Determining the Course of Chiropractic's Destiny:
ADVANCED PRACTICE
Idaho’s Experience with an Advanced Scope of Practice
Laurence V. Hicks
DC, DO
Nicolo Montecalvo
DC, ND, M.S.A.C.P.
Introduction
It has been the long-held belief of the authors that a profession must be free to determine the course of its own destiny.
For chiropractic, history has shown us that soon after its founding, B. J. Palmer elected to remain in Iowa and promote specialization in the form of HIO, the forerunner of the modern NUCCA adjusting approach. D. D. Palmer moved on to Oregon and postulated the notion that the three-legged stool of chiropractic included minor surgery, adjustments, and obstetrics. The senior Palmer’s view was likely why the current Oregon practice act, section 684, provides for the chiropractic physician to administer local anesthetics.1
In more recent years, several states, including Oklahoma, have expanded their scopes of practice, adding acupuncture, homeopathy, naturopathy, parenteral nutrition, and animal chiropractic. Other states, such as New Mexico,2 have promulgated an advanced practice paradigm for chiropractic professionals, which has included limited pharmaceuticals.3
Once relegated to limited practice, chiropractic physicians went directly to work following graduation from school. Now chiropractic physicians have developed specialization opportunities through ACA’s specialty councils dedicated to sharing and furthering knowledge in specific areas, including acupuncture, diagnosis and internal disorders, diagnostic imaging, forensic sciences, neurology, occupational health, orthopedics, pediatrics, rehabilitation and sports injuries, and nutrition.
It is simply the natural desire of practitioners and professions to expand their intellectual and artful boundaries, consistent with their philosophical moorings and the advancement of science, which has allowed for various aspects of the practice to explore broader vistas.
In Idaho, the chiropractic profession made a decision to include a limited formulary in the arena of clinical nutrition practice, thereby allowing qualified chiropractic physicians to administer certain nutritional pharmaceuticals. This modification in the scope of practice constituted an advanced capability in the delivery of nutritional supplementation.
Prescription Drug Products
Because intravenous and parenteral nutrients are considered pharmaceuticals, by definition, Section 54-716 of the Idaho code naturally was titled “Administering Prescription Drug Products.” Consequently, a licensed chiropractic physician, under this chapter, who is also certified in clinical nutrition, may obtain and independently administer the following prescription drug products during chiropractic practice:
Vitamins:
• Vitamin A
• All B vitamins
• Vitamin C
Minerals:
• Ammonium molybdate
• Calcium
• Chromium
• Copper
• Iodine
• Magnesium
• Manganese
• Potassium
• Selenium
• Sodium
• Zinc
Fluids:
• Dextrose
• Lactated ringers
• Plasma-Lyte
• Saline
• Sterile water
It is an easy observation that the vast majority of common folk are aware that even foodstuffs may produce life-threatening allergic responses in some people (e.g., peanuts and shrimp) and, when consumed, may occasionally result in anaphylaxis. Other individuals may exhibit medication allergies, and on several occasions, the authors have encountered patients allergic to even Benadryl, one of our most reliable stand-by agents used in the management of allergic reactions.
It should, therefore, come as no surprise then that when one administers vitamins parenterally, an allergic reaction might be anticipated to occur rarely. Thus, in the wisdom of Idaho’s chiropractic professionals and state lawmakers, it was deemed prudent to provide epinephrine4 as a life-saving remedy, available if needed, should a case of anaphylaxis arise during the course of administering intravenous and injectable nutrition.
Further, the legislature saw fit to allow chiropractic physicians the authority to administer oxygen for use during an emergency or allergic reaction. The promulgated statutes qualify that the prescription drug products listed in the act may be administered through oral, topical, intravenous, intramuscular, or subcutaneous routes. Furthermore, the appropriate route of administration and dosing shall be in accordance with the product’s labeling as approved by the federal food and drug administration or with the manufacturer’s instructions.
