Magician Prescriptions: Ontario Poised to Let Naturopaths Prescribe

The other day, I went to a magic show. The magician manipulated energy fields, pulled toxins out of my stomach, and then gave me a remedy - but there was nothing inside. Then he pulled out a prescription pad, prescribed some Tamiflu, and sent me on my way.

Seem unlikely? Well, the Ontario government is poised to give another type of magician -- the naturopath -- prescribing rights, despite the reams of evidence discrediting their approach to patient health. It's a move that legitimizes a well-meaning but baseless profession, and puts patients at significant risk.

Surely I must be exaggerating, right? After all, naturopaths practice "natural healing", and nature is good, isn't it? Unfortunately for patients, no evidence exists to suggest that naturopaths are capable primary care providers. Naturopathy is a fundamentally flawed idea - and a government blessing only entrenches and magnifies the health risks to Canadians.

Naturopathy's key premise is bogus: The key underlying premise of naturopathy is called vitalism: the idea that humans are possessed with a magical quality that transcends the laws of physics. Sometimes called vis medicatrix naturae (the healing power of nature), vitalism is essentially magical thinking: the belief that some type of "energy field" or "life force" can be harnessed and manipulated by the naturopath. Vitalism was rejected by the medical profession decades ago, about the time it was discovered that bloodletting to balance the body's "humors" was a bad idea. Substantial developments in medical science over the past hundred years have put the idea of vitalism in the dustbin of medical ideas. Naturopathic principles are, at their core, based around this profoundly unscientific and incorrect idea of health.

Naturopathy lacks a credible evidence base: With vitalism at its core, naturopaths accept and use just about every implausible or scientifically discarded therapy that exists. Without any minimum standard upon which to evaluate (and reject) treatments, anything can be "naturopathic". Homeopathy is an elaborate placebo system without any persuasive evidence of efficacy, yet naturopaths have it as a central component of their curriculum. Based on the implausible premise of "like cures like" and "dilution makes it stronger" advocates believe that the light reflecting off Saturn, raccoon fur, or even ultra-dilute table salt can be a homeopathic remedy. Other popular naturopathic treatments include reiki (magical energy healing), acupuncture (another placebo therapy, different invisible energy fields), even hydrotherapy (flushing the colon with water). Given the questionable curriculum, it is unclear how naturopathy can be credibly compared to any science-based health profession. Here's a description of Asian Medicine I, from the Canadian College of Naturopathic Medicine's curriculum:

"Students focus on the fundamentals of Traditional Chinese Medicine including basic history, philosophy, and development. They are introduced to fundamental theories including Yin/Yang, five elements and Zang-Fu. Therapeutic and diagnostic theories introduced include 8 principles, 6 Pathogenic Factors, Qi, Blood, Body Fluids and 7 emotions. There is discussion on acupuncture channels, pulse and tongue diagnosis as well as other therapies applicable for use in Traditional Chinese Medicine."

Not surprisingly, Canada's only naturopathy school is not affiliated with any university, medical school or publicly-funded hospital. Unlike health professionals, naturopaths do not do undergraduate and postgraduate training in teaching hospitals.

Faulty Science, Bad Health Care: A combination of a flawed premise and a credulous approach to evidence leads naturopaths to advocate all types of bizarre treatments for real medical conditions: cleansing diets for eczema, ginseng to treat cancer, and even homeopathy for diabetes. Naturopaths antagonize established public health goals, with their frequent opposition to vaccinations. Recent articles by naturopaths, advocating probiotics, herbal extracts or even homeopathy, instead of the H1N1 vaccine, underscore this concern. Vitamin supplementation for virtually every medical condition is common. If a treatment has been rejected as unscientific, or proven to be ineffective, there seems to be naturopath that recommends it.

Patient Risk: If naturopaths want to prescribe placebo treatments like homeopathy, and wave their arms over someone to manipulate their invisible energy fields, the biggest risk to consumers is likely limited to their wallets. But when patients avoid legitimate, evidence-based care from health professionals, or receive prescriptions based on pseudoscientific ideas about a disease, there is a real risk of harm. Prescription drugs have real effects and real side effects. There's no evidence that naturopaths have an evidence base equivalent to health professionals like physician and pharmacists. A review of the initial list of drugs that Ontario naturopaths want to prescribe is telling. Bioidentical hormones are on the list, with celebrity advocates like Oprah and Suzanne Somers, but unequivocal criticism from medical experts. Animal "glandular extracts" follow (dried thymus, spleen, and liver, anyone?), used to treat "adrenal fatigue", a condition that seems to exist only in patients that see naturopaths. Antibiotics, antifungals, and antivirals are on the list, despite any evidence that naturopaths can accurately diagnose and treat conditions that require these therapies.

Other jurisdictions have experimented with giving naturopaths prescribing rights. Despite the claims made about the safety of naturopathy, deaths and serious injuries have been documented as a consequence of prescribing privileges. Canadian heath professionals have raised pointed and specific concerns about naturopathy. A coalition of seven Canadian allergy organizations wrote to the British Columbia Minister of Health, George Abbott, protesting the British Columbia plan to allow naturopaths to perform allergy testing and treatment. See their letter here. (PDF) They point out that naturopaths do not define allergies in evidence-based ways, nor do they use scientifically-validated methods of testing allergies. They emphasize that naturopaths do not support immunizations.

Naturopath prescribing is also raising questions about the liability of of other health professionals who interact with their clients. 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?

Wasted Health Expenses: Despite what naturopaths purport, there is no persuasive evidence that they're capable of delivering the screening, prevention and treatment required of legitimate primary care providers. Given the lack of insight that naturopaths display into the basis and treatment of disease, and judging by their embrace of profoundly unscientific treatments, there is little reason to expect patients will receive prescription drugs based on scientific principles. In light of this, why are governments allowing naturopaths to prescribe? Ontario is now poised to become the second province to extend prescribing privileges to naturopaths.

When the Health Professions Regulatory Advisory Council (HPRAC) recommended that the Ontario government legislate a significant expansion of practice for naturopaths, health professionals were understandably concerned, and pressed for changes. In what appeared to be a decision in favour of evidence-based health care, the initial version of Bill 179 expressly omitted any expansion of scope for naturopathy.

It was clear the naturopaths were not going to let this pass without challenge, with British Columbia recently giving naturopaths prescribing rights. In June, Ontario naturopaths launched a write-in campaign to government that described naturopaths as primary care providers, comparable to family physicians, and worthy of the right to prescribe.

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.

Conclusion

This year, the Ontario Government projects it will run $24.7 billion budget deficit. Significant changes are expected throughout the health system. In light of this, why is it proceeding with changes that will reduce quality, increase risk, and waste health resources? Naturopath prescribing lacks a sound evidence base, addresses no clear medical need, and has the potential to increase patient harm and health care costs.


Full disclosure: The author is an Ontario pharmacist

Updated (12/02/09): Bill 179 has now passed  - edited for time sensitive content