DC received numerous letters to the editor following the publication of "Nonprescription Drugs: Should We or Shouldn't We?" in the Nov. 17, 2003 issue. The following is a representative sample of the responses we received regarding the ability of doctors of chiropractic in the United States to "prescribe" over-the-counter (OTC) medications. In some cases, responses have been excerpted substantially to accommodate space limitations. While this issue remains on the table, the profession should consider what is really at issue: Do patients need alternative pain solutions, or are OTC medications so widely accepted that they are the only course of pain management today's patients will accept?
It is my opinion that chiropractic has been stuck in the "Palmerian" times for too long. In order for anything to survive, it must change so it can grow. Sometimes, changes are subtle, as in adding a new modality; sometimes, they are more radical, as in including prescription rights. The scope of practice needs to be expanded to allow chiropractic to gain more strength and popularity. ... Increasing political power, leveling the health care playing field, increasing in public acceptance and awareness, increasing revenues, and putting chiropractic before medicine are just some of the arguments to be made for expanding the scope of chiropractic to include prescription rights.
David Schwartz, DC
Plantation, Florida
... The bottom line is that there is more than enough medication circulating throughout our society. In reality, there is probably
too much. There is no proof that medication (prescription or OTC) is decreasing the prevalence of morbidity and mortality in this country, yet a high percentage of doctors utilize drugs as the first step in treating most ailments, so much in fact that many people cannot even imagine maintaining "health" without them. As doctors of chiropractic, we know that there are other, better methods to address a majority of ailments, ones that actually correct the cause and not merely mask symptoms. We have been caring for people for more than a century without using medications. We can appropriately care for people for another century if we can just stay drug free. If we take on the task of prescribing OTC medications as one of our standards of care, then we will become just another pill pushing profession, adding nothing to the health of our communities, the world, or humanity as a whole.
Author unknown
My simple answer to the question posed by Mr. Petersen in his Nov. 17, 2003 editorial is, "Yes, we should!" We chiropractic physicians are fast moving ourselves in the direction of becoming recognized as the most important primary contact practitioners in the care of neuromusculoskeletal disorders. Some medications play a small but frequently important role in the management of patients with these conditions. And many of these medications can be obtained over the counter. Doesn't it seem silly that a patient's grandmother can advise him or her to take, say, Ibuprofen, but the chiropractic physician who is managing the patient's condition cannot?
Donald R. Murphy, DC, DACAN
Providence, Rhode Island
I could play devil's advocate and rationalize sound support for recommending over-the-counter medications or not recommending them. This issue gets more complicated when you start defining what OTC medications are. Is aspirin bad, but willow bark good? Is Naprosen bad, but bromelain good? What about vitamins, glucosamine sulfate, green tea and other herbs - are they ok? ... What is important for us to realize is that there are very different opinions on what chiropractic is or should be. Whether the issue is prescription or over-the-counter drugs, herbs or supplements, physical therapy or adjusting the atlas, Diversified or Gonstead, innate or diagnosis, etc., does not matter; there are very strong irreconcilable opinions that have been tearing our profession apart, much to the delight of our competitors. ... Whether or not we should recommend over-the-counter medication to our patients is up to the individual doctor of chiropractic and the laws of the state or country in which he or she practices.
Robert Jusino, DC, MPH
River Forest, Illinois
People turn to us to correct the health problems caused by their neglect, their drugs and their surgeries. Too many chiropractors were simply not taught the amazing potential of holistic, drugless healing. We offer the benefits of functional restoration of spinal biomechanics and neurologic integration, which affects every organ and system, and enhances the human condition thereby. What we don't offer are drugs!
Christopher Lyden, DC
Voorhees, New Jersey
... The time is long past due, in my opinion, to split the profession. This drug issue is merely one of many that divide us deeply. It is ridiculous to try and unite a profession that has the kind of fundamental differences we have. It would be like uniting Democrats and Republicans. While both are politicians, no one calls for unifying the two parties. Why continue the ludicrous position that chiropractors can be united? We should work to create two or three different types of chiropractors, with somewhat different education and separate licenses. ...