The act also specifies that the prescription drug products described in the appropriate subsection of the law are to be obtained from a wholesale distributor, manufacturer, pharmacy, or outsourcing facility licensed under chapter 17, title 54, Idaho Code.
As a matter of clarification, it was decided that no vitamin or mineral may be compounded, as defined in section 54-1705, Idaho Code, by a chiropractic physician. A compounded drug product containing two or more of the approved vitamins or minerals shall be obtained for office use from an outsourcing facility licensed under chapter 17, title 54, Idaho Code.
In accordance with scope of practice privileges, it was stipulated that nothing herein would remove or impact the ability of a chiropractic physician who does not obtain a clinical nutrition certification to continue to utilize nonprescriptive nutritional supplements. The legislators also mandated appropriate training to ensure that public safety issues were provided for.
Qualifications for Clinical Nutrition License
It has been determined that in order to qualify for certification in clinical nutrition, a chiropractic licensee under the act must have successfully completed a minimum of the following courses:
Seven credits (77 clock hours) of:
• Didactic human nutrition
• Nutrition biochemistry
• Nutritional pharmacology
• Twenty-four hours of practicum
Practicum content will cover intravenous and injectable nutrient therapy, which must include:
• Sterile needle practices
• Phlebotomy
• Proper injection techniques
• Intravenous therapy techniques
• Intramuscular injection techniques
• Safety practices
• Use and expected outcomes utilizing micronutrients
• Response to adverse effects
• Lab testing and blood chemistry interpretation
It was stipulated that the courses required by this subsection must be taken from an accredited chiropractic college or other accredited institution of higher education and must be from an accredited program at the college or institution or be a program approved by board rule. For purposes of this section, “accredited” means accredited by an accrediting agency recognized by the United States Department of Education.
In consideration of this language, arrangements were made with the University of Western States (UWS) Office of Continuing Education (CE) to develop and implement the practicum, which provides for 24 CE units, as well as satisfying the licensure requirements of the Idaho Board of Chiropractic Physicians (IBCP) for the Certification in Clinical Nutrition (CCN).
Also, those who have completed the seven-credit, 77hour course content in didactic human nutrition, nutrition biochemistry, and nutritional pharmacology, offered as a portion of the Master of Science in Human Nutrition and Functional Medicine at the UWS, could have these courses recognized for partial fulfillment of the CCN requirement by submitting a transcript to the IBCP.
An alternative for the completion of the 77-hour didactic human nutrition, nutrition biochemistry, and nutritional pharmacology courses was arranged for by the IBCP, in the form of graduate CE in conjunction with Kansas State University Global Campus, a national leader in the promulgation of nutritional sciences.
Further statutory language stipulated that until January 1, 2019, a licensee of this chapter who commenced obtaining the education requirements of subsection (1) (a) of this section no earlier than January 1, 2013, and thereafter successfully completed those requirements, may be determined to have satisfied the requirements of subsection (l)(a) of this section as provided in board rule.
Also, the practicum required for certification in clinical nutrition by subsection (l)(b) of this section must commence and be successfully completed after the effective date of this section and pursuant to board rule.
All active chiropractic physicians wishing to obtain certification in clinical nutrition must first successfully complete the education described in subsection (1) of this section.
Additionally, in order to maintain clinical nutrition certification, a chiropractic physician certified in clinical nutrition must obtain recertification in clinical nutrition every three years pursuant to board rule. Currently, 25 to 30 doctors of chiropractic are also licensed to practice advanced clinical nutrition.
Furthermore, all chiropractic physicians certified in clinical nutrition must maintain a current cardiopulmonary resuscitation (CPR) and basic life support (BLS) certification, as well as have BLS equipment on the chiropractic premises where treatment is being performed.
