New Mexico Chiropractic Physicians: A Pattern of Advanced Practice with Primary Care Privileges
ADVANCED PRACTICE
Laurence V. Hicks,
DC, DO & Gary Olaveson, DC
The New Mexico practice act has been modified to allow the most comprehensive scope of practice associated with chiropractic physicians in this country. Yes, it is true that New Mexico�s statutes allow for a certified advanced practice chiropractic physician (AP-C) to have prescriptive authority for therapeutic and diagnostic purposes as authorized by statute. That is not the whole story, though.
An important part of the story has to do with how the New Mexico chiropractic profession arrived at the decision to advance their practice.
Another interesting tidbit is that an �expanded practice� (EP) was also authorized by Section 61-14-8.1 of the Acupuncture and Oriental Medicine Act, and doctors of oriental medicine can be certified by their board after fulfilling the requirements, in addition to those necessary for licensure, defined in 16.2.19 NMAC. EP was granted in addition to the basic prescriptive authority common to all licensed doctors of oriental medicine, as defined in Section 61-14A-3. G. (2) of the act.
The final point of interest is simply that, in this time of concern for physician shortages in primary health care, the New Mexico has found a novel solution. This solution is far less expensive than training hundreds of additional DO or MD providers for future needs, takes advantage of already existing resources to serve present needs, and further aligns complementary and alternative methods with standard health care at a time when pain management alternatives are needed to combat the �war on opioids� for our nation�s patients.
Chiropractic Practice
The law appears to create two levels of chiropractic practice. Under Definitions, Section C, �chiropractic� means �the science, art, and philosophy of things natural, the science of locating and removing interference with the transmissions or expression of nerve forces in the human body by the correction of misalignments or subluxations of the articulations and adjacent structures, more especially those of the vertebral column and pelvis, for the purpose of restoring and maintaining health for treatment of human disease primarily by, but not limited to, adjustments and manipulation of the human structure.�
Section D also provides that the license, when granted by the board, carries with it the title of doctor of chiropractic and entitles the holder �to diagnose using any necessary diagnostic procedures, excluding invasive procedures, except as provided by the board by rule, and treat injuries, deformities or other physical or mental conditions relating to the basic concepts of chiropractic by the use of any methods as provided in this section, including but not limited to palpating, diagnosing, adjusting and treating injuries and defects of human beings by the application of manipulative, manual, and mechanical means, including all natural agencies imbued with the healing act, such as food, water, heat, cold, electricity and mechanical appliances, herbs, nutritional supplements, and homeopathic remedies, but excluding operative surgery and prescription or use of controlled or dangerous drugs.�1
Certified Advanced Practice Chiropractic Physicians
Under section B, the term �AP-C� means a chiropractic physician who has been included in the advanced practice chiropractic certification registry.
Under provisions in 61-4-9.1, a chiropractic physician in New Mexico authorized by the board to use the title �certified advanced practice chiropractic physician� shall have prescriptive authority for therapeutic and diagnostic purposes as authorized by statute.
It shall include, but not be limited to, the prescribing and administering of all natural agents to assist in the healing act, such as food, water, heat, cold, electricity, mechanical appliances, and medical devices; the selling of herbs, nutritional supplements, and homeopathic remedies; the administering of a drug by injection by a certified advanced practice chiropractic physician; and any necessary diagnostic procedure, excluding invasive procedures, except as provided by the board by rule and regulation. It shall exclude operative surgery, the prescription or use of controlled or dangerous drugs, and the practice of acupuncture.
AP-C chiropractic physician authority is defined, and an AP-C may prescribe, administer, and dispense herbal medicines, homeopathic medicines, over-thecounter drugs, vitamins, minerals, enzymes, glandular products, protomorphogens, live cell products, gerovital, amino acids, dietary supplements, foods for special dietary use, bioidentical hormones, sterile water, sterile saline, sarapin or its generic, caffeine, procaine, oxygen, epinephrine, and vapocoolants. A chiropractic formulary also includes:
Hormones for topical, sublingual, oral use
• estradiol
• progesterone
• testosterone
• desiccated thyroid
Muscle relaxers
• cyclobenzaprine
NSAIDs—prescription strength
• ibuprofen
• naproxen
Prescription medications for topical use
• NMDC Ca+2 dextromethorphan
• NSAIDSs (ketoprofen, piroxicam, naproxen, ibuprofen, diclofenac)
• Sodium channel antagonist
• lidocaine
Homeopathic remedies requiring a prescription Other substances by injection
• sterile water
• sterile saline
• sarapin or its generic equivalent
• caffeine
• procaine HCL
• epinephrine
• homeopathic medication for injection
• Glutathione for inhalation.2
How Did Advanced Chiropractic Practice Develop in New Mexico?
Robert C. Jones, DC, the current president of the American Chiropractic Association, and Steve Perlstein, DC, were kind enough to present the story behind New Mexico�s advanced chiropractic practice legislative effort in video format on June 20, 2011.
