Letter to the Editor: Prescribing Controlled Substances

To the Editor and members of the WANP:

How is it that naturopathic physicians have the same level of responsibility to their patients as other physicians yet have limited prescription authority of controlled substances? As physicians, naturopaths need to have all of the necessary “tools” to manage patients appropriately. This is a respectfully pressing commentary in promotion of naturopathic physicians receiving full prescription authority of controlled substances.

I would like to present you with several supportive reasons for a necessary change to our current prescriptive authority. I firmly know these opinions to be not only my own, but also represent the beliefs of many other naturopathic doctors, colleagues from other medical fields, and most impacting, from the patients we care for and treat with medications as appropriate.

Thankfully, the topic of naturopaths prescribing medications has been successful and beneficial through an ongoing understanding of our competency as physicians, continued improvements to our prescription authority and progression of care for our patients. As physicians, hindrance to our prescription authority should not be an issue and I would like to help resolve this matter.

Continuity of Care: Naturopaths guide their treatment decisions based on many factors, including the Principles of Naturopathic Medicine and by following the Therapeutic Order – working from least invasive treatments towards more aggressive options, which would include prescription medications and controlled substances.

For example, our first option for treating mild hypertension would not likely be an anti-hypertension medication like Lisinopril, but would involve diet and life-style changes, screening for sleep apnea, advising physical activity, stress reduction skills, and perhaps recommending a couple of supplements. However, many patients live a very healthy life-style and no medical cause can be found for their elevated blood pressure, so a medication becomes necessary and appropriate to reduce their risk for cardiovascular events like stoke.

Similarly, a patient suffering from severe anxiety may be actively engaged in counseling, learning new coping skills for stress trying natural/supplemental supports without satisfaction, and still not sleeping well or functioning adequately due to significant anxiety. No initial ‘allowed to prescribe’ medication intervention has proven effective (ex. SSRI, Mirtazapine, Hydroxyzine, Propranolol, etc.), so a benzodiazepine, a controlled substance, is the standard of care for such recalcitrant anxiety symptoms. The patient suffers while the naturopathic physician appears incompetent due to the inability to treat with a known, successful medication, or suggest that a patient try something else just for the sake of offering what we can currently prescribe versus what is actually the best treatment recommendation.

Additionally, it is often perceived as rude and significantly inconvenient to ask your established patient to seek care elsewhere for treatments we should be able to provide. Patients value continuity of care and “starting over” with another provider becomes frustrating, time consuming, and costly. This often results in loosing patients from your practice. In my 10 years of practice, I personally have experienced a plethora of situations where a treatment was needed for my patient – for which I felt very confident in my abilities and knowledge to manage – and I could not provide it due to our current scope of practice. This is disheartening to all parties involved.

Current Authority: Naturopaths are currently authorized to prescribe testosterone and codeine compounds in the scheduled classes III-V. I cannot make sense of why we cannot prescribe other controlled substances in these same classes or even schedule II agents. Are these medications somehow beyond our responsibility or comprehension to manage properly? No, they certainly are not. We are educated and can continue to educate ourselves regarding these or any other topic in medicine just as our other medical colleagues do and practice accordingly.

For example, Lyrica and Ambien are controlled substances in the schedules V and IV classes, respectively, with less abuse potential than the scheduled III substances we are currently permitted to prescribe. Here is my point: There is no rational explanation for what we are currently allowed to prescribe in relation to the controlled substance scheduling classes, nor with what we are capable of responsibly managing safely and effectively.

DEA License Cost: A DEA license cost $751 per term whether naturopaths simply prescribe testosterone and codeine or all controlled substances. Other professionals (i.e. MD’s, DO’s, and ARNP’s) pay the same price as naturopaths and have autonomous, full prescription authority. That is a steep price for such limited prescription authority. This does not make sense and is not justified.

Other Practitioners: Both Nurse Practitioners and Physician Assistants can prescribe beyond the scope of naturopaths – and they are not physicians. We are physicians and have obtained a doctorate degree in medicine. Our naturopathic colleagues in both Oregon and Arizona, where the other two long-standing, respected naturopathic colleges reside, also have full controlled substance prescription authority. [Editor’s note: While both Arizona and Oregon naturopathic statutes contain more controlled substances than Washington, neither state currently has ‘full prescriptive authority for controlled substances.] This lends credence to the rationale that Washington State should likewise grant full controlled substance prescription authority to its naturopathic physicians where Bastyr University resides, which is considered by most to be the best naturopathic university in the world.

Hindrance of Business: Personally, I have lost several patients (often first time visits) over the issue of not being able to prescribe something during the visit that was deemed necessary and prudent for the patients’ best interest. Patients are often confused and state, “but you are a doctor” when they are told one particular medication is not in our prescriptive authority and they will need to obtain it through another medical provider. This is so disheartening to ‘let patients go’ and refer them elsewhere when I have full confidence in my ability to manage and prescribe what is appropriate at that time. Understandably, patients do not want to pay another co-pay or schedule an additional visit at another providers’ office for something that should have been handled through their naturopathic physician. Like myself, others have undoubtedly ordered a brain/head MRI/CT to a patient with claustrophobia issues who requires a Valium in order to accomplish the procedure. I do not have the authority to prescribe Valium for this patient – so how am I supposed to support my patient through this necessary procedure? Rely on another professional who can? There are many examples where our current limited prescription authority hinders best medical practice guidelines.

Other Degrees: Some naturopaths have sought additional degrees or licenses, just to improve their scope of practice and/or prescriptive authority. Does this make sense for a medical professional with a doctorate in medicine who is already capable of these practices and certainly responsible to continually educate themselves regarding pharmacology to obtain another degree? Also, naturopaths will often have an MD or ARNP in their clinic, so they can write prescriptions for medications we cannot. Is this the best way to handle our patients’ needs? I believe now is the time for naturopathic physicians to have the scope of practice they have earned and deserve, and be granted full prescription authority of controlled substances.

Respectfully,

Robert Christopher Cotner, ND

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