Prior to providing a course of intravenous or injectable nutrition therapy, chiropractic physicians certified in clinical nutrition must provide their patients with informed consent documentation that explains the benefits and potential risks of the specific course of intravenous or injectable nutrition therapy that is being proposed. The physician must obtain from the patient written voluntary permission to perform the proposed therapy.
Observations on Delivering Nutritional Care under Idaho’s Advanced Chiropractic Practice Legislation
With the passage of the Clinical Nutrition License, Idaho’s chiropractors recently have been granted an advanced scope of practice opportunity to deliver nutritional care on a previously unprecedented clinical scale to the citizens of Idaho. As the second coauthor, I find myself in a unique position to discuss advanced chiropractic practice (ACP) legislation because I have been fortunate to have completed two different ACP programs. My first observation is that it does not appear that there will be a “one size fits all” approach to legislation from jurisdiction to jurisdiction. I expect states will organically grow to meet their practitioner’s inherent needs. Here, in Idaho, chiropractic physicians have a preeminent dedication to the therapeutic value of clinical nutrition. Thus, it was logical that this state’s first footsteps into advanced practice were founded upon parenteral nutrition.
Together, we advance a second observation, believing that professions are not static and change should be anticipated. Here are a few considerations that would seem logical next steps in the development of Idaho’s advanced practice statutes. As a nutrition-oriented body, I would anticipate that prescription-level oral nutrition should become a standard in the Idaho chiropractic community by adding highly purified prescription fish oils,6 high-potency reduced-folate products, and medical food.7 Furthermore, I would expect that injectable vitamin K,8 glutathione,910 and an iron preparation should be included in the future. Because the state saw fit to include certain medications to address emergencies, it is reasonable to include OTC products, making access to oral antihistamines, H2 blockers, and aerosol inhalant epinephrine available. The use of oxygen should become standard in routine health care,11 as well as during emergencies. Idaho’s chiropractic physicians should be granted latitude to administer nutritional injections at the point of care and not be limited to acquiring previously compounded IV product.
Health care is currently faced with various challenges, including an aging population,12 healthcare technological paradigm shifts, evidence-based demands on all players, and with increasing costs and no quality control incentives being offered, it only makes sense to use therapeutics that are inexpensive, safe, and effective to prevent illness and to promote wellness. We believe that Idaho’s chiropractic nutrition specialists are well positioned in this regard, and this ACP law will strengthen cultural position in Idaho in the challenging years to come.
Conclusion
As this paper’s authors, we began by stating that we believe a profession must be free to determine the course of its own destiny. Several jurisdictions have advanced the scope of their practices over the years. This time Idaho put into law advanced practice clinical nutrition. We explained that the change in the law included intravenous and parenteral nutrients, which are considered pharmaceuticals when produced as injectable agents.
We described the contents of the formulary allowed under the statutes. Then we described the need for and the requirements imposed to be undertaken to ensure that safety criteria and technical proficiency provide for competent practice. Lastly, we made some logical observations and suggested some reasonable future modifications to this section of the Idaho code.
Dr. Laurence Hicks is a Board certified Osteopathic Family Physician and a Chiropractic physician nutrition specialist. He practices full time, and has, for over 35 years. As an avid teacher in medicine, Dr. Hicks has trained many medical, chiropractic PA and NP students and practitioners. He is currently the instructor of the Clinical Nutrition Certification modules which lead to an Advanced practice licensure for qualified Idaho chiropractic physicians. Tel: 208-733-444.
A Chiropractic and Naturopathic Physician, Dr. Montecalvo enjoys 22 years of clinical experience. He completed the Advanced Chiropractic Practice Master's program at NUHS, satisfying New mexicos practice requirement, after which he was a leading participant in the Clinical Nutrition Certification program and is qualified and licensed in Idaho to provide IV and parenteral nutrition therapy.
References
1. ORS Chapter 684 - Chiropractors - 2017 Oregon Revised Statutes www.oregonlegislature.gov/BillsJaws/ors/ors684.html
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