A Prescription for Professional Disaster

The expansion of the scope of practice of chiropractors to prescribe drugs is an absolute non-starter for me. In recent weeks, this conversation has moved to center stage, as evidenced by activities in the states of New Mexico, South Carolina and Alabama, as well as at the biennial gathering of the World Federation of Chiropractic (WFC). Legislation proposed to expand the authority of chiropractors in New Mexico to prescribe broadly failed; the South Carolina measure appears to be mired in committee; and the Alabama State Chiropractic Association voted down a proposal to seek such an expansion. The WFC, while presenting a forum on this issue, has not changed its policy that the practice of chiropractic is without drugs and surgery.

The battle lines are rather well-drawn and clear. One element within the profession seeks to alter the history, tradition, conceptualization, culture, laws and regulations under which we have existed throughout our entire existence to include prescription authority of various extents. This view is being opposed by members of the profession who object and perceive the very heart of our clinical approach being hijacked and transformed into the practice of medicine.

"Conflicts Clarify!"

A recent legislative hearing in New Mexico did just that: it clarified the intent and extent of the drug lobby in chiropractic. In the past, whenever the question of prescription authority in chiropractic came up, it was always related to injected vitamins and nutritional support, as opposed to the common understanding of prescription medications associated with the practice of medicine.

In Santa Fe, N.M. on March 17, 2011, the veil was pulled back on that charade as representatives of the National University of Health Sciences and University of Western States joined members of the executive committee of the New Mexico Board of Chiropractic Examiners in seeking legislation that would allow the use of "primary care drugs." Further, these representatives indicated that they were part of the solution for New Mexico's primary care shortage with their willingness and self-perceived ability to treat patients with hypertension and diabetes, among other maladies. It is now clear and on the record that this is not about nutrition in any shape or form; this is about the practice of primary care medicine under the auspices of a chiropractic license.

During the recent meetings of the assembly of the WFC, held in Rio de Janeiro, our European colleagues repeatedly referenced Switzerland as an area of the world with prescription drug authority extended to chiropractors. In the process, it became clear that the "prescription" authority given to a chiropractor in Switzerland is the ability to tell a patient to take anything; the patient can walk into a pharmacy and buy without a recommendation of any prescriber. If the chiropractor suggests it, the federal health insurance will pay for it. The chiropractor has no authority for recommending drug use beyond that which every Swiss citizen possesses on their own!

This dialogue is laden with overlapping, confusing and variable meaning terms that must all be clarified for any rationale conversation. For example, what is a drug – a regulated/controlled product to address a specific health care circumstance. Some will point to the inclusion of high-dose vitamin therapy as potentially being removed from the practice of chiropractors if these products were defined as drugs, and therefore restrictions will exist if provisions aren't made for the prescription of "drugs." Further, the question of what a prescription embraces must be considered.

In the United Kingdom, the recommendation for a patient to obtain a lumbar support or a rib belt requires a "prescription." In the U.K., the British Chiropractic Association (BCA) polled its members on their thoughts about "prescription" authority for chiropractors. As the concept of what required a prescription was far broader than prescription medications and included products routinely associated with chiropractic practice, the survey question received considerable support. It must be noted that they never sought to address the specific question of prescription medications and never sought to involve members of the other three associations in the U.K. that collectively rival the size of the BCA.

For this conversation to be meaningful, regardless of which side of the question you support, the terms of reference must be understood. Additionally, the strengths and weaknesses of literature and survey data brought in support of this position must be appreciated.

Primary Care Provider

Consider the term primary care provider. Every chiropractic program in North America indicates that it educates and trains its students to be "primary care providers." This is a correct statement. It is informative to understand that if an institution does not assert this view it will not be accredited in the United States. Period. Therefore, to point to all of the chiropractic programs supporting the chiropractor as a "primary care provider" is a gun-to-the-head position. It may in fact be the view of all of the colleges, but it remains a fettered assertion. Primary care provider in the chiropractic context is not a primary care provider in the medical context. They differ in scope, education, clinical training and authority.

The very definition of primary care provider is open to wide interpretation and variance. These interpretations are not limited to the chiropractic profession, as profound differences are also found in medicine, nursing, etc. There is no agreed-upon definition of "primary care provider." Some definitions are procedure- and task-specific; others are more conceptual and related to broad duties. To use the term in a fashion that conveys universal agreement as to what the term means is dishonest.

The 2007 version of the CCE Standards does not define primary care provider; rather, a "primary care chiropractic physician" is defined as follows: Primary care chiropractic physician = An individual who serves as a point for direct access to health care delivery, the doctor of chiropractic's responsibilities include: (1) patient's history; (2) completion and/or interpretation of physical examination and specialized diagnostic procedures; (3) assessment of the patient's general health status and resulting diagnosis; (4) provision of chiropractic care and/or consultation with continuity in the co-management, or referral to other health care providers; and (5) development of sustained health care partnership with patients.

The only aspect of this definition that makes it unique to chiropractic is the phrase "provision of chiropractic care." This vague definition is further made troublesome because the Standards make repeated reference to "primary care physician" or to the "primary care setting," as opposed to the term defined.

Our colleagues, as evidenced in New Mexico, play "fast and loose" with this issue of "primary care provider," repeatedly and consistently linking the fact that every chiropractic college asserts to train "primary care providers," and further suggesting by inference and implication that primary care in the chiropractic context is the same as primary care in the medical context. This is simply not the case, and an error of omission or perhaps even commission to assert the same.

Taking Privileges With Prescriptions and Patient-Centered Care

Other arguments asserting "best practices" require us to have access to prescription authority are also being put forward. The reasoning goes as follows: The Neck Pain Task Force identified a series of interventions supported in the literature for the care of axial neck pain. Among these procedures were spinal adjusting (spinal manipulation, to be true to their language), certain exercises, nonsteroidal anti-inflammatory agents (NSAIDs), acupuncture, etc. In light of these findings, it is now being asserted that chiropractors need prescription authority for NSAIDs.

Little thought appears to have been given that this reasoning would call for every physician utilizing "best practices" relative to neck pain to be trained in spinal adjusting (manipulation). The reality is that NSAIDs were identified as an approach with adequate evidence to support it. Period. It was never asserted that NSAIDs required manipulation to be effective or that manipulation required NSAIDs to be effective, or that the use of the two together was superior to either alone. The use of the "best practices" argument in this area is disingenuous.

The "patient-centered care" argument is being used to advance the drug issue onward. This argument holds that we should be offering patient-centered care. Agreed! But the argument further suggests that this means if a patient comes to a chiropractor and wants prescription drugs for their problem, the chiropractor must provide the same to be consistent with the spirit and intent of the policy of patient-centered care!

The "if we can put them on drugs, then we can take them off of drugs someone else has prescribed" argument is next. From an interprofessional perspective, this  is "living in a powder keg and giving off sparks." The common-sense side of the consideration is that the drugs chiropractic patients would be given by other providers for pain, muscle spasm etc., are all patient required need (PRN) drugs that patients invariably remove themselves from without any professional advice or counsel.

The drug issue is being argued to be the panacea for the future of the chiropractic profession. It is asserted that interprofessional differences will lessen, interprofessional respect will increase, patients will flock to chiropractors and economic strength will follow the adoption of this practice. Those would all be nice things, but to assert that they will flow from such a central change in the paradigm of the profession causes me to ask, "What kind of drugs are you on?"