StateScape provides links to all state legislative websites and member contact information.