Each year, naturopaths who, via their closed-circuit educational and testing system, fancy themselves as primary care physicians on equal footing with MDs and DOs (they’re not), attempt to legitimize their self-regard by becoming state-regulated health care professionals, preferably via licensing. So far, thanks to the magic of Legislative Alchemy (the incorporation of pseudoscience into law by state legislatures), they’ve succeeded in 22 states and D.C. Once licensed, naturopaths return to the state legislatures year after year seeking to expand their scope of practice, the Holy Grail being (despite all the rhetoric about “natural” remedies) full prescription privileges, a goal they’ve met in only one state: Oregon.
2020 was no exception to this scheme, although their efforts were largely a failure. True to form, naturopaths are back in 2021, lobbying state legislators to perform that old legislative magic again.
Before we take a look at the 2020 and 2021 legislation, let’s briefly review why state licensing of naturopathic “doctors” or “physicians” is a terrible idea.
- 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”. (I’d argue its worse, given the fact that at least the medical student has been taught reality-based medicine.)
- 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 . . .”
When we last reviewed naturopathic legislative efforts on SBM a year ago, covering 2019, a couple of bills introduced that year remained pending in 2020. (Some states have two-year legislative sessions.) In Hawaii, a bill sought to allow naturopathic “physicians” to exempt patients from vaccination. With talking points straight out of the anti-vaccination playbook about vaccine package inserts, vaccine ingredients, and adverse reactions, the same bill added a “conscientious belief” exemption to vaccination, watered down the requirements for claiming a religious exemption, and loosened the standard for exemption certificates.
Another bill in Hawaii would have permitted naturopathic “physicians” to certify that patients with debilitating medical conditions needed access to cannabis. (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.)
Fortunately, neither bill passed.
Other failures in 2020 legislative sessions (or 2019-2020 sessions in some states) include licensing bills in Illinois, Wisconsin, Wyoming, Michigan, Oklahoma, North Carolina, and New York.
In what we might call a “bait-and-switch” strategy, after accepting a limited scope of practice in exchange for legitimization via state licensing or registration, naturopaths will return to the legislatures year after year to add either initial or expanded prescription privileges.
A few years ago, in an attempt to burnish naturopathic prescribing credentials, the North American Board of Naturopathic Examiners (NABNE) created an optional pharmacology examination, apparently in hopes that the states, as they do with other naturopathic educational qualifications, would farm out a determination of competency to prescribe to the NABNE. The entire exam consists of 75 multiple-choice questions to be completed in 90 minutes. This effort has been partially successful, including the two states most recently licensing naturopaths, New Mexico and Idaho, both of which accept the NABNE’s pharmacology exam as a prerequisite for prescribing privileges. Unfortunately, that is pretty much the entire sum of our knowledge about the exam because, as far as I know, no one outside naturopathy has ever seen one and its validity has never been determined by any outside authority.
Which brings me, incidentally, to one of my favorite quotes from the inimitable Dr. Mark 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.
Perhaps legislators in some states agree. Attempts to initiate or expand naturopathic prescribing privileges failed in Washington, Massachusetts, and Maryland. In Rhode Island, a bill to add IV therapy, the authority to counsel patients on “their use of prescription drugs” prescribed by their (real) physician, and phlebotomy, to the naturopathic scope of practice failed as well.
I was particularly impressed with the opposition to Maryland’s bill by the state affiliate of the American College of Nurse-Midwives, the Maryland Nurses Association, and the Secular Coalition of Maryland, whose written testimony served as a demonstration to the legislature that the issue is not just a “turf war” between physicians and other practitioners, as is sometimes falsely claimed. (The state medical society, MedChi, also testified in opposition.) As the Nurses Association succinctly pointed out:
This opposition is based on a lack of clarity about whether the education and experience of naturopathic doctors aligns with the provisions of the bill. The bill grants broad prescriptive authority for naturopathic doctors to prescribe any medication, excluding controlled dangerous substances, on a formulary determined by an advisory committee.
Our questions include:
- What is the content of naturopathic education?
- Does naturopathic education include training on pharmacology beyond naturally derived medications?; and
- Is naturopathic education on pharmacology standard or do programs differ?
We think these basic questions should be addressed before considering this legislation.
So do we! Of course, these are the very questions naturopaths would prefer not to answer.
Other practice expansion bills met a similar fate. In Arizona, an attempt to give naturopathic “physicians” some privileges reserved to (real) physicians and other health care professionals, such as writing standard orders for epi pens and limitations on liability related to the delivery of infants, failed. Kansas practice expansion bills, including expanded prescription and diagnostic procedure authority, failed as well.
With that, we’ll turn to 2021. Some of this will sound familiar.
At the beginning of this year, a licensing effort in Virginia, carried over from 2020, was tabled in a Senate Committee and voted down in a House Committee. As the Virginia General Assembly adjourns today, licensing is presumably dead in that state for this session. The scope of practice was fairly broad, including IV administration of “botanical medicines” and “homeopathic medicines”, although prescription drugs weren’t authorized. It contained some interesting limitations as well: no psychological testing or treatment for moderate or severe mental illness, no diagnosis and treatment of the eyes, and no diagnosis and treatment of minors without a parent’s signed consent attesting that the minor is also a patient of a physician.
Licensing bills are pending in New Jersey (not for the first time) and Arkansas.
In New Jersey, the bill, which has yet to be heard in committee, defines “naturopathic medicine” as primary care and gives “naturopathic doctors” a broad scope of practice, including the authority to diagnose and treat any injury, disease, or condition in patients of any age. They would be regulated by a Board of Naturopathic Examiners, consisting of six naturopaths, two consumers, and a state executive.
