Articles

Ontario naturopathic prescribing proposal is bad medicine

Two weeks ago, Canadian Skeptics United published on their Skeptic North site a piece by an Ontario pharmacist criticizing a proposal by the province to grant limited prescribing rights to naturopaths. The essay, which was reprinted in the National Post on Tuesday, outlines the intellectual and practical conundrum presented by allowing those with education that diverges from science-based practices to prescribe drugs.

The naturopath lobby came out in force and was relatively unopposed in the 54 comments that followed, primarily because the NP closes comments 24 hours after online posting. Therefore, those with a more rational and considered viewpoint based in facts were locked out from commenting. This is quite disappointing to me personally and professionally because of the wildly emotional appeals, strawman arguments, and smears and attacks on the author himself without, of course, addressing his well-founded criticism of the prescribing proposal before the provincial government.

At the Skeptic North post, the piece even drew a naturopath who equated the criticism of his/her field with the Nazis and Mussolini. However, you can’t write critiques of these practices without attracting attacks ad hominem, especially Godwin’s Law, that are the resort of those whose arguments are logically flawed.

Naturopathy, sometimes called naturopathic medicine, is an unusual and inconsistently regulated alternative medical practice that co-opts some evidence-based medicine, often in nutrition and natural product medicines, but also subscribes to “vitalism” (vis medicatrix naturae) and makes use of homeopathic remedies that defy the rules of physics and dose-response pharmacology.

Naturopathy is, however, a warm and fuzzy term, especially when equated with “natural medicine” and the fact that people with naturopathy degrees advertise themselves with the honorific of “Dr.” The increasing popularity of naturopathy is also supported by cultural influences. I’ve written elsewhere that many, uh, natural product enthusiasts have become interested in naturopathy following the relocation of musician Dave Matthews from Charlottesville, VA, to Seattle, WA, where his wife, Ashley Harper, earned a naturopathy degree at Bastyr University.

In addition to the description of the practice in the NP op-ed, an excellent review and critical analysis of naturopathy by SBM’s Kimball C Atwood IV, MD, can be found at Medscape General Medicine. The abstract is as follows:

“Naturopathic medicine” is a recent manifestation of the field of naturopathy, a 19th-century health movement espousing “the healing power of nature.” “Naturopathic physicians” now claim to be primary care physicians proficient in the practice of both “conventional” and “natural” medicine. Their training, however, amounts to a small fraction of that of medical doctors who practice primary care. An examination of their literature, moreover, reveals that it is replete with pseudoscientific, ineffective, unethical, and potentially dangerous practices. Despite this, naturopaths have achieved legal and political recognition, including licensure in 13 states and appointments to the US Medicare Coverage Advisory Committee. This dichotomy can be explained in part by erroneous representations of naturopathy offered by academic medical centers and popular medical Web sites.

Like many alternative practices, naturopathy claims to harness the body’s own healing power as if differentiating that fact-based medicine does not also employ the body’s capacity to heal. The very same drugs that naturopaths wish to prescribe are those which can only work because they interact with targets in the body for which our endogenous compounds already act.

It seems to me that naturopathy adopts either science-based medicine or pseudoscience depending on the venue in which it serves the organization.

Because of my oft-expressed love of Canada, I had always thought that our neighbors to the north were more rational and had more finely-tuned critical thinking skills than we in the United States. However, I learned from the op-ed that British Columbia has already given prescribing rights to naturopaths.

I’m really surprised about this because of the furor that erupts whenever a proposal comes up to confer limited prescribing rights to pharmacists. Having taught in US colleges of medicine and pharmacy, I can state confidently that pharmacists have roughly four times the pharmacology and therapeutics coursework of physicians (albeit with not nearly as intensive postgraduate training). With the Doctor of Pharmacy degree firmly established as the entry-level pharmacy degree, pharmacists are now participating with physicians to gain practical clinical training in specialty areas.

But even with this extensive training in the same environment, legislated pharmacist prescribing is extremely limited worldwide. I remember it being a monumental achievement when my former PharmD student became the first pharmacist in the state of Arizona to have earned limited prescribing rights.

Therefore, I am amazed that Canadian politicians and health authorities are lending support to naturopath drug prescribing.

