Science and evidence-based medicine took a hit in 2019 with new laws passed licensing naturopathic “doctors” in New Mexico and Idaho, making naturopathy a regulated health care profession in almost half of the U.S. states. Licensing gives naturopathy an undeserved imprimatur of legitimacy and fools the public into thinking regulation will protect it from unproven and unsafe practices.
In states where they are already regulated, naturopaths came back to the legislatures asking for even more privileges in 2019. Most disturbingly, this includes giving naturopaths the authority to grant medical exemptions to vaccination in two states, a topic we’ll return to in a moment.
All of this is yet another example of the continuing scourge known as Legislative Alchemy, the incorporation of pseudoscience into law (especially health care practitioner licensing) by state legislatures and Congress.
SBM has covered naturopathy extensively, but here are a few main points to remember about naturopaths as you read this post:
- Although they call themselves “doctors” and “physicians” and claim expertise as primary care providers, their education and training takes place in naturopathic “medical schools” that operate outside the mainstream American higher education system. These schools reject science and evidence-based medicine. Unlike conventional medicine, only a handful of residencies are available to graduates, and most go directly into practice after school. Or, as Dr. Mark Crislip put it: “Next time you see a naturopath, remember it is the same as seeing an unsupervised medical student”.
- Licensed naturopaths are only nominally regulated by the states in which they practice, with naturopaths themselves controlling licensing standards (like exams), continuing education, and the standard of care, the latter of which apparently does not exist. In many states, they control the boards that are supposed to regulate them.
- Naturopaths do not practice evidence-based medicine, which they reject in favor of folk remedies and pseudoscience. Many are anti-vaccination. Their practices include dubious diagnostic methods, like hair analysis for “toxicities” (used as a pretext for “detoxification“), and unproven treatments, like herbs, supplements, homeopathy, and colonic irrigation, many of which carry risks, including death, but provide no proven benefit. While they claim otherwise, there is no compelling evidence that “naturopathic medicine” improves health, prevents disease, or saves money. In fact, “what little data there is suggests that utilizing a naturopath for primary care is associated with worse care . . .”
Unfortunately, the new naturopathic practice acts in both New Mexico and Idaho will allow naturopaths to practice primary care and will give them the authority to treat the undifferentiated patient, that is, any person of any age with any disease or condition, within the primary care scope of practice. Patients will be depending on these licensed naturopaths to perform a competent differential diagnosis and provide safe and effective treatment or refer appropriately, skills their woefully inadequate education and clinical training call into question.
In New Mexico, licensed naturopaths, as primary care practitioners, will be able to, “in alignment with naturopathic medical education” (an undefined term without direction as to who will decide what, if any, limitations this actually imposes):
- Perform physical exams, including orifical exams and physiological function tests
- Order and interpret lab tests, including venipuncture and obtaining samples of human tissues
- Order diagnostic imaging studies and “take action” based on the radiologist’s report
- Prescribe, administer and dispense legend drugs (as used in New Mexico, this means unscheduled drugs that require a prescription), testosterone products, and Schedule III, IV, and V controlled substances (excluding benzodiazepines, opioids and opioid derivatives) after passing an exam authorized by the Medical Board
- Use intramuscular, intravenous, subcutaneous, intra-articular and intradermal injections
- Use oral, nasal, auricular, ocular, rectal, vaginal and other routes of administration
- Perform minor office procedures, including “minor surgical care” but excluding surgical care to treat a lesion suspected of malignancy
- Perform hypnosis
- Perform allergy testing and treat allergies (presumably for both real and fake allergies)
- Use colon hydrotherapy and electromagnetism
- Use barrier contraception, intrauterine devices, hormonal and pharmaceutical contraception and durable medical equipment
- Use the title “naturopathic doctor”, ND, and NMD, but not “physician”
In addition to the broad authority to prescribe drugs, particularly disturbing is authority to use “therapeutic substances”, administered via the extremely generous list of methods noted above, including vitamins, minerals, nutraceuticals, botanical medicines, oxygen, homeopathic medicine (defined as being “based on the use of infinitesimal doses of substances capable of producing symptoms similar to those of the disease treated”, which is pure, unadulterated quackery), hormones, hormonal or pharmaceutical contraceptive devices, and “other physiological substance[s]”, whatever that means. (If administered by injection, they are legally prescription drugs, presumably compounded.) These “therapeutic substances” seem to be (it’s not entirely clear) limited to those “exemplified in a standard naturopathic medical text, journal or pharmacopeia”. I’m not sure what that means either, but it presumably includes the Textbook of Natural Medicine, which Dr. Harriet Hall’s review aptly described as
mix[ing] good science with bad science, pseudoscience, outright errors of fact, vitalism, philosophy, ancient history, superstition, gullibility, misrepresentations, metaphysics, religion, hearsay, opinion and anecdotes.