My proposal would be to split our profession on objective, not on procedure. One objective is to diagnose and treat symptoms, conditions and diseases. This group can call itself "chiropractic medicine" or "chiropractic physicians." While those with this objective have some differences, all in this category want to diagnose and treat a variety of ailments. ... The other objective is to locate and correct vertebral subluxations, in order to remove nerve interference and improve the expression of innate intelligence. Those pursuing this objective wish solely to correct vertebral subluxations, because they in and of themselves are bad, not as a way to treat ailments or as a substitute for medicine. Also they want to remain unique and nonduplicative in their service. This group would just be called "chiropractors." ...
Jason Meyerson, DC
Baltimore, Maryland
I believe that most medications cause problems most of the time; I prefer nutritionals. They work with the body, rather than against or for the body. I also think that the lure of being able to prescribe medications could cause some chiropractors to stop practicing the way they were trained to do: conservatively. ... I believe that over-the-counter medications, basic antibacterials, nystatin (antifungal), guaifenesin (cough medications), in addition to other medications that have been proven safe and effective, and with few adverse reactions, may be helpful in a conservative practice. This needs to have advanced training that is not available to the students. That way, they are forced to practice conservatively at first. I also think the training needs to be done only through chiropractic colleges, with none of the instructors receiving or having received salary or financial incentives (gifts) from drug companies, and also that the seminar/program not be sponsored by drug companies.
Michael D. Berglund, DC
Kenosha, Wisconsin
I work in Oregon, where we have the right to prescribe OTC medications. In the last two years of practice, I have prescribed OTC medications once. It helped my 78-year-old patient immensely. Whether the Motrin was helpful physically or psychologically for her, I do not know. It was appropriate for this one patient out of 178 I had at the time. ... I am happy that I may prescribe OTC if I feel it necessary. This is not likely to happen often. However, it has been necessary once so far, and will likely be necessary again in the future. I find that manual medicine and homeopathics work very well, as does food. Medication is reserved for emergency measures. These occasions are rare, since I deal with chronic conditions, rather than emergency medicine. ...
I like the ability to prescribe OTC because it is a backup in my "tool box" for caring for patients' conditions. Rare use still happens. I feel it is better to be prepared than to be lacking in options.
Seth Goldstein, DC
Portland, Oregon
Here is my opinion of why recent surveys reflect that a majority of chiropractors want drug dispensing/prescription rights. It's my belief that these recent surveys are a result of two factors: the increasing economic stresses on the doctor of chiropractic, and the relentless movement of the colleges toward a medical paradigm of chiropractic practice that is a "diagnosing and treating" approach. ... The problem with chiropractors wishing to dispense/prescribe drugs is that it would place us squarely in competition with the medical and osteopathic professions. As it is, we are unique, nonduplicating and distinct from these allopathic professions. Our unique philosophy and approach to health care is so effective and compelling, other professions are attempting to steal it from us.
Be very careful, doctors of chiropractic: Abandoning our unique, drug-free approach to health and wellness, on the eve of our full acceptance by the culture, would be tragic and frankly, really stupid.
Thomas M. Klapp, DC
Ann Arbor, Michigan
The drugs available during the practices operated by your grandfather and father were few in number and as crude as chiropractic practices themselves. Times have changed. Yes, drugs run the gamut from ineffective, to appropriate to dangerous, as do the methods and suppositions of my colleagues. OTC drugs, by definition, do not require prescription. I recommend them freely, as necessary. Many DCs, I assume, do not recommend them due to fear of malpractice suits; prolongation of physical conditions, for the sake of prolonged treatment; or a blind belief in monocausal/monotherapy philosophy of yore. Further, your publication is rife with advertisements for OTC products (Biofreeze, herbs, vitamins, etc., as well as procedures and equipment, e.g., laser spine surgery and black cohosh for treatment of breast cancer). Moreover, I am comfortable in indicating that it is likely that a good many of my colleagues seek out and are prescribed both OTC and RX drugs for personal physical/mental complaints and conditions.
Harry R. Mellas, DC, DABCO
Fort Collins, Colorado
I believe that it is a noble and wonderful thing that we are trained in and given such a gift as is chiropractic. To be able, with little exception, to perform literally "miracles" with not much more than our hands, is quite remarkable. Take away my X-ray machine, take away my neurocalometer, take away my pinwheels, otoscopes, stethoscopes and MRIs, but don't take away my hands and the knowledge of what chiropractic is. The knowledge of what chiropractic
is makes me
who I am! Therefore, knowing that means that all the tests, gadgets, high-tech wonders and yes, limited prescription rights, will not shake what I know I am and what I know I can do for my patients.