Another major challenge of this proposal relates to medical liability, an issue that seems to have been ignored previously but is articulated nicely in the NP op-ed:

A key role of the pharmacist is to double-check the safety and appropriateness of a prescribed drug. When required, the pharmacist resolves drug related problems with the prescriber. This is only possible because pharmacists, physicians, and nurse practitioners work from a common, science-based understanding of drugs and disease. In contrast, naturopaths may not share this science-based approach to illness, and may rely on references that are unknown to, inconsistent with, or directly contradict the medically accepted standard of care. If naturopaths prescribe a drug based on a naturopathic belief system, and a pharmacist determines that the prescription is not appropriate from a scientific and evidence-based perspective, what will the pharmacist’s responsibility be? Will pharmacists be held liable for prescriptions written by naturopaths who do not share a science-based view of illness?

Here’s a question, though: if the legislation moves forward, could pharmacists refuse to fill a prescription from a naturopath the same way that some states allow for “conscientious objection” by pharmacists for filling emergency contraceptive prescriptions?

I also wonder why pharmaceutical companies have not gotten involved in this debate. Corporate liability is also likely to be influenced as improper prescription of drugs is bound to increase the number of reported adverse reactions.

Nevertheless, the bill is moving forward:

The Bill passed second reading and was referred to the Standing Committee on Social Policy. Several naturopath organizations were on the agenda, and argued for “unambiguous authority for prescribing, compounding, dispensing or selling a drug as designated in the regulations” – essentially a clause that will allow naturopaths gain access to prescription drugs, developing a list out of the public eye. The standing committee accepted this request (the revisions may be viewed here [PDF]), and put naturopath prescribing into Bill 179. Third reading is expected sometime this fall. If it passes, the right for naturopaths to prescribe drugs will become entrenched in Ontario law.

The legislation of quackery presents a major threat to public health, pure and simple.

A rebuttal from two naturopaths has now appeared at the National Post. Therein, the typical distancing from science-based medicine is claimed while concomitantly arguing that naturopathy is based in science, followed then by excoriation of the randomized, controlled clinical trial. The typical chesnuts of distinction are invoked such as recognizing the healing power of the body, individualized patient care, and focus on disease prevention – all of which science-based medicine employs no matter how it is spun. One cannot simultaneously claim to embrace and reject science, yet this is done in the NP rebuttal. The responses are much more reasoned including an especially superb point-by-point comment by “steveisgood” (the page doesn’t provide unique URLs for each comment so you’ll have to scroll down by hand).

Posted in: Science and Medicine

Leave a Comment (27) ↓

27 thoughts on “Ontario naturopathic prescribing proposal is bad medicine

  1. jedischooldropout says:

    Just a heads up – Canadian Skeptics United… we are amused by this name dhtat cropped up from somewhere, but if it exists at all, it’s not us.

    Figure we should start knocking the name down before it propagates!

    Thanks for the post!

  2. jedischooldropout says:

    …Just figured out how the misunderstanding on the bogus moniker occurred.
    It DOES say that on the blog. But it’s not a title, it’s a statement of solidarity.

    “Skeptic North – Canadian Skeptics United.”

    Anyhow… STILL thanks for the post!

  3. Grinch says:

    When will the insanity end? ND’s, chi-practitioners, psychics, chiropractors, acupuncturists, homeopaths, behavioral optometrists, voodoo doctors, witch doctors, shaman, chelation therapists, anti-vaxers, CAMers, and whoever hell I missed. Will they not stop until they kill every single person they come across? Why don’t they do what most of us did. Go to medical school and learn. I cannot understand why this is so difficult. I also cannot understand why someone would think that these quacks have any answers that science has missed…why would any rational human being that these charlatans know something secret that doctors don’t know?
    Sorry. End of rant.

  4. daijiyobu says:

    In that rebuttal, when I read the blatant ‘we are indeed scientific’ labels…

    my jaw dropped.

    But, science SELLS.

    It’s sells seats at colleges and universities offering pseudoscience naturopathy degrees, and it gets patient’s in the door for them.

    -r.c.

  5. I’m from BC, and I am certainly amazed and dismayed by the ease with which NDs acquired the right to prescribe here. So much irony!

    Grinch asks: “Why would any rational human being that these charlatans know something secret that doctors don’t know?”

