Washington bill would expand naturopathic prescription authority

A bill has been filed in Washington State (House Bill 2034) to substantially expand the prescriptive authority of naturopathic doctors (or "physicians," as they like to call themselves). If the bill passes, naturopaths will be very close to having the same authority to prescribe as MDs and DOs.

Under current law, naturopaths can prescribe and administer vitamins, minerals, botanical medicines, homeopathic remedies and hormones. They can also prescribe and administer legend drugs and controlled substances, limited to Schedule III, IV and V codeine and testosterone and "consistent with naturopathic medical practice in accordance with rules established by the board [of naturopathy]."

However, the board's rules are so liberal that the only limitation on the parameters set by the legislature are that naturopaths cannot prescribe Botulinum Toxin (e.g., Botox) and "inert substances used for cosmetic purposes."

Intramuscular, intravenous, subcutaneous and intradermal injections are permitted, again "consistent with the practice of naturopathic medicine" but these rules are established by the secretary of the state department of health.

The contrast between the training rules established by the naturopathy board and the health department secretary is interesting. The naturopathy board has decided that a paltry 4 hours of instruction is sufficient to prescribe controlled substances. Note that this is "instruction" only, no clinical training is required.  Apparently, whatever little training in pharmacology naturopaths get in naturopathy school is sufficient.

The secretary, on the other hand, requires 16 hours of training before a naturopath can use IV therapy. Unfortunately, this too can be done in naturopathy school.

It is always instructive to see how the deficiencies of naturopathic education and training are inadvertently revealed in these additional educational requirements. Naturopaths adamantly maintain that they graduate from 4 years of school ready to practice primary care with the same level of competency as an MD or DO, even though the latter have been through at least 3 years of residency following graduation from med school. Yet, only one state (Oregon) actually gives naturopaths the same scope of practice, and in the few states where they are licensed or registered, the law often grants either limited or no prescription rights and requires additional training in various subjects (such as prescribing and delivering babies) before naturopaths can perform certain tasks all MD and DO PCPs already know how to do. This should speak volumes to the state legislatures about the veracity of their claims.

HB 2304 would allow naturopaths to prescribe and administer:

  • All legend drugs;
  • Hydrocodone combination products contained in Schedule II (under state law);
  • Controlled substances contained in Schedules III through V.

The naturopathy board "may" adopt rules relating to education and training requirements for legend drugs and controlled substances "in consultation with" the pharmacy quality assurance commission. If the bill passes, let's hope the commission does its homework on naturopathic education and insists on new rules that offer a real opportunity to overcome its deficiencies.

The commission, as well as legislators, would be well advised to start with the revelatory blog posts (Naturopathic Diaries) of former naturopath Britt Hermes. Hermes was instrumental in preventing a 2015 practice expansion bill that came uncomfortably close to passing in North Dakota.  She has written extensively about the many defects of the naturopathic educational system, including shortcomings in clinical training, and how naturopaths fail their patients with incompetence and, in some cases, outright mendacity.  A review of Scott Gavura's Naturopathy vs. Science series on Science-Based Medicine will further educate them about the deeply-embedded pseudoscience that governs naturopathic practice.

In one post, Hermes offered this startling information about how little pharmacology training naturopaths get in school:

BC 6305 Pharmacology for ND Students: "pharmacology for the ND student population"

  • 55 lecture hours in one course
  • No additional pharmacology training provided in other courses
  • Minimal, if any, additional pharmacology training provided in clinical training hours

Legislators should be wary of the attitude toward prescription drugs expressed by the Washington Association of Naturopathic Physicians. One article on its website (which appears to be woefully out of date, the most recent article having been posted in 2014) bears the headline "Chinese herbal remedy 'just as effective as methotrexate against arthritis." The touted study which came to this conclusion had no placebo control and was unblinded, making it so flawed as to be meaningless. While the study's limitations are noted at the end of the article, why mention it if it is worthless as a guide to clinical practice?

There is also a link to an article by Andrew Weil, MD, in which he expresses concern that Americans take too many prescription drugs. Perhaps this is true, but he argues, with no real supporting evidence, that plants are "usually better than drugs."

Perhaps the appeal of these articles can be explained by the fact that the WABP is supported financially by dietary supplement and herbal remedy companies. Of course, many naturopaths sell these products, creating a conflict of interest when they must make decisions on appropriate therapies for their patients.

The bill also requires the naturopathy board to adopt pain management rules appropriate for acute pain treatment based on the state's "interagency guidelines on prescribing opioids for pain . . . including, but not limited to, patient examination, screening for comorbidities and risk factors, and maximum dosage limits and treatment periods." Hopefully this will leave little wiggle room for the board to enact the sort of slack rules currently governing prescribing.  In addition, naturopaths must register in the prescription monitoring program database.

Despite this minimal effort to protect the public from ill-advised prescribing by poorly trained practitioners, the best way to accomplish that goal would be the defeat of House Bill 2304. Washington residents can express their opposition to the bill on the legislature's website. (Including links to Britt Hermes's and Scott Gavura's posts is a great idea.)

Points of Interest 12/20/2015
Points of Interest 12/19/2015

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