As we learned in Legislative Alchemy I: Naturopathy, legislative alchemy is the process used by state legislatures to transform implausible and unproven diagnostic methods and treatments into legal health care practices.
Today, we review how chiropractors are faring in the 2011 state legislative sessions.
Chiropractic 101
In 1895, a self-described “magnetic healer,” Daniel David Palmer, claimed to have discovered that every person possessed an “Innate Intelligence,” defined as the body’s capacity to heal itself, which flowed from the brain out through the nerves in the spinal cord. Misaligned vertebrae impinged on nerves and interfered with the flow of Innate Intelligence, causing “95 percent of all disease.”
Palmer named these putative misalignments “subluxations,” and began teaching students how to detect and correct them based on his notion that removing this interference would return the free flow of Innate Intelligence and the body would heal itself. In other words, chiropractic was — and, as we shall see, still is — simply another form of vitalism, a long-discredited notion that illnesses are caused by a disturbance or imbalance of the body’s “vital force,” which is distinct from the body’s biochemical processes.
Palmer and his disciples were arrested for practicing medicine without a license, which led to a strategy of chiropractors lobbying state legislatures for their own chiropractic practice acts. This effort stretched from 1913, when Kansas became the first state to license chiropractors, to 1974, when Louisiana became the last.
Subluxation: it’s the law
The non-existent chiropractic subluxation remains the central tenet of the 50 state chiropractic practice acts to this day.[1]
Twenty-one state chiropractic acts mention it specifically as the basis for chiropractic practice. For example, Connecticut defines chiropractic practice as:
the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of the disease, are adjusted, manipulated or treated.
Twenty-three states refer to its purported attributes — without actually using the “s” word. In North Carolina, chiropractic practice is defined as:
the science of adjusting the cause of the disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.
Did they say “science”? Here’s how much science is involved in chiropractic’s core concept — there’s not even a plausible hypothesis of what a subluxation is or how it might affect human functioning.
Six states simply incorporate by reference practices and procedures taught in chiropractic schools, which remain loyal to the subluxation although some have tried to distance themselves from the word, if not the concept.
This doesn’t mean, of course, that chiropractors are permitted by law to treat any disease or condition by detecting and correcting subluxations, just most any disease or condition, as long as the problem is defined in terms of the patient’s having one or more subluxations stopping up the “flow” of “nerve energy.” Asthma, allergies, ADHD, painful periods and earaches are a few of the many conditions widely advertised as treatable by chiropractic adjustment.
You might think it would cause the chiropractic industry some alarm that legislators might wake up to the fact that subluxations don’t exist. And apparently that is the case. In a few states chiropractors are attempting to expand the chiropractic scope of practice by including authority to prescribe that former anathema to chiropractic: drugs. For years chiropractors branded themselves as doctors who treat patients “without drugs or surgery.”
With drugs but not surgery
Chiropractic lobbying in New Mexico, the state where anyone can practice medicine, provides a perfect lesson in the insidious nature of CAM practitioner licensing. A few years ago, the state legislature invented a new iteration of chiropractor, the “certified advanced practice chiropractic physician.” With minimal training, this new type can, by statute, “prescribe, administer and dispense herbal medicines, homeopathic medicine, over-the-counter drugs, vitamins, minerals, enzymes, glandular products, protomorphogens, live cell products, gerovital, amino acids, dietary supplements, foods for special dietary use, bioidentical hormones, sterile water, sterile saline, sarapin or its generic, caffeine, procaine, oxygen , epinephrine and vapocoolants.”
Then, in 2009, the New Mexico legislature granted the state chiropractic board authority to develop a formulary for the “advanced practice chiropractic physician.” The requirement that substances be “natural or naturally derived” was eliminated, but there was a catch: “Dangerous drugs or controlled substances, drugs for administration by injection and substances not listed [in the quoted section, above] shall be submitted to the board of pharmacy and the New Mexico medical board for approval.”
Apparently, approval was not forthcoming to the chiropractors’ satisfaction, so they returned to the New Mexico legislature this year, seeking to dump the pharmacists and medical doctors. A new, improved version of the “advanced practice chiropractic physician” was proposed: one with a “prescription certificate.”
And just to make the point clear, the term “chiropractic” would be discarded from the New Mexico chiropractic practice act in favor of “chiropractic medicine.” Thus, the purpose of the practice act went from “granting chiropractors the right to practice chiropractic as taught and practiced in standard colleges of chiropractic” to granting “chiropractic physicians the right to practice chiropractic medicine …” [Emphasis added.]
Gone was the requirement of a pharmacy and medical board approved formulary. Instead, those with the “prescription certificate” would be authorized by statute to “prescribe, administer and dispense dangerous drugs, including compounded preparations for topical and oral administration and injection, testosterone in all its forms and codeine in cough syrup.” [Emphasis added.]
One can read between the lines thinking that goes something like: “If the pharmacists and medical doctors won’t let us prescribe testosterone ‘in all its forms’ and cough syrup with codeine, we’ll just put it in the statute and they can’t do a damn thing about it.”
Instead of pharmacy and medical board approval, the proposed legislation provided that “the [chiropractic] board, with the New Mexico Medical Board and the Board of Pharmacy serving in an advisory capacity, and with all parties agreeing to act in good faith, shall establish by rule a formulary …” [Emphasis added.]
Yeah! That’ll show ‘em!
Except the proposed legislation didn’t pass. It was still in committee when the legislature adjourned. New Mexico’s governor recently declared a special session of the legislature to deal with certain pressing problems, such as redistricting, and that has begun. We can only hope the chiropractors don’t try to shoehorn their bill into the special session agenda.