    Alas, because there are several relevant glitches in human nature that makes us prone to it! Wishful thinking, confirmation bias, the seductiveness of conspiracy “logic,” and so on and on.

    As a skeptical alternative health professional (I’m a Registered Massage Therapist), I can comment pretty authoritatively on why patients go looking for alternative care: they tell me about it all the time, even the skeptical ones. There are a whole bunch of common objections to medical care, some fair, some unfair, almost all of them revolving around fear, red tape and the institutionalization of medical care.

    And, bless them, a great many patients are just as cranky about so-called alternative medicine as they are with the regular sort. I hear plenty of frustrated ranting from patients about alternative treatments that they believe are over-priced and ineffective. Naturopaths, I suspect, have no clue how bitterly their ex-patients complain about things like vega testing, chelation, detoxification, applied kinesiology, and many other staples of naturopathy. Patients rarely tell their naturopaths about their discontent, but they are certainly happy to talk to their massage therapist about it!

    Trust me, alt-med is irritating just as many people as it’s attracting.

  6. steveisgood says:

    Dr. Kroll,

    Thanks for posting about this at SBM. We’ve been fighting like mad up here and I appreciate you taking the time to help spread the word.

    Interested readers and HCP’s might want to read my recent post at the Swift blog, for some helpful links on how to respond, and who to respond to.

    It’s not too late to stop this bill, but the window for action is closing extremely fast.

    Thanks again,
    Steve Thoms,
    Editor-in-Chief,
    Skeptic North

    P.S.
    I’m the “steveisgood” you mentioned :)

    P.P.S.
    If anyone would like more tips and information, feel free to contact me, skepticnorth [at] gmail [dot] com.

  7. @jedischooldropout – Apologies to all of you for misreading your tagline, “Canadian Skeptics United.” While I may have misunderstood, you have to admit that would look pretty good on a soccer jersey.

    @steveisgood – Thank you so much for commenting. I will reiterate your comment in bold to visit your Swift blog post for detailed information on who to e-mail in provincial government. Do you think it would still be of value for non-Canadians to send messages of objection?

    By the way, thank you for your exhaustive 23-point response to the NP naturopath rebuttal. I would love to see that reprinted somewhere that can be more readily searched than in that comment thread. Your opening point is well-taken:

    The science-based community is always at a disadvantage in these sorts of outcries, because we’re limited to the evidence, and we can’t just make stuff up.

  8. TheCashin says:

    “Therefore, I am amazed that Canadian politicians and health authorities are lending support to naturopath drug prescribing.”

    Don’t you remember who our Minister of Science and Technology is ? :)

    Gary Goodyear, Chiropractor, Acupuncturist, Creationist, Science-Defunder (perfectly cromulent word)

    Woo medicine is alive and well in Canada. People go about their lives without hearing a negative word about it.
    For those who don’t know better, the word Natural invokes warm and fuzzy wholesome feelings regardless of context..
    similar in reputation to the word Organic

  9. windriven says:

    Expanding the federal imprimatur to given to shamans, cranks and quacks to include the right to prescribe drugs is short-sighted and potentially very dangerous. Dollars for health care are a limited resource. Roughly 70% of Canadian health expense is publicly funded. Can Canadians – or any other people – afford to squander limited resources on nonsense?

    Further, there are problems with over-prescription of some drugs – notably antibiotics – among carefully trained medical doctors. What disasters are we inviting by allowing magical thinkers to prescribe drugs whose usefulness is also a limited resource (i.e. resistance to antibiotics)?

  10. steveisgood says:

    @David J Kroll

    Obviously, the priority in Ontarians first, Canadians second, Everyone else third.

    But in the “everyone else” category, more weight would be given to the voices of people that are health care professionals (especially MD’s). Non-Canadian HCP’s can get involved in this debate by making the Ontario government (and opposition parties) know that the medical and scientific communities of the world are watching, and are expecting the gov’t to make the right decision, lest they turn Ontario into a medical and legislative laughing stock.

    Another great thing for non-Canadian HCP’s to do is to contact any Canadian HCP’s that they know personally or professionally. Far too many doctors and nurses are frustratingly ambivalent on this issue, and Skeptic North should NOT be the ones who are leading this fight: it should be the medical community itself defending its standards of practice. Having a non-HCP writer like myself trying to get an apathetic MD or Nurse into action is like trying to chop down the mightiest tree in the forest with a herring. But I’m fairly certain that at least some of them will listen to their foreign-colleagues.

