Friday, January 1, 2010

Questions and Answers about Perscribing rights for ND's in BC

For many decades, BC’s naturopathic physicians have been seeking from government recognition for a scope of practice in keeping with the contemporary and historical practice of NDs. In the 2008 Throne Speech, the BC Liberals made a commitment to proceed with two facets of naturopathic medical care: prescriptive rights and diagnostic facility access. The process leading to this announcement involved many years of negotiation, research, and collaborative assessment. The government’s commitment is based on this lengthy and detailed process; it is a commitment based on sound judgement having reviewed the educational criteria, current and historical practice of NDs, and, most importantly, ensuring the highest levels of patient-centred health care are available to all British Columbians. The BCNA believes that this commitment is the right choice for British Columbians: It reduces the existing burden on MDs while ensuring the provision of safe and effective primary health care in a measured fashion. This document addresses some of the questions that have arisen during the negotiation process.

Why Seek Prescribing Rights Now?
Access to a “schedule of preparations” is an issue that has been in negotiation with government for over 50 years. The naturopathic profession was in fact regulated by the College of Physicians and Surgeons from 1921 until 1936 when the Naturopathic Physicians Act was proclaimed. Prior to 1936 all naturopathic physicians were given the ability to prescribe exactly the same substances as allopathic physicians; however, with the new Act, prescribing ability was left undefined. Since 1936 the naturopathic profession has been waiting patiently for their formulary to be formally approved by government, yet all previous governments have failed to act. Naturopathic physicians have continued to prescribe traditional substances to the benefit of our patients and without harm to the public. We expect this government to be bold and step up to the plate and solve this issue. When the BC Liberals made a Throne Speech commitment in 2008, the BCNA applauded the government’s willingness to take this important and essential step to providing a better health care system for all British Columbians.

Why do Naturopathic Doctors Need Prescription Medications?
Making a prescription is fundamental to the practice of medicine in any and all forms. Another element, however, is that over the decades NDs have lost access to many botanical medicines and natural therapeutics. These “traditional” substances, such as high dose vitamins, some amino acids, hormones, botanicals and herbs, which NDs have used for decades, have slowly become “scheduled”—right here in B.C. But more importantly, NDs are providing primary care without the capacity to practice at the full extent of their skills and expertise. Naturopathic physicians have traditionally acted as primary care practitioners and continue to do so today. As such, it is imperative that NDs be allowed to retain their historical right to prescribe. The existing bias is further exacerbated by allowing other professions schedules without addressing the issue in this profession. And in some cases, as with MDs, core competency, education and training were not required for theuse of the naturopathic pharmacopoeia. One example is that MDs are free to practice all forms of complementary medicine without constraint or oversight.

How Does Prescribing Impact Patients?
At present, the lack of access to some pharmaceuticals puts naturopathic physicians in a position of ambiguity. It leads to confusion both on the part of the practicing ND and the patient, vis-à-vis patient protocols. Worse, it impairs the College of Naturopathic Physicians, the licensing body, from fulfilling its regulatory function. This issue has been outstanding for decades, and has been continually perpetuated by successive governments. As drug laws have changed, and as natural items have become scheduled, the historical naturopathic formulary is now seriously eroded. As this process drags on and governments change the cycle repeats itself. The naturopathic profession is between a rock and a hard place. On one hand NDs are bound by the same legal duties and obligations as MDs. On the other hand, NDs lack, due to government neglect, the supporting legislative mandate that would allow us to fulfill these proscribed legal duties and obligations. This discrepancy carries with it an inherent danger to the public and to the naturopathic profession. A case in point is bronchial pneumonia where the naturopathic physician deems antibiotics are required, yet cannot prescribe them. This inability to prescribe places the patient at risk due to the delay in receiving proper medical treatment.

Do Naturopathic Physicians (NDs) have the Education Required to Prescribe Medicines? NDs already prescribe pharmaceuticals in many jurisdictions across North America. They could not prescribe if their education excluded pharmacology and pharmacognosy training. [Pharmacognosy is the study of medicines derived from natural sources. The American Society of Pharmacognosy defines pharmacognosy as “the study of the physical, chemical, biochemical and biological properties of drugs, drug substances or potential drugs or drug substances of natural origin as well as the search for new drugs from natural sources.’] All licensed naturopathic physicians complete a minimum of three-years university level pre-medical training, then four years at an accredited naturopathic medical college. [There are two in Canada and four in the USA.] Following pre-med, the fouryear ND program covers many of the same science courses as at “conventional” medical school. Drug education is of course a core part of pharmacology training, but also an inherent part of biochemistry, microbiology, physiology, botanical medicine, pathology and other core science courses in the ND curricula. Pharmacology training for NDs is similar to the training MDs receive: It is focussed on the principles of pharmacodynamics, including drug absorption, metabolism, distribution, excretion and mechanism of action. All students must be able to classify and describe the pharmacodynamics, side effects and therapeutic uses of drug prototypes from the myriad conventional drug classes. In addition, the ND must thoroughly understand the pharmacology of all natural substances. Upon graduation from the four-year ND program, each doctor must pass internationally standardized licensing exams. Pharmacology is one specific exam—as well, pharmacology as a subject is covered in many other exams, including the clinical therapeutic courses such as botanical medicine and nutritional medicine, physical, clinical, and lab diagnosis, diagnostic imaging, minor surgery and emergency medicine.

