|Prescription of drugs in chiropractic is the subject of much debate within the profession, each side making a case for patient benefits.
Others, however, believe this debate has been a long time coming.
“If the patient can benefit from something and you say, ‘No,’ because of your belief, you’re doing a disservice to your patient,” says Dr. Rod Lacy, president of First Chiropractic Physician Association of America (FCPAA). Dr. Lacy is a chiropractor, but he is also a medical doctor, licensed to practise in the Dominican Republic.
The FCPAA, which according to Dr. Lacy has about 2,500 members to date, is calling for an expanded scope of practice for chiropractors to include drug prescription rights. The group will begin to actively lobby U.S. state legislatures for prescriptive rights beginning next year, Dr. Lacy says.
By the looks of it, however, the FCPAA may have an uphill battle ahead, as rival (and older) association, the International Chiropractors Association (ICA), is bent on keeping prescription pads out of the hands of chiropractors.
In New Mexico, the ICA has successfully filed a suit against the Board of Chiropractic Examiners to oppose its regulation granting authority to chiropractors to do injections on their patients. That dispute ended with the New Mexico appeals court ruling on the side of the ICA.
“One of the central tenets of the appeals court’s reasoning was that anything injected, by federal law, automatically falls under the category of a dangerous drug and the doctors of chiropractic are not allowed by law to prescribe dangerous drugs,” explains Dr. Michael McLean, president of the ICA.
Dr. McLean argues drug prescription is not, and should not be, part of chiropractic practice, maintaining that the profession is a “drugless healing art” and should remain that way.
“We already have a profession that prescribes drugs and performs spinal manipulation and that profession is called osteopathy,” Dr. McLean says. “If we are going to be a profession that prescribes drugs and does spinal manipulation, then what is the need for (chiropractors) if we’re only duplicating osteopathy.”
The ICA, on behalf of its members, has been actively working to maintain the status quo for chiropractors in the U.S. with regards to prescription rights. New Mexico was a recent victory for the group.
In other states, where the issue seems to be gaining momentum, the ICA also is making its position known.
“Our members have requested that we be active in these other states,” says Dr. McLean. “This movement is one that is relatively recent and the ICA is determined that we will stand up for drugless chiropractic and we’re not going to back down. We are not going to compromise.”
The ICA has more than 8,000 members internationally, according to Dr. McLean.
If the World Federation of Chiropractic (WFC) policy statement is any indication, the ICA does not stand alone on this issue. Under its policy statement, the WFC maintains the “practice of chiropractic does not include the use of prescription drugs, and chiropractic patients who may benefit from prescription drugs should be referred, where appropriate, to a medical doctor or other suitably qualified health care
In an e-mail response to Canadian Chiropractor, WCF confirms the WFC policy on the use of prescription drugs “still stands and that the WFC has no desire to change it.”
Those advocating for expanded rights for chiropractors, however, acknowledge that current education programs for chiropractors are not sufficient to provide would-be chiropractors the necessary training for drug prescription. If the FCPAA succeeds in getting legislative teeth for prescriptive rights, chiropractors should not expect to be able to prescribe right away. A level of certification needs to be achieved first.
“Training is inadequate right now,” explains Dr. Lacy. “Chiropractors do have adequate training as far as anatomy, physiology, diagnostics, x-ray, and most schools do teach pharmacology. But they definitely do need hands-on clinical experience.”
Dr. James Lehman, a chiropractor and director of the University of Bridgeport Health Sciences Postgraduate Education Department in Bridgeport, Conn., believes if chiropractors want to be neuromusculoskeletal specialists, they need to understand the medications that people take.
Furthermore, Dr. Lehman says if chiropractors truly want to be recognized as primary care providers, they need expanded scope of practice and prescriptive authority.
“I think it’s essential because... in the United States we do not have enough primary care providers; chiropractors with advanced clinical training could certainly serve in that area,” Dr. Lehman says.
The University of Bridgeport recently introduced a new program designed for practising chiropractors to become specialists in neuromusculoskeletal medicine. It’s a three-year program that includes 100 hours of on-site training, 400 hours of distance learning and 500 hours of experiential learning. Thirty hours of this three-year, 1,000-hour program is on pharmacology, which teaches students to understand the effects of medication.