    Sorry to refer to you as a foreign country just now ;)

  11. daijiyobu says:

    Steve G., by the way, regarding your label “bogus”, I’m wondering if you are concerned that you may be blessed with a libel lawsuit from CAND or OAND, as Singh was by BCA for use of the same word?

    Though I don’t know much about libel laws in Canada and the Canadian ND’s collective temperament, might you have waved the red flag at the bull and now it can’t help but charge?

    -r.c.

  12. steveisgood says:

    @daijiyobu

    Not particularly concerned. The word bogus only occurs once in the 1-2 punch that Scott and I offered, and it was Scott’s characterization of the practice of naturopathy as bogus, not the CAND, OAND, or any naturopath in particular. (It was also re-posted at the National Post entry)

    In any case, our free-speech laws are very clear, and they work like the American version. We’re safe, because we’re not breaking any laws (and if they tried it, then we would have LOTS of ammunition to fight back). A small part of me (very small) wants them to go after us for libel….My academic background is in political science and I know the laws dangerously well for them to come after me or the team at SN.

    But as to your point about the collective temperament of Canadian naturopaths (I refuse to call them naturopathic doctors), they, and their supporters can be very twitchy about this sort of thing….the National Post got flooded with angry emails after Scott’s piece.

  13. Grant Jacobs says:

    I’m struck by the similarity of the “vitalism” beliefs underlying naturopathic thinking and some of the thinking underlying chiropractic thinking. Is there a direct connection here, or is this just an example of independently picking up the same thing?

  14. Fifi says:

    TheCashIn – Let’s be fair to Harper, he’s just as busy selling out Canadian medical research and public healthcare to pharmaceutical companies as he is to CAM. How about his appointment of a Pfizer executive (who is still works for Pfizer) to the board that oversees funding public health research? This isn’t about science vs woo or Big Pharma vs Big sCAM, it’s about turning citizens into consumers and patients into profit. Harper’s agenda is only ideological in that it’s about handing over government to corporations and trying to get rid of any and all organizations that focus on reality-based thinking and providing non-corporate research.

    The CBC is a pale ghost of itself now, real news gets buried in the back pages while sensationalism leads the way. This is a result of handing over the reins to someone with a big business background, it’s about selling entertainment and advertising, not reporting the news.

    So, on one side you have a chiropractor involved in funding scientific research and on the other you have a Pfizer exec involved in funding health research. Like I said, this is about attacking science while getting us rabble to fight about science vs woo or Big Pharma vs Big sCAM so he won’t noticing that he’ll sell us out and give our tax dollars to any old corporation.

  15. I’m struck by the similarity of the “vitalism” beliefs underlying naturopathic thinking and some of the thinking underlying chiropractic thinking. Is there a direct connection here, or is this just an example of independently picking up the same thing?

    Good pick-up; it’s some of each. The 19th century roots of chiropractic are distinct from those of naturopathy, but both retained the “vitalism” notions that were then still common. By the mid-20th century in the U.S., “mixer chiropractic” had become almost indistinguishable from naturopathy. The current plague of “naturopathic doctors” is a direct result of this history:

    National College of Natural Medicine (NCNM) is the oldest programmatically accredited naturopathic medical school in North America. NCNM had its beginnings in the early 1950′s, in response to the termination of the naturopathic program at Western States Chiropractic College.

    So, in my opinion, is their relentless clamoring for legitimacy through governmental fiat, rather than by scientific validation–a strategy which for chiropractors has been wildly successful.

  16. Grant Jacobs says:

    Thanks Kim,

    I’m after a little more historical background so I understand this better. Right now I stick to the things I can say with authority. It’s not hard to reply to a chiropractor writing that “synthetic chemicals” are bad, by pointing out what synthetic means and asking if they’re happy with the vitamin pills they bought. The deeper “feel-y” stuff is harder without the historical background.

  17. Grant Jacobs says:

    Oh, rats. Kimball, not Kim. Reading in too much of a rush. (Writing this in a break for prepping for a meeting.)