Do Naturopathic Physicians Licenced In Other Jurisdictions Prescribe? Yes. Naturopathic physicians in various US jurisdictions with similar education and training and identical licensing requirements as in BC already use “scheduled” substances in their naturopathic practices on a daily basis. But a more important point is that many “traditional” substances, such as high dose vitamins, some amino acids, hormones, botanicals and herbs, which NDs have used for decades, have slowly become “scheduled”—right here in B.C. Imagine a medical doctor losing the ability to run diagnostic tests or prescribe an antibiotic, or a surgeon unable to use anaesthetics. That’s exactly what’s happened over the years to naturopathic doctors in terms of many traditional medicines. In addition, naturopathic physicians have demonstrated extensive education and training as well as historical and contemporary safe and effective usage of scheduled substances, especially those items which have been moved from over-the-counter status to prescription only. The safety record speaks for itself. Naturopathic medicine, like allopathic medicine, is an evolving art and science and as such requires a formulary and legislation that reflects the changing nature of medicine and healthcare. Further, being granted the right to prescribe represents the trend in most health care professions. Examples include pharmacists, psychologists, nurse practitioners, midwives, optometrists, etc.; some of whom have considerably less clinical education than NDs.

Will There Be Conflict Between MDs and NDs? There is no reason or rationale for conflict. Naturopathic doctors are already using various therapeutics to treat patients, as are MDs. The only change would be that some additional therapeutics will become available to NDs. Dentists, for example, have access to all scheduled substances yet the vast majority of practicing dentists use only a very small number of items: antibiotics, analgesics and local anaesthetics. There is no conflict between dentist and doctor, just as there would be no conflict between MD and ND. It’s important to remember that in BC we have a “shared scopes of practice” model whereby, for example, MDs, NDs, acupuncturists and physiotherapists all have the ability to obtain licensure in acupuncture. Many elements of scope of practice are common amongst two or more health professions. This is just another element of the existing medical model.

What Will Occur if the Government Fails to Act?
Health care for all British Columbians will suffer. The current shortage of primary care practitioners will be further impaired. The unique skills that NDs bring to the health care table—a focus on disease prevention, patient-centred health care, and extensive expertise in the compounding and dispensing of natural therapeutics—will be eroded or lost.

What About Patient Safety? If Naturopathic Physicians Haven’t Dealt With Prescription Drugs in the Past, How are they Eligible for the Added Responsibility?
Naturopathic doctors deal with prescription medicines on a daily basis: With patients already on a drug regime, considering pharmaceuticals and/or an alternative, drug/non-drug interactions, and myriad other interconnected health issues. The substantial change with new regulations won’t be so much an added responsibility, but rather the ability to improve patient care. Currently, hundreds of thousands of BC residents see naturopathic doctors for care, many for primary care, and BC’s licensed NDs attend to over a million patient visits each year.

Won’t it Confuse Patients Already on Prescription Medications?
Given the shared scopes of model already in existence, there should be no confusion. Many patients may see, for example, an ND, physiotherapist, chiropractor, acupuncturist and MD over the course of a year, sometimes simultaneously. Shared scopes of practice is the status quo in BC. Even for a patient seeing both a general practitioner and specialist, they may be under two different “traditional” protocols without confusion or error. But this question also begs a further clarification. There is a difference between prescriptions for chronic and acute conditions. A patient on medication for, say, depression, and seeing an ND, would require immediate attention for an acute condition such as bronchitis. The provision for access to scheduled drugs allows for more effective, timely and appropriate medical care.

Why do Naturopathic Physicians Want This Change in Regulation?
Strictly speaking, naturopathic doctors don’t “want” the change in regulation, they require it—to provide safe, effective, economical preventative health care. The regulation changes are in keeping with a “shared scopes of practice” model being implemented across the province—whereby many health professions have access to prescription items relevant to their respective practice. The change is in keeping with the record of safety and effectiveness of this profession, and ensuring that modalities arbitrarily removed, over time, continue to be used appropriately and in a timely fashion.

Don’t Naturopathic Doctors Only Use “Natural” Medicines?
No and yes. Even to this day many prescription drugs are derived from natural sources—where there is overlap and emphasis in naturopathic medical training. Some “natural” medicines are prescription only (e.g., amino acids, high-dose vitamins). But really this is a question about employing basic medical diagnosis and laboratory analysis. Naturopathic doctors’ primary focus is on treating the underlying nature or cause of disease. Put simply, naturopathic medicine is the “nature” of the “pathos” or disease, not simply “natural” medicines. This focus is about supporting the natural healing processes of the patient, not simply using a product. Thus, naturopathic medicine is about the removal of any impediment to the healing process; the prevention and treatment of physical and mental disease, disorders and conditions; and the promotion of good health using not only natural methods but methods that support and enhance a patient’s overall health. Unfortunately, even those “natural” medicines naturopathic doctors have used for many decades are often, now, by prescription only.

The BCNA believes that the government’s commitment to providing a schedule of preparations for licensed naturopathic physicians is in keeping with a public responsibility to: Ensure shared scopes of practice; improve access to primary health providers; enhancing disease prevention from qualified health professionals; providing greater public choice while not increasing health care costs.