Terra Sigillata

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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 has come out in force and appears to be relatively unopposed in the 54 comments that follow, primarily because the NP closes comments 24 hours after online posting. Therefore, those with a more rational and considered viewpoint based in facts have been 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, ad hominem attacks, especially Godwin’s Law, are quite common when one’s stance is 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 before 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 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. 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.

If and when the National Post reopens the comment thread, please feel free to register your feelings on this issue below.

Update 27 Nov 2009: In the meantime, a rebuttal from two naturopaths has appeared at the National Post. 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.

Comments

  1. #1 Kim Moir
    November 26, 2009

    Good article. For Ontario residents, I think it would be more appropriate to send your comments to our health minister the Premier regarding your opposition to this legislation. They might not be reading the the National Post’s comment board :-)

    Premier
    http://www.premier.gov.on.ca/feedback/default.asp?Lang=EN

    Ministers
    http://www.premier.gov.on.ca/team/default.asp?Lang=EN

  2. #2 meryl333@comcast.net
    November 26, 2009

    While some of the points you make may make some sense, it is clouded by your biased view of naturopathy. Qualifications and curriculum for becoming a naturopath is similar to that of becoming a doctor. One difference is the lack of deep influence by the for-profit pharmaceutical influence that has been producing a selective evidence based cures for all manner of diseases. There is value in conventional medicine to be sure. There is also tremendous value in the naturopathic approach. You sound foolish to dismiss it outright.

  3. #3 Ian Musgrave
    November 26, 2009

    Three words: “drug-drug-interactions”

    Giving naturopaths access top prescribing WITHOUT a basic training in pharmacology will lead to clueless people prescribing drugs along with herbal products that will have hazardous or lethal interactions.

  4. #4 Katherine Cheah
    November 26, 2009

    Ian Musgrave: Perhaps you should have considered the fact that licensed naturopaths _are_ actually given a more-than-basic training in pharmacology before making that statement…

  5. #5 Ian Musgrave
    November 27, 2009

    Katherine wrote:

    Perhaps you should have considered the fact that licensed naturopaths _are_ actually given a more-than-basic training in pharmacology before making that statement…

    But nowhere near enough to be a prescriber (I’ve taught pharmacology to would be naturopaths).

  6. #6 Anonymous for this one
    November 27, 2009

    “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.”

    It is possible that the American health care system as it stands is such a clusterfuck of poor communication, pathetic excuses for CME training, overworked staff making honest mistakes, not enough time spent per patient to review medical records and gather sufficient history, shady/lazy docs giving out painkillers and SSRIs for everyfuckingthing, that pharmaceutical companies figure it could hardly be worse.

    A large part of getting a new drug to market is spent attempting to teach MDs how to use it. Through much hard & expensive experience, the lesson we’ve learned is, “Make it so simple a toddler could administer it without screwing up.” This past year especially, thanks to Diana Levine, that aspect of drug discovery and development has been strongly emphasized to us lab geeks by our corporate overlords.

  7. #7 Orac
    November 27, 2009

    While some of the points you make may make some sense, it is clouded by your biased view of naturopathy. Qualifications and curriculum for becoming a naturopath is similar to that of becoming a doctor.

    No, they aren’t. That’s just not true, particularly if you count the many years of postgraduate training after medical school required to be able to practice as a physician. Worse, whatever science is taught in naturopath school is tainted with a world view based on magical thinking.

  8. #8 Scott
    November 27, 2009

    First, I would like to point out that licensed Naturopathic Doctors complete a minimum of 7 years of post secondary studies. I agree that there is a requirement for further educating Naturopathic Doctors if prescribing rights are passed and so do the boards that govern them. If prescribing rights are passed it’s not as though Naturopathic Doctors will be given free rein. Nobody wants that, not even Naturopaths. Think about it. Why would someone spend so much time learning about natural medicine just to turn around and give someone a statin? Prescription rights only ensure that as more natural health products are moved to Schedule I, as some should be, that those trained to use them have access.

  9. #9 daijiyobu
    November 27, 2009

    Regarding naturopathy’s claims of ‘science-basis’, their schools’ consortia, the AANMC, says that naturopathy is ASSUREDLY science-based. AANMC has communicated this to me personally this month:

    (see http://naturocrit.blogspot.com/2009/11/facebook-fun-with-aanmcs-we-are-science.html ).

    AANP, the mother organization of AANMC, also claimed this in 1997:

    (see http://www.scribd.com/doc/2203649/AANPAlliance-Science-Based-Not-Belief-Claim ).

    Don’t believe them, in terms of education standards and labels.

    You’ll just end up hugely in debt, hugely dyseducated, and obligated to bogus premises and labels.

    -r.c.

  10. #10 tonie
    April 18, 2010

    Get over it.Spend more time on working as a team with Naturopathic Doctors for the patients benefit. You are not even sounding frustrated.You sound threatened.You know that Naturopathic Doctors can take all your patients away from you because they do a very good job.

  11. #11 Joe
    April 19, 2010

    @tonie,

    http://www.naturowatch.org

    NDs are worse than ignorant, they are malinformed. They are only good for holding the hands of the worried well; but they go beyond that with bad advice. Get over yourself.

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