Naturopaths could prescribe and, in certain cases, dispense, drugs “consistent with” naturopathic education and training (apparently a decision up to the individual naturopath), along with the usual dietary supplements and homeopathic remedies. They could also administer drugs and other “natural” remedies via an IV, among other methods of administration (ocular, vaginal, oral, etc.). Without limitation, they could order and perform physical and lab exams and order diagnostic imaging studies (e.g., MRIs), although not perform them or read the results. The Board would establish qualifications for “naturopathic childbirth attendance”.
The Arkansas bill would license “naturopathic physicians” and put them under the jurisdiction of the state medical board, which would enact regulations governing their practice. The bill does not specify much about their scope of practice, although it is quite broad, giving naturopaths the authority to diagnose and treat any patient of any age with any condition, including the use of “drugs”. This bill is before the House Public Health, Welfare and Labor Committee.
According to the American Association of Naturopathic Physicians (AANP), licensing bills are now pending in several states where I could find no record of a bill on either LegiScan or Bill Track 50 — Wisconsin, Michigan, New York, and North Carolina — although bills could be introduced later in the year. This list also includes states where the filing deadline has passed without a bill having been introduced: Wyoming, Oklahoma, and Illinois.
Bills have been introduced in Maryland (prescription privileges), Hawaii (cannabis), and Arizona (epi-pen, etc.) to revive efforts that failed last year. Although no specific bill language is yet available, a Connecticut bill has been filed to give naturopaths prescription privileges. Several previous attempts (here, here, here, here, and here) have rebuffed by the Connecticut legislature and, in 2017, the state Department of Public Health issued an unfavorable report on naturopathic prescribing privileges.
A North Dakota bill would have given naturopaths the authority to prescribe (and dispense in some circumstances) any legend (that is, prescription) drug, including DEA Schedule II-V drugs. However, after a recent hearing, a committee amended the bill to include only testosterone (a naturopathic favorite) and non-scheduled legend drugs. It then recommended that its own version not pass the legislature, presumably reducing its chances of becoming law.
One person submitting testimony at the committee hearing was the wonderful Britt Hermes who, as she had done with a previous North Dakota bill seeking prescription privileges, set out forcefully and cogently for the committee why naturopaths are not qualified to prescribe drugs. With her Bastyr transcript submitted as evidence, she demonstrated that a measly 55 hours in one course amounted to her entire classroom education in pharmacology, with “minimal, if any additional pharmacology training provided in clinical training hours”. (Her letter is well worth reading and filing away for use in opposing naturopathic licensing and practice expansion.)
Under the guise of addressing the primary care provider shortage (a favorite chestnut with naturopaths), a bill in Washington grants expanded prescription privileges to include “legend drugs and controlled substances contained in Schedules III through V.” As is the case currently, the state Board of Naturopathy (5 naturopaths, 2 public members) establishes the education and training necessary for these privileges.
Finally, another Washington bill would allow naturopaths to corner the market on colon hydrotherapy by requiring all colon hydrotherapists to get a certificate from the Board of Naturopathy and allowing them to perform colon hydrotherapy only if affiliated with a naturopath, with a referral from a naturopath, and pursuant to a plan of care devised by a naturopath (such as for “detoxification”, one presumes). The bill made it through its first Senate committee, Health & Long Term Care.
However naturopaths may fare in 2021, the AANP claims it has big plans for 2022, where “advocacy initiatives are planned” for Texas, Iowa, Tennessee, Mississippi, Indiana, Ohio, Georgia, and Florida. We’ll be watching.
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.
Addendum: Idaho licensed “naturopathic medical doctors” in 2019. In one of the stranger licensing bills I’ve come across, on February 15th, a bill was introduced in the Idaho legislature which apparently would license two more types of “naturopathic practitioners”, the “doctor of natural health” and the “licensed naturopathic doctor”. The former must have an “approved naturopathic doctoral degree” as determined by a new regulatory board, the Board of Naturopathic Health Care, which “shall use the national naturopathic board of examiners, as the resource for accreditation”. (The currently licensed “naturopathic medical doctors” are regulated by the state board of medicine in coordination with a naturopathic advisory committee.) The “licensed naturopathic doctor”, on the other hand, is
an individual who has graduated from an accredited doctoral program in the medical sciences, including but not limited to MD, DO, DPM, ND, DC, DMD, PA, NP, DNP, and PharmD and who has obtained an approved naturopathic doctoral degree, as set forth in rule [presumably promulgated by the newly-created Board of Naturopathic Health Care].
It’s not clear to me why any MD or DO would want to go to the trouble of obtaining an “approved naturopathic doctoral degree” when they can already do anything within the licensed naturopathic doctor’s scope of practice. Or why an ND would want to get an additional naturopathic degree.
The licensed naturopathic doctor has a broader scope of practice than the “doctor of natural health”, although the bill leaves many details up to the new Board (which consists of a public member, a doctor of natural health, and three people who have a degree from one of the “accredited doctoral programs” listed in the above quote) in deciding who can do what.
Some explanation for this mish-mash can be found in the bill’s “Statement of Purpose“, which says that the Naturopathic Physicians Association of Idaho agreed not to oppose licensing of naturopathic medical doctors in 2019
providing that a naturopathic license be formed to license graduates of their schools [presumably those not accredited by the Association of Accredited Naturopathic Medical Colleges] and that a licensing board would be established to license “The Other Naturopaths of Idaho.”