Dr. Jones recalled that the concept began for him approximately 13 years earlier while participating in an integrated practice format with an osteopathic physician. He marveled that the injection theories being provided by the DO as an adjunct to the adjustment were highly effective, and the demand was so intense that an overly long waiting list quickly developed.
Dr. Jones said, in consideration of the injection therapies and the way in which the New Mexico codes were written, it made him wonder if chiropractic physicians were entitled to provide similar services. When he approached the chiropractic board for an opinion on the topic, his question was deferred to the attorney general�s (AG) office.
After careful research, an assistant AG provided a negative opinion based on the supposition that DCs were not actually physicians. This caused quite a stir among the board members, as you might imagine. When asked why they were not considered physicians, the assistant AG informed them that in 1936, DCs were requested to provide immunizations, and when they declined, they lost their physician status.
Of course, the profession wanted to regain its physician status, and a developing interest in AP-C caused a desire to begin legislative activity. Because it was important to gain the endorsement and consensus, Dr. Perlstein and others had meetings with the boards of medicine and pharmacy, etc., and enlisted lobbying efforts and garnered support with key politicians.
Their efforts paid off in 2008 when the 48th legislature signed House Bill 272, as amended into law under chapter 44. The bill placed the chiropractic profession in the Pharmacy Act and Drug, Device, and Cosmetic Act. Placement in these acts was necessary to be able to offer IM injections or IV treatments with even sterile H20, because H20 is regulated as a drug when injected. This placement also protected the ability to prescribe nutritional products. If the FDA, following the example of Codex and the World Trade Organization, restricted the availability of natural substances, including vitamins, minerals, and herbs to prescription-only items, New Mexico DCs would still enjoy access to those items through prescription.
The bill also enumerated a list of natural substances that DCs would be able to prescribe. Because the list would include many things, a �formulary� was developed by the New Mexico Board of Chiropractic Examiners with the approval of the medical board and pharmacy board, which details all the substances that DCs may prescribe by any appropriate route of administration.
In order to obtain the AP-C, a 90-hour course providing training in pharmacology and toxicology was required. The course included pharmacognosy, the study of naturally derived substances. Naturally derived substances available for prescription include vitamins, minerals, herbs, accessory nutrients, etc. Knowledge of administration of those prescription items and their routes of administration, including oral, topical, rectal, intravenous (IV), and intramuscular (IM), was also taught.
Doctors completing AP-C would be prepared to do IM injections (B12, homeopathics, magnesium, trigger point, etc.), neural therapy injections, intravenous procedures (Myer�s cocktails, H202, chelation, ascorbates, amino acids, minerals, etc.), emergency procedures, laboratory testing, and diagnosis.
Lastly, the doctors need to apply for credentialing and testing by ACPCC to receive AP-C status and could begin applying those newly learned advanced skills.3
New Mexico, interestingly, allows a similar scope of practice for its acupuncturists.
Acupuncture
Section (26) defines a �doctor of oriental medicine� as a physician licensed to practice acupuncture and oriental medicine pursuant to the act and, as such, has responsibility for his or her patient as a primary care physician or independent specialty care physician
Oriental Medical Scope of Practice
Pursuant to Section 61-14A-3 NMSA 1978, the practice of oriental medicine in New Mexico is a distinct system of primary health care with the goal of prevention, cure, or correction of any disease, illness, injury, pain, or other physical or mental condition by controlling and regulating the flow and balance of energy, form, and function to restore and maintain health. Oriental medicine includes all traditional and modern diagnostic, prescriptive, and therapeutic methods utilized by practitioners of acupuncture and oriental medicine. The scope of practice of doctors of oriental medicine shall include but is not limited to: A. evaluation, management and treatment services; B. diagnostic examination, testing, and procedures; C. the ordering of diagnostic imaging procedures and laboratory or other diagnostic tests; D. the surgical procedures of acupuncture and other related procedures; E. the stimulation of points, areas of the body or substances in the body using qi, needles, heat, cold, color, light, infrared and ultraviolet, lasers, sound, vibration, pressure, magnetism, electricity, electromagnetic energy, bleeding, suction, or other devices or means; F. physical medicine modalities, procedures and devices; G. therapeutic exercises, qi exercises, breathing techniques, meditation, and the use of biofeedback devices and other devices that utilize heat, cold, color, light, infrared and ultraviolet, lasers, sound, vibration, pressure, magnetism, electricity, electromagnetic energy, and other means therapeutically; H. dietary and nutritional counseling and the prescription or administration of food, beverages, and dietary supplements therapeutically; I. counseling and education regarding physical, emotional, and spiritual balance in lifestyle; J. prescribing, administering, combining, providing, compounding, and dispensing any noninjectable herbal medicine, homeopathic medicines, vitamins, minerals, enzymes, glandular products, natural substances, protomorphogens, live cell products, amino acids, dietary and nutritional supplements; cosmetics as they are defined in the New Mexico Drug, Device and Cosmetic Act and nonprescription drugs as they are defined in the Pharmacy Act;
Expanded Practice
Section (30) covers �EP,� which is authorized by Section 61-14-8.1 of the act and is granted to a doctor of oriental medicine who is certified by the board after fulfilling the requirements, in addition to those necessary for licensure, defined in 16.2.19 NMAC. EP is in addition to the prescriptive authority granted all licensed doctors of oriental medicine, as defined in Section 6114A-3. G. (2) of the act.
