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The DC as PCP? Revisited

There is a disturbing effort afoot to rebrand chiropractors as primary care physicians, a subject both Harriet Hall and I have discussed in previous posts. Part of this effort includes convincing state legislatures to grant prescription privileges to chiropractors, an effort that succeeded in New Mexico, as reported in a post a couple of years ago. Let’s return to New Mexico and see how that is working out for everyone.

By way of background, in 2008, the New Mexico legislature created a new iteration of chiropractor called “certified advanced practice chiropractic physicians” with the authority to

prescribe, administer and dispense herbal medicine, homeopathic medicines, vitamins, minerals, enzymes, glandular products, naturally derived substances, 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.

As those familiar with primary care will no doubt be aware, these aren’t exactly the type of thing the family practice doctor, pediatrician or internist would consider essential tools of practice.

The chiropractic formulary expands

The statute directed the Board of Chiropractic Examiners to develop a formulary for these substances but it had to be approved by the NM Medical Board and Board of Pharmacy. As might be expected, however, chiropractors wanted more expansive prescriptive authority and succeeded in getting it from the legislature in a subsequent amendment to the original law. This amendment eliminated the approval requirement for the listed substances and added the authority to prescribe “dangerous drugs or controlled substances, drugs for administration by injection and substances not listed” in the statute but only with approval from the medical and pharmacy boards.

This “advanced practice” status can be achieved with only 90 hours of education with whatever additional training the chiropractic board deems necessary for new substances it might want to add to the formulary. These hours can be obtained in weekend and online continuing education courses.

It didn’t take long for the chiropractors to clash with the pharmacy and medical boards over what should be included in the newly expanded formulary. (The details of this clash are chronicled, with supporting exhibits, in this document filed in the New Mexico Court of Appeals.) In September, 2009, the chiropractic board adopted a formulary which including certain drugs to be administered by injection which had not been approved by those boards. The pharmacy board appealed the chiropractic formulary to the New Mexico Court of Appeals. Later that month, representatives of the three boards ironed out their differences and a new formulary was put into place, to be effective in July, 2010.

In spite of this agreement, the chiropractic board nevertheless voted again, in June, 2010, to include in the formulary certain drugs to be administered by injection without getting the required approval. Although the chronology of events is not entirely clear, apparently the chiropractic board was about to add even more drugs for injection and dangerous drugs to the formulary in August of 2011. It will likely come as no surprise to anyone that the proposed formulary included the decidedly fringe practices of chelation therapy and prolotherapy. It also included glucosamine, which has not been approved by the FDA for medical use in humans, by injection. As well, it included a number of vitamins and minerals by injection, muscle relaxants (including metaxalone and baclofen), and glutathione for inhalation, an unproven remedy for pulmonary diseases.

Medical Board objections

At this point the medical board stepped in with a strongly worded letter to the chiropractic board stating it had voted not to approve the proposed formulary changes and set forth the reasons why. In addition to the problems noted above, the medical board complained that

  • New drugs have been added which have not been approved by the pharmacy board.
  • Drugs have been specified for injection which are not within the scope of practice of chiropractic.
  • Drugs were added without stating their intended use.
  • Additional hours of training specified by the chiropractic board do not appear to be sufficient.

The medical board also objected that no mention was made of a restriction previously agreed upon by the medical and chiropractic boards, which provided:

The patient must first be screened, by appropriate medical and laboratory means, for existing problems and contra-indications (such as renal or other diseases). Appropriate coordination with the patient’s allopathic or osteopathic physician is strongly recommended.

In another report, the medical board (here referred to as the NMMB) also said that

In February 2010, after a thorough review of the proposed chiropractic formulary and educational criteria, the NMMB adopted the position that they could not approve either the proposed drugs, or the proposed routes and dosages of administration or their safety and effectiveness. MDs and DOs would never use many of the proposed substances, especially in the manner which the chiropractors proposed for their use. . . . The NMMB also did not approve administration of dangerous drugs or controlled substances by the Advanced Practice Chiropractors based on the lack of sufficient, appropriate education, specific clinical training, and hands-on experience . . . .

So what did the chiropractic board do? Although it did drop chelation therapy, it went ahead with most of the formulary (including prolotherapy and glucosomine injections) without medical or pharmacy board approval. And it did so even though the general counsel for the New Mexico Department of Licensing and Regulation  advised against approval. The attorney sat there at the meeting and specifically told the board they shouldn’t approve the formulary because no medical or pharmacy board approval had been obtained and that it was outside the scope of statutory authority granted the chiropractic board by the legislature.

At this point, the pharmacy board, this time with the medical board, went back to the New Mexico Court of Appeals seeking a stay of implementation of the new formulary. The International Chiropractic Association (ICA) filed its own action also seeking a stay. In February of this year, the Court of Appeals granted the ICA’s and boards’ motions, and stayed implementation of the 2011 formulary. These cases remain pending before the Court for a determination whether the chiropractic board exceeded its statutory authority in enacting these rules. It’s hard to imagine any reason why the Court wouldn’t strike down the challenged rules for good.

Meanwhile, back in the legislature . . .

