Naturopathic Physicians Are Qualified for Expanded Drug Authority
A recent article in the Times Argus and Rutland Herald publicized legislation passed last year in Vermont that would give Vermont naturopathic doctors (NDs) expanded prescription drug authority. The goal of this legislation is to fix problems with the current limited prescription formulary for NDs and in so doing, improve the quality of care that NDs can provide to the increasing number of Vermonters who choose this type of medicine every year.
Naturopathic physicians specialize in treating the whole person using minimally invasive techniques to help people get and stay well. These techniques include dietary and lifestyle modification, nutritional supplements, herbal medicine, and hormone therapies, to name a few. These techniques are very powerful and can help many people get well, including when prescription drugs fail.
Naturopathic physicians treat people of all ages and most of the chronic and acute medical conditions they experience, including arthritis, irritable bowel, fatigue, mood problems, high cholesterol, allergies, headaches, etc.
In addition to acting as specialists to treat conditions such as these with natural medicines, Vermont law also recognizes NDs as primary care physicians (PCPs). As PCPs, naturopathic physicians address the spectrum of an individual’s health needs, including asthma, infections, and high blood pressure. While the first priority of an ND is to prevent and treat illness with lifestyle and natural medicines, there are times when pharmaceutical medications are necessary.
For example, naturopathic medicine can be very effective at preventing and treating the following three conditions, and NDs currently have the authority to prescribe a limited number of prescription drugs to treat each of these conditions as well. Sometimes, however, these natural and prescription medications are not adequate.
Asthma — most people with asthma need to have a prescription rescue inhaler in case of a life threatening asthma attack, and some need to take steroid inhalers. The current naturopathic formulary includes one fast acting rescue inhaler, one long acting inhaler, and one steroid inhaler. If a patient of ours is allergic to one of these medications, or they are ineffective, we are left without an effective way to treat that person.
Infection — Sometimes it is necessary to treat infections with antimicrobials such as antibiotics, antiparasitics, and antifungals. In any given infection, the organism is likely to be resistant to a number of the antimicrobials. If the organism is resistant to all of the antimicrobials in the naturopathic formulary, which can happen, we are left without an effective way to treat that infection. Furthermore, there are no oral prescription antifungals in the naturopathic formulary that are effective in the treatment of vaginal yeast infections.
High blood pressure — Sometimes when natural medicine isn’t working prescription drugs can help control blood pressure. While there are 4 different classes of drugs commonly used to treat high blood pressure, the naturopathic formulary includes only one drug from one of those classes.
In the above0mentioned situations and others, naturopathic doctors have to try to find another physician who will prescribe the necessary medicine. This process can be time consuming, delay care, and add unnecessary costs to the health care system.
In addition to the aforementioned limitations, sometimes medications that are on the naturopathic formulary are discontinued, and the replacement medication is not on the formulary.
A good example of this is the medication mebendazole, which was used to treat pinworm infections until it was discontinued. The replacement medication albendazole is not on the naturopathic formulary, leaving us without an effective treatment for this common infection. While in theory the formulary is supposed to be updated annually, in practice it has been updated only once since 1996.
Access to primary-care physicians is very limited, especially in central Vermont, by a lack of available PCPs who are accepting new patients. It can take months for a new patient to get an appointment at one of the few practices accepting new patients in this area. Meanwhile, NDs are providing more and more primary care to Vermonters each year.
As of 2011, approximately 7 percent of all PCPs in Vermont were naturopathic physicians. It is therefore important for public safety and necessary for effective healthcare that NDs have broader access to prescriptions drugs than is provided by the current limited formulary.
Unfortunately this necessary and important legislation has been strongly opposed by the Vermont Medical Society (VMS). The VMS has stated that they don’t think naturopathic physicians have adequate training to prescribe these medications, or that they are afraid naturopathic physicians will prescribe chemotherapy or other powerful drugs that have no place in a primary care setting.
Let’s examine both of these concerns:
Training — A 1997 study published in Alternative and Complementary Therapies found that the average MD receives 114 hours of pharmacology training in medical school and the average ND receives 100 hours of pharmacology training in medical school. This represents a difference of only 6 percent. Furthermore, the rules created for the proposed formulary expansion require NDs to pass a National Board of Medical Examiners subject matter exam in pharmacology, or the examination given in the Medical Pharmacology course taught at the University of Vermont’s College of Medicine, the same exams given to medical doctors.
Chemotherapy — In the words of Secretary of State Jim Condos, “The new law authorizes a naturopathic physician to prescribe, dispense, and administer prescription medicines within a naturopathic physician’s scope of practice. Accordingly, the law did not open the floodgates and authorize an individual naturopathic physician to prescribe all pharmaceuticals.” All other doctors in Vermont, including medical doctors, osteopathic doctors, dentists, and podiatrists already have unlimited prescribing authority, including chemotherapy and other drugs. Dentists don’t prescribe chemotherapy drugs even though they have the prescription authority because they aren’t trained to do so and it isn’t within their scope of practice. Neither are podiatrists and most medical and osteopathic doctors.
If the VMS is actually concerned about unfettered prescription drug authority, they should be acting to limit the prescription authority of all of these doctors, including medical doctors practicing in emergency rooms, primary care doctors, plastic surgeons, and pretty much any physicians other than oncologists. They are not doing this, however. What the VMS has been doing, according to Condos, is making “vigorous and ever-changing objections” to this rule.
This brings us to what is likely to be the real motive behind the Vermont Medical Society’s efforts to limit primary care provided by naturopathic physicians — protecting its own turf. The American Medical Association (AMA), and its state affiliate the VMS, have stated policies of opposing the expansion of the scope of practice of other (non MD/DO) provider types. This policy is known as the Scope of Practice Partnership, and has been employed across the country to oppose licensing of naturopathic physicians, designation of NDs as primary care physicians, and any change in the scope of practice of NDs and nine other provider types.
Harry Chen, a medical doctor and the Vermont commissioner of health, has testified before the Vermont legislature on multiple occasions that he believes that removing the formulary for NDs and allowing NDs to practice within our scope when it comes to prescription drugs is good for public health.
“I’m in support of the regulation and I think they (the Office of Professional Regulation) are carefully considering this to ensure safety,” states Dr. Chen.
The Office of Professional Regulation (OPR), the state agency that regulates naturopathic doctors, has also testified to this. Condos has stated, “The House and Senate Government Operations Committees took extensive testimony on these issues and ultimately the full Legislature has weighed the safety of naturopathic physicians against this new model of regulation and deemed it appropriate that they be treated like any other licensed professional with prescriptive authority based on their education and training.”
Naturopathic physicians have been prescribing prescription drugs in Vermont and elsewhere for decades with few to no complaints. According to the OPR’s Report on the Education and Clinical Training of Naturopathic Physicians, “The safety record of naturopathic physicians regarding pharmacologic substances is well demonstrated in the northwest where NDs have broad prescriptive authority. Jury Verdicts Northwest, a legal database which records court cases in Washington and Oregon, the area of the country with the largest number of naturopathic physicians, shows no judgments for malpractice against NDs since the database was started in 1983 through 2010.”
Bernard Noe, ND, is a naturopathic physician who practices in Montpelier.