The facts are that if we know who we are, the introduction of the use of OTCs or even some limited prescriptive authority (LPA) for lower-level controlled substances, will not change our ultimate objective - the delivery of chiropractic. This issue does not even begin to discuss the financial and time inefficiency. ... How much did it cost the health system to lose that patient to a system of care that has time and time again shown to be less efficient and overall more costly? Besides, who better to utilize OTCs or LPA than a properly trained chiropractic doctor whose ultimate aim is the delivery of chiropractic and who does not use pharmaceuticals as a stand-alone therapy? Individually, if any chiropractic doctor opts not to use OTCs, fine. I say the same thing for therapeutic modalities. But to those of us who do wish to expand our clinical management, there is no reason why chiropractic doctors, who so chose, cannot perform at an exemplary level. At least until a more perfect world comes along.
Steven R. Mooring, DC
Pueblo, Colorado
I cannot in words overemphasize the importance of chiropractors' broadening their scope of practice. In my opinion, it is the only way the profession will grow. ... Why should we as doctors be limited to just manipulation? ... Clinically, I have found heart murmurs, diagnosed pneumonia, reviewed X-ray findings and found an abdominal aneurysm. Yet in my state, I cannot even draw blood to run a CBC? ... Medical doctors are not interested in nutritional or homeopathic injectables. Physical therapists cannot perform injections; neither can naturopaths in most states. Where can the public receive these types of beneficial treatments? ... Our profession should strongly pursue limited prescriptive drugs, along with injectable forms of vitamins and homeopathic applications.
Mark Clemente, DC
Washington, Pennsylvania
I am against prescriptive rights for OTC drugs for chiropractic doctors. ... The following are [some of my] reasons: 1) People seek chiropractors because they do not want medication. It is our identity. 2) Commonly, patients have already taken over-the-counter drugs first; the drugs did not help, so they make an appointment with a doctor of chiropractic. 3) I have good relationships with local medical doctors in my community. When I feel that the patient will benefit from medication, I will refer them to an MD I know or the patient's family doctor. This opens the door for cross-referrals. 4) Chiropractic side-effects are less than for OTC medications. Why have our malpractice insurance rates go up? 5) It will potentially water down the adjusting skills of chiropractors, similar to osteopaths.
James Santiago, DC, LAc, MA, DABCSP
Newark, New Jersey
I practiced for 17 years before becoming president of National University, and I always believed that chiropractic physicians should practice
as conservatively as the clinical circumstances dictated within the scope of licensure. At the same time, I recognize the value of prescription drugs when they are clinically indicated and at times, the same thing can be said about OTCs.
Perhaps a decade ago, Dr. William Dallas, then president of Western States Chiropractic College, made a very cogent argument for the use of prescription rights by chiropractic physicians who were properly trained. He noted, rightly so, that part of what is necessary in the treatment of human beings is the authority to recommend removal of drugs from a patient's treatment regimen when the clinical signs indicated this need. Unfortunately, when a physician does not have the right to prescribe, he or she also does not have the clinical authority to remove drugs from a patient's regimen.
The same argument holds true for OTCs. Too often we find patients who take some OTC "just because." As uneducated members of the public they have a perfect right to do that even if it is detrimental to their health, but if they ask their chiropractic physician whether or not it is a good idea, the DC has to "talk around the edges" of the question by saying something like "if I were you, I would not take that particular medication." To do anything else is to be in the business of prescribing, and if the statutes do not allow this activity, then the DC is in violation of the law, while the uneducated public member continues his or her detrimental activity.
I think the real answer here is to tier the profession - a not-so-difficult proposition if we put our minds to it. Let those who have the education about pharmaceuticals, beginning with the OTCs, use them. This has been part of the practice rights in Florida for years now. Those could be the chiropractic physicians (which they are in Florida). Let those who do not have the education and do not wish to have it be the chiropractors who do not use pharmaceuticals.
James Winterstein
Lombard, Illinois