Apparently New Mexico chiropractors determined that a more direct approach was necessary toward the goal of rebranding chiropractors as primary care physicians, with the full scope of practice that entails. So, in 2011, a sympathetic legislator, Ben Lujan, introduced a bill into the New Mexico House of Representatives. The bill’s aim was to increase substantially the scope of chiropractic practice, which was renamed “chiropractic medicine.” In addition to “locating and removing . . . misalignments or subluxations” the bill would expand “chiropractic medicine” to include “diagnosis and treatment of a condition for which the chiropractic physician has been educated and trained. . . .” And who would make the decision whether the chiropractor had been “educated and trained” to treat a “condition?” The New Mexico chiropractic board.

I have to ask: doesn’t this seem awfully cumbersome? How would the chiropractic board decide whether a particular chiropractor has been sufficiently educated and trained to diagnose or treat a particular condition? I’m no doctor, but it is my understanding that there are lots and lots of conditions. (Thousands, maybe?) Is the board going to keep a list of all of them along with the training necessary to diagnose and treat each one?

Under the bill, practitioners of “chiropractic medicine” would also be allowed to use invasive diagnostic procedures, and, if permitted by chiropractic board rule, perform operative surgery, prescribe or use controlled or dangerous drugs, and practice acupuncture.

The “chiropractic advanced practice” status was retained, again only requiring 90 hours of additional education and training, the adequacy of which was solely within the purview of the chiropractic board. With board approval, the advance practice chiropractor could prescribe and administer

any dangerous drug or controlled substance and perform and procedure that is accepted for use within the certified advanced practice chiropractic physician’s clinical specialty and for which the certified advanced practice chiropractic physician can demonstrate appropriate clinical education and hands-on training that has been approved by a nationally recognized credentialing agency or nationally recognized institution of higher learning.

No standards were imposed to determine exactly how a “clinical specialty” would be defined or what constituted a “nationally recognized credentialing agency” or “institution of learning,” leaving those determinations solely in the hands of the chiropractic board. And gone were the pesky medical and pharmacy boards. From now on, the formulary would be determined solely by the chiropractic board.

In short, the proposed statute would empower the New Mexico chiropractic board to decide when and under what circumstances any chiropractor could perform surgery and prescribe controlled substances or dangerous drugs. I say “any chiropractor” because, although the bill retained the “chiropractic advanced practice” status, it did not limit the board’s ability to allow surgery and drug prescribing authority to that status. It would also allow chiropractors to immediately start using invasive diagnostic procedures. And it would permit some vague “clinical specialty” designations by advanced practice chiropractors.

And here’s the really scary part – this bill came very close to passing. With some amendments upping the hours of training, it passed the New Mexico House of Representatives. It was finally stopped in the Senate Judiciary Committee, mostly due to a massive lobbying effort by the ICA and other chiropractors who didn’t want these changes. According to one chiropractic publication, a spokesperson for the New Mexico Medical Board testified before the legislature that the Board did not oppose the bill. If true, this position is at odds with a legislative committee report, which noted that the Board had several objections to the bill. Among those was the misleading nature of the terms “chiropractic physician” and “chiropractic medicine.”

A national movement?

Unfortunately, this ill-advised attempt to transform chiropractors into primary care physicians with prescriptive authority is not limited to New Mexico. That this may be a national effort is hinted at in the Council on Chiropractic Education’s (CCE) removing the standard phrase “without drugs or surgery” from its description of chiropractic practice. (The CCE is the national accrediting agency for chiropractic schools.) This effort is also reflected in recent changes to the Federation of Chiropractic Licensing Board’s new draft Model Practice Act for chiropractic and petitions to the National Board of Chiropractic Examiners to develop a “chiropractic advanced practice” exam.

There is a small national association of chiropractors, the First Chiropractic Physician Association of America (FCPAA), devoted to

expanding your rights as a primary care physician with full prescriptive rights and the ability to specialize you can increase your knowledge and your ‘bag of tools.’ It all adds up so you could offer more services to the public.

(Emphasis added.)

The FCPPA has 11 affiliated state organizations working toward its goal of passing legislation to accomplish this. Perhaps the reason for this movement is best summed up by one affiliate, the Florida Chiropractic Physician Association:

Aren’t you tired of worrying where your next patient will come from? Expansion means prosperity for you and better health for your patients.

Last year, the Alabama Board of Chiropractic Examiners proposed legislation (not yet introduced) which would allow that board to authorize prescribing of certain legend drugs without any additional education or training. It would expand the scope of practice to include any procedure or service taught in a chiropractic college or in courses sponsored by a chiropractic college, leaving the scope virtually open-ended.

Conclusion

The attempt to rebrand chiropractors as primary care physicians is bad enough, but giving them the legal authority to prescribe is beyond the pale. New Mexico’s ill-conceived legislation has turned into a debacle, with the pharmacy and medical boards having to haul the chiropractic board into court to comply with the law. And once they got limited privileges, chiropractors lobbied for increasing privileges to the point of wanting to prescribe controlled substances and dangerous drugs without any oversight and the right to practice surgery to boot. If you think this can’t happen in your state, think again. Remember that chiropractors got all 50 state legislatures to grant them the privilege of “detecting” and “correcting” the imaginary “subluxation.”

Posted in: Chiropractic, Legal, Politics and Regulation

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