The Various Types of Advanced Practice
FEATURE
Stephen Perlstein
In my previous article, “History of New Mexico Advanced Practice and the Launch of AACP,” which appealed in the May 2016 issue of this magazine, I mentioned two important facts:
1. Many states today are engaged in the creation of advanced practice laws.
2. The type of advanced practice that states seek varies state by state.
In this article, I will explore the types of advanced practices and their practical applications in chiropractic practice.
It is an established fact that certain New Mexico chiropractors have had prescriptive privileges since 2008. Those chiropractors who have followed a legislated program of postgraduate education in pharmacology and toxicology and passed a board-level examination in primary clinical practice have earned the designation of advanced practice certified (APC) by the New Mexico Board of Chiropractic Examiners. The formulary that these chiropractic physicians can utilize is comprised of analgesics, muscle relaxants, hormones, and NSAIDs that aie dispensed by prescription only, as well as injectable homéopathies. These physicians aie part of the New Mexico Advanced Practice Chiropractic Registry, and the FDA has granted them a schedule 3N DEA license for the prescription and use of testosterone. Since 1995, chiropractors in Switzerland have been able to prescribe over-the-counter analgesics and NSAIDS, many of which aie available only in Europe. One of the distinctive differences between Swiss chiropractors and American chiropractors is that the chiropractic profession in Switzerland is one of five government-recognized medical professions and aie integrated and accepted by the medical community, whereas in the US, this is not necessarily the case.
Presently, a voice louder than ever before is advocating for advanced practice within the chiropractic profession. Within this domain, there aie several ideas of what constitutes advanced practice. We can divide these types into two sections. The first section is the use of medications for neuromusculoskeletal conditions seen in chiropractic practice. The second section encompasses medications used in traditional medical practice. Let’s take a look at them.
They are prescriptive privilege for:
Neuromusculoskeletal Medicine:
1. Common OTC analgesics and NSAIDS in prescription strength.
2. Prescription-only analgesics and NSAIDS.
3. Muscle relaxants.
^Chiropractic’s message that
“drugs are bad” does not resonate
well because it is not drugs that are bad, but the use of them that is called into question. J Ï
Traditional Medical Practice:
4. Medications commonly used in primary care practice without controlled substances.
5. Number 4 with controlled substance schedules 3-5.
6. Number 5 with controlled substance schedules 2-5.
7. Plenary licensure.
1. Being able to prescribe common OTC analgesics and NSAIDS in prescription strength is a very simple step into advanced practice. Many of our patients already take, for example, four 200 mg ibuprofen on their own, which constitutes prescription strength when given as one 800 mg tablet. Some patients prefer to have that dose in one
tablet and will opt to get a prescription filled so they can take it that way If a chiropractor suggests that the use of ibuprofen may be helpful to reduce inflammation, and that taking four of them within limitations is acceptable, then being able to prescribe the same dose in one tablet isn’t a substantial difference horn that suggestion, and allows the patient to receive the advice and prescription h orn the doctor who suggested it. Keep in mind that being able to prescribe it does not mean that one has to prescribe it. Having the ability to do so supports the patient’s needs in a significant way
Being able to prescribe prescription-strength NS AIDS and analgesics, such as Celebrex, for example, is simply having more tools to help our patients move forward with their treatment plans. These non-narcotic medications can assist chiropractic manipulative treatment programs immensely.
Being able to prescribe a muscle relaxant such as Flexeril, which we APCs aie able to do in New Mexico, is again another tool. From my professional experience prescribing this drag, it has helped give patients in pain the sleep that they require for proper healing when getting good sleep has been difficult.
Medications commonly used in primary care practice take us into the realm of caring for our patients beyond the typical neuromusculoskeletal complaints that we chiropractors see every day. This also is the realm of functional medicine that many chiropractors practice,
and includes the addition of prescription medicines to the toolbox. In this section, we are utilizing a broad variety of medications for common ailments, but without those that are controlled substances. Antibiotics are a good example in this category.