Here, for example, is Dr. Hall’s comment on the Textbook‘s discussion of intravenous magnesium (which naturopaths can legally administer in New Mexico as a “therapeutic substance”) in the treatment of asthma:
The Textbook recognizes [that asthma attacks can kill], but it gives dangerous advice. It says, “If intravenous magnesium cannot be administered, the patient should be referred to an emergency department immediately”. Intravenous magnesium is used in treating an acute asthma attack only as an adjunct to conventional treatment. Treating the patient with IV magnesium before or instead of referral to an ED could have fatal results.
While “therapeutic substances” “exemplified” in naturopathy textbooks may offer practitioners a cornucopia of quack treatments, journals could guarantee a virtually unlimited supply of “exemplified” “therapeutic substances” for future use. As I read the law, all one need do is get an article published in one of the many CAM-friendly journals (Medical Hypotheses comes to mind) touting this or that “therapeutic substance” (a “physiological substance” perhaps) and, voila, it’s in the naturopathic scope of practice in New Mexico. What could be easier?
There are two potentially significant limitations on naturopathic practitioners in New Mexico. First, licensed naturopaths will be regulated by the New Mexico Medical Board, although a naturopathic advisory committee (which can consist solely of naturopaths and a public member) will recommend rules and licensing requirements, including the amount of malpractice insurance naturopaths must carry. The legislature has already specified that licensees must graduate from an accredited naturopathic school and pass the NPLEX exam, created and administered by the North American Board of Naturopathic Medical Examiners (NABNE). (Lest you think this imposes any sort of reasonable standard on their education and competency testing, former licensed naturopathic doctor Britt Hermes will easily disabuse you of that notion.)
The Board is specifically authorized to define “primary care” and decide which “screening or test[s]” naturopaths can perform outside those already permitted by the new law, and create pharmacy and state jurisprudence exams.
I could not determine whether the New Mexico Medical Board had enacted naturopathic practice rules yet, or even proposed rules, or that the advisory committee had recommended rules to the Board. Therefore, I do not know how the New Mexico Association of Naturopathic Physicians is claiming that naturopaths must pass the NPLEX Clinical Elective Examinations on Pharmacology (created after the NABNE admitted naturopathic education in pharmacology was insufficient, which is absolutely correct) and Minor Surgery. I hope the Board will not adopt these tests as a demonstration of proficiency in either prescribing drugs or minor office procedures. (It will undoubtedly be the recommendation of the naturopathic advisory committee.)
Per the NABNE, the minor surgery exam is “case-based, i.e., 15-20 brief clinical summaries are presented and several questions are asked about each case”. The pharmacology exam is “comprised of 75 stand-alone items” to be completed in 90 minutes. Given the lack of clinical training in minor surgery and prescribing drugs (remember, no residencies), this seems a remarkably inadequate measure of the competency of naturopaths to safety and effectively perform these essential components of primary care, especially prescribing. To quote the inimitable Dr. Crislip:
If I were Pfizer I would be turning my sales force loose on the 800 plus ND’s in Oregon: they have no background to understand the truth of what they are told, they have no critical thinking skills, they are used to accepting authority over evidence, they have no issues with being subsidized by industry, and crave respectability. Perfect fodder for the drug rep.
The second limitation on naturopaths is the requirement that they practice in collaboration with a licensed medical or osteopathic doctor, although I am not confident that this is a meaningful curb on their pseudoscientific practices. “Collaboration” is defined as
the process by which a licensed physician and a naturopathic doctor jointly contribute to the health care and medical treatment of patients [in which] each collaborator performs actions that the collaborator is licensed or otherwise authorized to perform; and [is not] construed to require the physical presence of the licensed physician . . .
Thus, the physician has no authority to prevent the naturopath from doing anything harmful, or just plain stupid for that matter. Query what sort of physician would want to take this on.