Dr. Lehman stresses, however, that the objective of the program is to allow chiropractors to pursue neuromusculoskeletal specialty – not teach drug prescription.
“What we’re really trying to do is prepare the chiropractor to become the neuromusculoskeletal specialist for primary care providers,” he explains. He says the 30 hours on pharmacology the program offers would serve only as introductory to the more extensive training a chiropractor would need to learn drug prescription, if ever they do get expanded scope of practice through legislation.
Meanwhile, in Canada
Much of the movement around the issue of drug prescription in chiropractic has been in the U.S., but that does not mean Canadian chiropractors don’t have their own opinions on the matter.
Canadian practitioners seem as divided on this issue as their American counterparts. However, those this writer spoke to seem to agree on one thing: additional training is needed for chiropractors to be able to prescribe medication.
Toronto-based chiropractor Dr. Martin Gurvey, who has been practising chiropractic for the last 31 years, says he would not be advocating for prescriptive rights but those who want this expanded scope of practice should pursue post-graduate specialty that would educate them on pharmacology and enhance their knowledge and training on prescription medication.
“Rather than giving chiropractors widespread abilities to prescribe, the profession may want to consider another post-graduate stream, a specialty for chiropractors to become some kind of spinal care specialist who, in that case, may have the ability and the proper training of using medication according to their training,” says Dr. Gurvey, who also teaches at Canadian Memorial Chiropractic College and is a nutrition and wellness consultant at Yorkdale Wellness Clinic in Toronto.
Dr. Gord McMorland, owner and director at National Spine Care in Calgary, shares Dr. Gurvey’s views that current education for chiropractors does not allow them to have the necessary knowledge and training to prescribe medication.
However, Dr. McMorland takes a different position when it comes to granting chiropractors prescriptive rights.
“If you look at the literature for managing back pain, the current guidelines include or recommend limited use of meds,” Dr. McMorland says. “So, if the literature supports that treatment modality, why wouldn’t a chiropractor want the opportunity to learn a new intervention to help their patient?”
While some proponents of prescriptive rights cite increased business viability for chiropractors in a highly competitive market, many chiropractors who support expanded scope of practice, like Dr. McMorland, say economics should not be the main driver for chiropractors to seek prescriptive rights.
While he understands that aspect of the argument, he says improved and more efficient patient care should be the top priority. Without prescriptive rights, chiropractic patients who may need prescription medication – for pain, for example – would have to go back to their family doctor to get their prescription. Giving chiropractors prescriptive rights will eliminate that extra trip to the family doctor and allow for better patient care.
In some cases, chiropractors have been able to alleviate that by joining a multidisciplinary health practice, where they work closely with a medical doctor under one roof, which offers more convenience for the patient. This is not the case for many chiropractors, however, says Dr. Ken Mueller, chiropractic clinic director at Queen Spadina Medical Centre in Toronto.
“I work alongside family doctors so it’s not the most inconvenient thing in the world for me to send (the patients) back downstairs to the medical clinic, but we don’t all have that privilege,” Dr. Mueller says.
He says as a chiropractor, he understands that chiropractic had traditionally been a non-drug, non-surgical health-care option, but adding the capability to endorse medication when needed does not “decrease our market position.”
Dr. Mueller points out, however, that chiropractors should not be forced to prescribe if they do not want to.
“Having the right to do (prescription) would be good, but I don’t think anyone should be forced to do additional certification,” he says.
It is unclear where the Canadian and provincial chiropractic associations stand on the issue. Requests for comments from the Canadian Chiropractic Association and the Alberta College and Association of Chiropractors were declined.
In an e-mail response to an interview request, the Ontario Chiropractic Association’s (OCA) Miguel Pacheco, manager of external communications, says there currently is “no consensus around this topic (of drug prescription rights) from our membership or in chiropractic generally.”
However, according to Pacheco, OCA’s 2008 and 2011 membership survey asked members about their view on chiropractors prescribing anti-inflammatory medications or analgesics. In 2008, 55.5 per cent said they were in favour, 8.9 per cent were neutral and 35. 7 per cent were not in favour. In 2011, the number of those in favour of chiropractors prescribing anti-inflammatory medications or analgesics increased to 61 per cent, while those who were not in favour went down to 27 per cent. Some 13 per cent took a neutral position.