Under part B, the EP shall include: (1) the prescribing, administering, compounding, and dispensing of herbal medicines, homeopathic medicines, vitamins, minerals, amino acids, proteins, enzymes, carbohydrates, lipids, glandular products, natural substances, natural medicines, protomorphogens, live cell products, gerovital, dietary and nutritional
supplements, cosmetics as they are defined in the New Mexico Drug, Device and Cosmetic Act (26-1-1 NMSA 1978), and nonprescription drugs as they are defined in the Pharmacy Act (61-11-1 NMSA 1978); and (2) the prescribing, administering, compounding and dispensing of the following dangerous drugs or controlled substances as they are defined in the New Mexico Drug, Device and Cosmetic Act, the Controlled Substances Act (3031-1 NMSA 1978) or the Pharmacy Act (These provisions look interestingly similar to the chiropractic advanced practice privileges):
• sterile water
• sterile saline
• sarapin or its generic equivalent
• caffeine
• procaine
• oxygen
• epinephrine
• vapocoolants
• bioidentical hormones
• biological products, including therapeutic serum
Part C provides that, when compounding drugs for their patients, doctors of oriental medicine certified for EP and prescriptive authority shall comply with the compounding requirements for licensed healthcare professionals in the United States pharmacopeia and national formulary.
Also, under section (6), �animal acupuncture� is defined as acupuncture performed on any animal other than man. Animal acupuncture is authorized under the supervision of a doctor of veterinary medicine licensed in New Mexico and only under the guidelines of the rules of the New Mexico Veterinary Practice Act (61-14-1. to 61-14-20) and
the rules of the New Mexico Board of Veterinary Medicine (16.25.9.15 NMAC).4
Breaking News: Naturopathic Doctors Have Become Licensed in New Mexico
As of April 2019, naturopaths (NDs) have become licensed in the New Mexico. Naturopaths may provide primary care, as defined by the regulatory board and/or in collaboration with a licensed medical physician.
Title: NDs may use the titles doctor, naturopathic doctor, doctor of naturopathic medicine, doctor of naturopathy, and the abbreviations ND and NMD.
Despite being allowed to use the credentials NMD, the statutes do not specify that NDs can use the title naturopathic medical doctor.
May not use the title physician or naturopathic physician.
Scope of practice includes:
Prescription drugs—May prescribe legend substances and testosterone after passing pharmacy exam.
Controlled substances—May prescribe Schedule III, IV, and V drugs, excluding benzodiazepines, opioids, and opioid derivatives after passing pharmacy exam.
IV administration—May administer subcutaneous, intramuscular, and intravenous substances.
Diagnostic tests—May order and interpret diagnostic labs. May order but not interpret radiographic images. May �take action� on radiographic report.
Minor office procedure—May perform minor office procedures.
Spinal manipulations—May perform spinal manipulations, excluding procedures involving nerves, tendons, arteries, veins, eyes, or ears.
Cancer—May not treat cancerous lesions or any lesion suspected to be cancer.
Childbirth/midwifery—Not specified. May not perform a surgical abortion.
Vaccine waiver—Not specified.
Naturopathic assistants—Not specified.
NDs are prohibited from performing acupuncture. 5
Summary
In conclusion, we have seen that New Mexico DCs now enjoy broad advanced practice privileges. We discussed the backstory behind the advanced practice. We noted that acupuncturists in New Mexico also have obtained an expanded practice. Most recently, naturopaths passed a practice act into law, and New Mexico, through active legislative, seems to have solved its physician shortage problem by licensing novel but not MD or DO physicians to provide primary care. References
1. www.rld.state.nm.us > uploads > files > Chiro Rides and Laws
2. www.nmms.org > wp-content > uploads > 2018/07 > 2017-Chiropractic-Sc...
3. https, www. nm chiro. org
4. www.rld.state.nm.us > Acupuncture Rides - Book format - Rev 03 02 2015
5. www.naturopathicdiaries. com naturopathic-medicine-new-mexico
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.
Dr. Olaveson has been in private practice as a chiropractic physician since 1999. He completed his Undergraduate Studies at Utah State University in 1995 and thenstarted his professional training at Life West Chiropractic College, Graduating in 1998. He completed the Certified Clinical Nutrition advanced practice training program in Idaho and is Currently eligible for licensure.
