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In 2019, via the magic of Legislative Alchemy, chiropractors across the nation continued their push for practice expansion as well as their campaign to promote “chiropractic care” (whatever that means) as an alternative to opioids in the treatment of pain, to the point of legal mandates requiring physicians to endorse them.

This legislation should be viewed in the larger context of the ultimate, and partially achieved, goal to rebrand chiropractors as “primary care physicians” capable of treating, in the words of the American Chiropractic Association (ACA), “anything a medical doctor can”. The authority to prescribe drugs is a key element of the ACA’s plan. Remember, too, that chiropractors want you to pick up the tab for all of this, in the form of insurance premiums and tax dollars paid to private and publicly-funded insurers required by law to cover anything within the chiropractors’ state scope of practice.

Prescribing

In Florida, chiropractic “physicians” (as they are allowed to call themselves) can recommend and dispense (i.e., sell) dietary supplements* and over-the-counter homeopathic drugs to patients, but they are prohibited from injecting substances like vitamins, minerals and botanicals, as well as homeopathic products, because they lack the authority to prescribe drugs. (If administered by injection, substances that normally constitute dietary supplements, like vitamins and minerals, as well as homeopathic remedies, legally become prescription drugs.)

A bill was introduced lifting this ban by allowing chiropractors to prescribe and administer “articles of natural origin” (which has no legal definition), including vitamins, minerals, enzymes, antioxidants, botanicals, glandulars,** and homeopathic remedies. If passed, chiropractors would have been able to administer all of these substances by injection, including via IV, thereby allowing them to, for example, plug their patients with Meyer’s cocktails as well as other “articles of natural origin” mixed up for them by a compounding pharmacy.

Expanded privileges would also include the drug Armor Thyroid, a prescription form of a pig thyroid extract (a glandular) used to treat hypothyroidism. In addition, the bill would have allowed chiropractors to prescribe and administer “cellular components”, a broad term that presumably includes stem cell therapies, granting them entrée into the lucrative stem cell clinic market without having to hire a medical doctor.

This vast expansion of their scope of practice would be allowed after a mere 36 hours of training. Fortunately, the bill didn’t pass. In fact, it didn’t even get a committee hearing and was eventually withdrawn from consideration.

Several years ago, New Mexico created the “certified advanced practice chiropractic physician” who could, after 90 hours of education and training, prescribe and administer certain substances by injection if approved by the pharmacy and medical boards. In 2019, House and Senate bills were introduced to expand those privileges, eliminating the requirement that the pharmacy and medical boards approve some substances (like live cells, bioidentical hormones, and homeopathic remedies) for injection and allowing the administration of prescription drugs in any form, not just injection, although some would still need pharmacy and medical board approval. Fortunately, the bills failed.

More scope of practice expansion

One way to sneak in the back door of primary care practice is getting the authority to perform certain examinations, like school and sports physicals, or return student athletes to play after a concussion, despite the fact that chiropractors are not properly educated and trained for any of this.

Nevertheless, a 2019 bill remains pending in Illinois that would add “chiropractic physician” to the definition of “physician” in a law addressing student athletes and concussions, thereby allowing chiropractors to remove a student from play if a concussion is suspected and return the student to play after examination and treatment. In Connecticut, a bill allowing chiropractors to clear student athletes for participation in athletic activities after a concussion failed.

Companion bills have been introduced, and are still pending, in the New York Assembly and Senate to “modernize”, which actually means “greatly expand”, the chiropractic scope of practice, currently fairly narrow. Instead of detecting and correcting the phantom “subluxation” to remove “nerve interference” (although still allowed), chiropractors could call themselves “chiropractic doctors” and “chiropractic physicians”, and could examine patients for, among other things, clearance for school sports participation and school attendance. They could also “give patients consultation, advice, recommendations, and counseling” regarding anatomy, physiology, neurology, general health matters, wellness, and “health optimization”.

If approved by the state education department (not the state chiropractic board, which acts in an advisory capacity only), the bills would expand the use of diagnostic testing beyond X-rays to include other ionizing and non-ionizing imaging methods, clinical laboratory testing, and electrodiagnostic testing. Chiropractors could also provide “wellness care” (which is undefined in the bills), nutritional counseling, and dietary advice including (of course!) dispensing dietary supplements. The reduction of dislocations and manipulation under anesthesia are added to the scope of practice. In addition, the one medical doctor on the state board of chiropractic would be removed.

Interestingly, New York’s narrow scope of practice and regulation by the state department of education (as opposed to a chiropractor-controlled regulatory board) appears to have a laudable limiting effect on chiropractors’ foraying into so-called “chiropractic medicine” and “functional medicine“. The Institute for Functional Medicine’s proprietary courses allow chiropractors to become “certified” in functional medicine, but the state of New York is having none of it. The department does not allow continuing education credit for courses in functional medicine and considers functional medicine beyond the scope of chiropractic practice. It also currently limits the scope of nutritional advice chiropractors can give patients. Notably, the American Chiropractic Association’s list of “chiropractic internists” does not include any New York chiropractors, presumably because their scope of practice does not include the lab tests and broad-scope dietary supplement and homeopathic drug dispensing this “specialty” requires.