Idaho at one time licensed naturopaths, “de-licensed” them in 2015, and has now turned around and, once again, passed a “naturopathic medicine” licensing act. Like New Mexico, naturopathic “doctors” (who are not allowed to call themselves physicians) are given the authority to provide primary care but, unlike New Mexico, no collaboration with a physician is required. They, too, will be regulated by the state’s medical board, advised by a naturopathic medical board, which, like New Mexico’s advisory committee, has no authority to require the enactment of its suggestions. The Idaho Board of Medicine has the exclusive authority to adopt rules governing naturopathic practice, including licensure requirements, “ethical standards of practice”, and disciplinary proceedings, although the Idaho legislature, again like New Mexico, has already defaulted to the naturopath-controlled naturopathic “medical” schools and the NABNE-controlled NPLEX exam as licensing standards for education and examination.
Naturopaths will also be able to prescribe drugs per a formulary devised by the Medical Board, which can include “legend medications excluding scheduled controlled substances except for testosterone”. (Naturopaths apparently find testosterone an absolute necessity. They’ve been trying to get the authority to prescribe testosterone in Hawaii for years.)
The new Idaho law is short on details, but naturopaths will also be able to employ diagnostic physical and lab exams and perform diagnostic and imaging tests “consistent with naturopathic medical education”, although no particular person or agency is assigned the task of defining just what this limitation entails. They can also perform minor office procedures.
And the other states
The news is not all bad: Licensing efforts failed in Indiana, Wyoming, and Mississippi. Unfortunately, licensing bills have been introduced in the 2020 legislative session, or carry over from the 2019 session, in New York, Illinois, Michigan, North Carolina and Virginia. The American Association of Naturopathic Physicians says it is “aiming to” file licensing bills in 2020-2021 in Wyoming, Texas, Oklahoma, Mississippi, Tennessee (where naturopathy is currently illegal), Iowa, Wisconsin, Ohio, Georgia, Florida, and New Jersey.
Naturopaths attempted practice expansions in seven states in 2019. They failed in five, while bills remain pending in two states. Those of are of particular concern as they allow naturopaths to exempt patients from vaccination requirements.
In Hawaii, House Bill 1182, with talking points straight out of the anti-vaccination playbook about vaccine package inserts, vaccine ingredients, and adverse reactions, adds a “conscientious belief” exemption to vaccination and waters down the requirement for claiming a religious exemption. It also allows naturopathic “physicians” to exempt patients from vaccination and changes the standard for exemption from a certificate stating that “because of a stated cause the health of the person would be endangered by the vaccination or immunization” to a letter claiming that “the person shall not be subject to immunization requirements because the vaccine could pose undue risks to their health”. The bill eliminates the requirement that a copy of the exemption document be filed with the state department of health.
A bill to permit licensed naturopaths to certify that patients with debilitating medical conditions need access to cannabis is also pending in Hawaii. (Senate Bill 1430) As Britt Hermes has described, pot certifications are a big money maker for naturopaths, many of whom are burdened with student debt but have few job opportunities.
Although I have not been able to locate the actual bill, according to LexisNexis, a Maine “Legislative Reference Bill 2845” has been filed, described as “an act to authorize naturopathic doctors to provide medical exemptions from the laws governing immunization requirements”.
Failed scope of expansion efforts mostly sought adding, or increasing, the authority to prescribe drugs. In Connecticut, a bill to add drug prescription privileges to the naturopathic scope of practice failed, as did an attempt to expand prescription privileges in Maryland. Bills permitting licensed naturopaths to certify that patients with debilitating medical conditions need access to cannabis failed in Oregon. Adding prescription drugs, minor office procedures, and diagnostic imaging to the scope of practice in Alaska didn’t pass either. In an unusual attempt to contract naturopathic practice, an Oregon bill removing naturopaths from the list of medical practitioners who conduct medical evaluations for child abuse cases failed.
What to do?
If you live in a state where a naturopathic bill is pending, please go to your legislature’s website and read the bill and any committee reports or staff analyses (which too often simply regurgitate naturopathic talking points). Contact your state senators and representatives to oppose licensing, registration, and practice expansion. Or, in the rare case of practice contraction, to support a bill. Many legislative websites will allow you to sign up for notifications about bills on specified subjects. You can use this feature to learn of new bills or follow pending ones. In too many cases, naturopathic bills get passed without significant opposition, even from the medical community. Naturopaths are very good at presenting themselves to lawmakers as well-qualified primary care practitioners. It is up to us to tell legislators the truth.