5. The next two categories aie the addition of controlled substances to a formulary, either schedules 2-5 or schedules 3-5. An example of a schedule-5 drug is cough medicine with codeine. Examples of schedule-4 drags aie Xanax and clonazepam (Klonipin) to treat anxiety. An example of a schedule-3 drag is Vicodin, which is acetaminophen with a small amount of hydrocodone. Schedule 3 is where the narcotics are found, although an example of a non-narcotic schedule-3 drag is benzphetamine (Didrex), a weight-loss drag. Anabolic steroids ai e another example of a non-narcotic schedule-3 drug. An example of a schedule-2 drug is OxyContin. The schedules are distinguished by their potential for abuse, with schedule-5 drugs being the lowest and schedule-1 drags the highest. Although schedule-1 drugs are not necessarily prescribed drags, such as heroin and LSD, marijuana is in this schedule and, as we all know, in certain states it is a prescription drag.
6. Plenary licensure means prescriptive authority to provide all medications. It means that there aie no restrictions to what one can prescribe. Your typical MD and DO has plenary licensure. Nurse practitioners’ prescriptive authority varies by state.
In New Mexico, APC chiropractors can prescribe various prescription-only topical medications for pain and inflammation, a muscle relaxant, testosterone, prescription-strength NS AIDS, prescription-only topical hormones, homeopathic injectable medicines, and other substances for injection, such as procaine, sarapin, and saline. There is a formulary of what can be used and prescribed.
■ ^Advanced practice is not only about pharmaceutical intervention, but it is also about how drugs work, their indications, their interactions, their contraindications, and how to use them efficaciously and as a secondary treatment modality. J J
In Oklahoma, a chiropractor is able to administer naturopathic and homeopathic remedies, including injectable nutrients. There is no formulary in their rales. They must provide proof to the board that they have satisfactorily completed at least 24 hours of education and training in the administration and use of injectable nutrients from a program approved by the board.
In Wisconsin, there has been legislative progress toward the creation of a primary care spinal practitioner. This bill requires a new and separate practice act governed by the Wisconsin Medical Examining Board. The educational requirement is a master’s program and 500 hours of clinical training. Chiropractors who complete this program would have dual licensure.
As you can see, advanced practice encompasses a variety of forms of medication administration. Advanced practice means incorporating the use of accepted prescription-only medicines into chiropractic practice. It means using prescription medications judiciously in addition to common chiropractic treatment. It means proper training in order to perform this level of service. It does not mean the elimination of chiropractic examination and adjusting methodologies. Chiropractic’s message that “drugs aie bad” does not resonate well because it is not drugs that are bad, but the use of them that is called into question. A message that drugs can be used as secondary treatment when appropriate makes more sense. It also makes sense that chiropractors, trained conservatively, should be able to advance their education to meet their patient’s needs in a broader sense. This does not compromise the chiropractic profession. It expands it.
Knowing how to interact with our patients who are under prescribed medication is of value to everyone. Advanced practice is not only about pharmaceutical intervention, but it is also about how drugs work, their indications, their interactions, their contraindications, and how to use them efficaciously and as a
secondary treatment modality. Advanced practice doctors do not utilize drugs because they no longer consider the chiropractic adjustment valuable. They do so because they understand the limitations of chiropractic adjustments and wish to utilize efficacious adjunctive treatments in our patients’ best interests. Our education gives us the background to be trained further in the use of medication administration. By doing so, we are providing additional services to our patients and ending the marginalization of our profession.
The American Academy of Chiropractic Physicians (www. aacp.net) is the national organization working to bring together those who want the chiropractic profession to include advanced practices. AACP advocates for it legislatively on a national and international level. If you think that there is a place for advanced practice in the chiropractic profession, please check out the website and join. Membership puts you in touch with the growing community who see the benefits of advanced practice hi the chiropractic profession.
„j. Dr. Perlstein graduatedfrom Palmer West in 1981
i,,4 and has practiced in Santa Fe, New Mexico for TW over 33 years. He is currently Chair of the NMCA PAC, as well as the co-author and expert witness for advanced practice legislation in New Mexico. He is the President of AACP which is on the web at www.aacp.net.