A bill introduced in Texas would have expanded the scope of practice for chiropractors from treatment of the musculoskeletal system to the “neuromusculoskeletal” system, giving chiropractors the authority to treat conditions of the nervous system. The bill was defeated with vigorous opposition from the Texas Medical Association, including legislative testimony from an Austin neurologist, who pointed out that

Adding the term “neuro” is not merely the addition of the nerves that may connect muscle tissue, or bones. It is the addition of the entire neurological system that includes the brain, spinal cord, and the regulation of many bodily functions beyond chiropractors’ education and training.

Regrettably, chiropractors in other jurisdictions do have the legal authority, if not the actual education and training, to treat disorders of the nervous system, to the point of manufacturing the ersatz specialty of “chiropractic neurology,” which SBM ’s Dr. Steve Novella, himself a neurologist, has described as “rank pseudoscience“.

Finally, in Nevada, “dry needling” was added to the chiropractic scope of practice, while in Texas a bill was defeated which would have allowed chiropractors who had completed an acupuncture course to treat patients with acupuncture.

Co-opting the opioid epidemic to promote “chiropractic care”

Pennsylvania’s House Resolution 597, passed in 2019, is a master class in co-opting the opioid crisis for promotion of “chiropractic care”. After several paragraphs of scary stats on opioid abuse, the Resolution notes that “numerous published studies . . . document spinal manipulation as effective for the management of low back pain”. Thus, the House resolves to

raise public awareness that chiropractic care is the primary first-line, nonpharmacological approach to safely and effectively relieve acute, sub-acute and chronic pain.

See what they did there? The effectiveness of spinal manipulation for low back pain, a manual therapy also provided by physical therapists and physicians, magically becomes a prescription for “chiropractic care”, a nebulous term that can include all sorts of pseudoscience (subluxation detection and correction, dubious nutritional advice, unvalidated testing, and homeopathy, to name a few) which is “the” (not “a”) “primary first-line” method (not a choice among several of equal or greater merit) to “safely and effectively” (no evidence cited) treat all pain, whatever its origin (ditto for no evidence). Fortunately, this Resolution carries zero weight as legal authority, but does make for some good chiropractic PR.

As part of this continuing effort to sell chiropractic as an non-opioid alternatives in the treatment of pain, a bill was introduced, but did not pass, in Connecticut, “to encourage the treatment of chronic pain without the use of opioid drugs and in accordance with the treatment provided by chiropractors” although no details are given regarding exactly how this encouragement would be executed and by whom.

Tennessee law requires physicians to discuss “reasonable” alternatives to opioids for the patient’s condition and the benefits and risks of those alternative treatments. In another incident of co-opting the opioid crisis, the Tennessee legislature amended this law by defining “alternative treatments” as including, but not limited to:

treatments such as chiropractic care, physical therapy, acupuncture, and other such treatments that relieve pain without the use of opioids.

Hopefully, the adjective “reasonable” leaves some discretion in the hands of the physician who believes “chiropractic care” (and acupuncture, for that matter), are not appropriate for the patient because of lack of evidence of safety and effectiveness for the patient’s condition and the risk of subjecting the patient to pseudoscientific diagnoses and treatments.

That discretion is unavailable in Florida, where the legislature passed a bill requiring physicians to endorse chiropractic, acupuncture, and massage as non-opioid alternatives to pain, even if the physician disagrees with that advice.

Animal chiropractic

In Arkansas, chiropractors “certified by the American Veterinary Chiropractic Association” had to “perform chiropractic” on animals under the direct supervision of a licensed veterinarian. The supervision requirement was eliminated in 2019, passing unanimously in both the House and Senate. Animal chiropractic is based on the notion that animals, like humans, suffer from the chiropractic “subluxation” and require “adjustments”, which is just as nonsensical in veterinary medicine as it is in human medicine. Because it is permissible to ignore science (even basic anatomy) in veterinary chiropractic, other pseudoscientific practices, like applied kinesiology and craniosacral therapy have crept in.

Thankfully, a bill adding animal chiropractic to the scope of practice of both veterinarians and chiropractors failed in Missouri.

Finally, falling into no particular category, yet speaking volumes, the Idaho Board of Chiropractic Physicians convinced the state legislature that its peer review process, which is intended to “to review the appropriateness, quality, utilization and costs of chiropractic services”, was “unnecessary” and got the legislature to pass a bill (HB 0005) eliminating peer review.

Notes:

*A 2017 review of studies of chiropractic practice revealed that almost a third of chiropractic patients are treated with nutritional supplements. This seems an extraordinary number given the lack of evidence of effectiveness for supplements.

**Glandular extracts come from the hormone-producing glands of animals and contain dried and ground-up raw animal glandular tissues from the thyroid, thymus, adrenals, pituitary, ovaries, testis, and pancreas. As long as they are taken orally and are not marketed for the treatment of disease, they can be sold as dietary supplements. They are pushed by chiropractors and others without medical training for “adrenal insufficiency” and other “hormonal imbalances”. Even Dr. Weil admits they are a waste of money at best and, at worst, dangerous.