As a cautionary tale about the dangers of mission creep in “CAM” practitioner licensing, it is instructive to look at the education and training which would have been required of the “certified advanced practice chiropractic physician” in obtaining a “prescription certificate.”
In addition to the minimal requirements for “advanced practice” certification, the applicant must complete “pharmacological training from an institution of higher education approved by the [chiropractic] board or from a provider of continuing education approved by the board.” [Emphasis added.]
The applicant must complete a program, again approved by the chiropractic board, of 200 classroom hours in pharmacology, physiology, pathophysiology, physical and lab assessment and clinical pharmacotherapeutics, which, you’ll have to admit, is a really long word. Whether this is simply descriptive of, or in addition to, the education described in the previous paragraph is not clear. What is clear is that all of this can be accomplished within the current chiropractic educational system, a subject to which we will return in a future post.
But where, you might ask, would the chiropractor get experience actually treating patients with drugs, so essential to proper training? Well, remember those pesky medical doctors who were gumming up the formulary works? The ones the legislation sought to remove from the process? From them, that’s who.
In order to get the coveted “prescription certificate,” a chiropractor would have to complete 400 hours “of clinical rotation practicum in clinical assessment and pathophysiology” and 400 hours of 100 patients “with disorders relevant to the certified advanced practice chiropractic physician’s clinical specialty.” All done “under supervision of a medical doctor.”
One must wonder where one would find a medical doctor willing to take on supervision of a chiropractor treating patients with drugs.
A bad idea metastasizes
The chiropractic faction interested in foisting chiropractors as primary care physicians on the public was obviously not going to stop with New Mexico, and it didn’t.
In South Carolina, a bill would have created the same sort of “advanced practice chiropractic physician” as presently exists in New Mexico along with the option of obtaining a “prescription certificate” as proposed in the failed New Mexico legislation. The bill never made it out of the Senate Committee on Medical Affairs.
Likewise, in Alabama, a bill was introduced to allow prescription of “natural” compounds, “bio-identical hormones,” homeopathic remedies and other woo remedies favored by “CAM” practitioners. If the chiropractor took the same sort of 90-hour course as New Mexico allows, he or she could also prescribe and inject these substances even if they were classified as legend drugs. This bill also died in committee.
More scope of practice
Prescription authority was not the only means of increasing ways to make mon … I mean, increasing the scope of chiropractic practice attempted in this year’s legislative sessions.
In Illinois, lobbying efforts took a more subtle approach and attempted only an inclusion of authority to provide advice regarding the use of non-prescription products. Translation: they can advise patients regarding dietary supplements. And, of course, having given that advice, they can sell patients the supplements they’ve recommended. This bill, which also authorized chiropractors to administer atmospheric oxygen, made it into law. A bill in Hawaii, authorizing the use of “clinical nutritional methods” (whatever that means), died in committee.
Minnesota, another state where anyone can practice medicine, saw a failed attempt to include acupuncture within chiropractic scope of practice. Perhaps wary of attempts to make chiropractors actually go to acupuncture school and learn “real” acupuncture, this proposed legislation invented an entirely new form, defined as “a modality of treating abnormal physical conditions by stimulating various points of the body or interruption of the cutaneous integrity by needle insertion to secure a reflex relief of the symptoms by nerve stimulation as used as an adjunct to chiropractic adjustment.” Maybe they should have called it “acujustment”.
And on it goes
Last year, the Connecticut Board of Chiropractic Examiners issued a ruling that chiropractors need not warn patients of the risk of stroke following cervical manipulation, a ruling based largely on a study which specifically states it does not rule out such a risk.
In response, Connecticut Senator Len Fasano promised to introduce legislation in 2011 mandating a warning. Sen. Fasano testified at a hearing before the Board that he and others in the legislature were under the distinct impression the Board would indeed require this type of warning. Obviously, the Board did not do that, so Sen. Fasano kept his promise and introduced a bill requiring chiropractors to obtain informed written consent prior to any treatment of the cervical spine, including information on the risk of stroke. Unfortunately, the bill did not make it to the floor for a vote.
Finally, chiropractic lobbying in Florida screwed up passage of a perfectly good bill designed to protect the public’s health, safety and welfare.
A bill introduced to educate coaches, parents and young athletes about sports-related concussions and to require that an M.D. or D.O. sign off on return to play post-injury passed the House, where an attempt to include chiropractors was rebuffed in committee. However, the bill got bogged down in the Senate because of a similar attempt to force the inclusion of chiropractors in the type of health care practitioner with authority to clear the young athlete for continued play. The implication, of course, was that chiropractors were qualified to diagnose and treat traumatic brain injury, a conclusion not universally shared in the Senate, and rightly so. That squabble ran the clock out on what would have been a laudable safety measure for school athletes. And that’s a shame.
Conclusion: An error made worse
It is unfortunate enough that the state legislatures have legitimized a figment of the imagination first proposed by a charlatan in 1895 — the “subluxation” — by creating a licensed health care profession known as chiropractors to “detect” and “correct” them. Giving chiropractors authority to prescribe dietary supplements, and, even worse, drugs, only exacerbates their original mistake. Instead of expanding the scope of practice, state legislatures should remove diagnosis and treatment of the nonexistent “subluxation” from the chiropractic practice acts.
References
- Bellamy J., Legislative Alchemy: the US state chiropractic practice acts, Focus on Complementary and Alternative Therapies (2010)15(3): 214–222.