  18. I notice that comments are now closed at National Post for the article by the naturopaths. I posted a comment there yesterday, but since then a commenter calling himself “ModerateThinker” has made several dubious assertions. Two of them are typical of the genre, and betray an absence of RigorousThinking:

    If you pubmed acupuncture and nausea, you can find countless publications showing positive results greater than that shown with placebo.

    Scientists tried to discredit the person who discovered that H. Pylori causes ulcers……….yet decades later, this gentleman receives the nobel prize.

    If comments were still open there, I’d post links to rebuttals. Since they aren’t, I offer these to readers who were involved in the thread there:

    http://www.sram.org/0802/acupuncture.html

    http://www.csicop.org/si/show/bacteria_ulcers_and_ostracism_h._pylori_and_the_making_of_a_myth

  19. steveisgood says:

    Just an update,

    I wrote a new, updated call-to-action at Skeptic North, with emails, tips on how to write, and updates to the proceedings.

    Hint: WRITE YOUR LETTER NOW!

  20. GwennyD says:

    Despite having written to Dalton McGuinty, Premier of Ontario and to Deb Matthews, Minister of Health and Long Term Care for Ontario, along with (I hope) many other citizens expressing their concern about this issue, the Bill was passed on November 30th, 2009.

    Direct quote from Premier McGuinty in his response to my letter: “As you may know, Bill 179 was passed on November 30 with unanimous support.”

    I find it appalling that there was unanimous support for this ridiculous bill! Why would every Ontario Representative support woo? Its disheartening.

    G

  21. gtrowan says:

    What’s more appalling is that MD’s make up the largest segment of physicians that practise ‘natural medicine’ in north america. Perhaps MD’s with no training in nutrition and botanical medicine are a threat to the health of their patients.

    The threat to the public by a Naturopathic Doctor prescribing the odd antibiotic for a patient that can’t get a visit to their family physician for one month is in the best interest of the public.

    Naturopathic physicians in the US have already proven safety with a clear track record of prescribing medication.

    In 10 years from now, this will not be an issue as ND’s will eventually be replaced by MD’s practising the very medicine they discredited for the past several decades. As the evidence grows, MD’s will take claim for nutritional supplements, herbal medicine and acupuncture. The trend in north america certainly supports this. Havard, stanford, university of chicago, maryland etc… with integrative medicine clinics and research departments.

    For those who are threatened by ND’s prescribing drugs, you may want to realize they already prescribe drugs – just not drugs “owned” by another profession.

    Perhaps dentists should refer their patients back to the family physician for prophylactic use of antibiotics with certain
    dental procedures for the prevention of bacterial endocarditis.

    When control is lost, people get upset. ND’s will hopefully forgive all the MD’s prescribing natural molecules with no training.

    ND’s are obviously practising non evidenced based medicine by asking – is it possible the headache could be caused by the one meal per day, 5cups of coffee and no water? Is the PMS an antidepressant deficiency or caused by the obesity, stress, poor sleep and lack of exercise.

    Yes, MD’s are better trained to prescribe medication. At the very least, ND’s are wiling to take rigorous pharmacology exams to have the privilege of prescribing drugs. MD’s have taken no such examination in the privilege or prescribing natural medicines.

    GwennyD – the public has already spoken, so you can stop holding your breath and relax. I heard there is no drug for lack of oxygen to the brain.

  22. GwennyD says:

    gtrowan you don’t have to end your point of view by being an asshole, thank you.

    If ND’s are going to take extensive medical training to prescribe pharmaceuticals then fine, but there is, so far, no requirement for them to do that. How would an NT know when to prescribe an antibiotic? Do they know what tests to perform to check if an infection is bacterial or viral? Dentists go to medical school and their training is based in science, unlike NT’s.

    Pharmacists take extensive training in pharmaceuticals and cross referencing with regard to drug interactions and yet they are not allowed to prescribe, but now NTs are? Ridiculous.

    If MD’s want to “prescribe” herbs I am sure they will, but herbs are not concentrated pharmacological drugs and for the most part are slow to work and generally do no harm. Pharma drugs on the other hand can be very dangerous if used for the wrong things as well as in combination with other drugs. That is why doctors, nurses and pharmacists have to go through 5-10 or more years of science-based medical training before they are allowed to prescribe.

    I sure do hope your prediction is correct that all ND’s will eventually be replaced by MD’s

Comments are closed.