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Proposal would allow practitioners to dispense meds, give injections

By Olivier Uyttebrouck
Journal Staff Writer
       New Mexico chiropractors are moving into new realms of practice now associated with medical doctors and practitioners of alternative medicine.
    The New Mexico Board of Medicine is to consider this week a proposal that would allow chiropractors to dispense a variety of substances ranging from some prescription drugs to injected substances such as vitamins and trigger-point injections for treating pain.
    Some chiropractors already are allowed to inject a short list of substances under a law approved by state lawmakers earlier this year. The proposed list includes a variety of substances that are injected into joints and connective tissue to treat joint pain and weakness.
    "In New Mexico, it's a big change," said Bill Harvey, executive director of the New Mexico Board of Pharmacy, which helped negotiate the proposal. Chiropractors here "have never had prescriptive authority before."
    The proposal already has been approved by the Board of Pharmacy.
    The New Mexico Board of Chiropractic Examiners and the Board of Pharmacy also are negotiating a list of intravenous drugs to add to the proposal. Members of both boards had no estimate on when the list would be ready and did not discuss what it might include.
    "Eventually, we hope to expand into a larger array of prescription drugs," said Dr. Leslie Schmidt, an Albuquerque chiropractor and chairman of the Board of Chiropractic Examiners. "We're going to have needle injectables and IV drugs."
    Stephen Perlstein, a Santa Fe chiropractor, began using a technique in September never before permitted for New Mexico chiropractors that involves injecting patients with procaine, a local anaesthetic.
    The technique, called trigger-point therapy, targets "hardened knotty areas" in the body that can be a source of chronic pain, Perlstein said. The injections are intended to relieve or eliminate pain, he said.
    Pharmacists and Western physicians have little familiarity with some of the substances listed in the proposed formulary, said Joe Anderson, a University of New Mexico pharmacist and member of the state pharmacy board.
    Among them is a group of substances called "prolotherapies" that involve injecting substances such as glucosamine sulfate and platelet-rich plasma into joints and connective tissue as a way of treating joint weakness and pain.
    Anderson said he has found few studies showing the safety or effectiveness of such therapies.
    "We don't know about their efficacy," Anderson said. However, the board felt it had no authority to exclude those drugs from the proposal.
    "We didn't feel like we were in a position to deny them based on the statute," he said.
    Other drugs on the proposed list include nonsteroidal anti-inflammatory drugs, such as ibuprofen, and a muscle relaxer, cyclobenzaprine. Also listed are hormones, such as progesterone and testosterone, which are used in both mainstream and alternative medical practices, and prescription pain medications in the form of ointments.
    If the Board of Medicine approves the proposed formulary, Perlstein said he probably will offer prolotherapy at his clinic and add a variety of injectable homeopathic substances to his medical bag.
    Lynn Hart, executive director of the Medical Board, said members are studying the formulary and will consider the proposal on Thursday.
    Perlstein, the owner of Family Chiropractic Center of Santa Fe, said techniques such as trigger-point therapy and prolotherapy have long been used safely and effectively by chiropractors in other states.
    "There is a good history of success using homeopathic injectable products for pain management," Perlstein said.
    Chiropractors won approval from state lawmakers in 2008 to dispense a wide variety of herbal and homeopathic medicines, vitamins, dietary supplements and other substances. But the law also stipulated that the pharmacy and medical boards had to approve chiropractors' use of those substances.
    In February 2009, lawmakers added new language that limited oversight of the medical and pharmacy boards to "dangerous drugs or controlled substances" and injected drugs.
    The new wording led to wrangling between the pharmacy and chiropractic boards. The pharmacy board filed a legal challenge in September with the New Mexico Court of Appeals, Harvey said.
    In court records, the board argued that a formulary proposed by the chiropractic board was too vague and that many of the substances chiropractors wanted to dispense are considered dangerous drugs if injected.
    Harvey said the pharmacy board used the Court of Appeals challenge as leverage to get chiropractors to negotiate a new formulary that more clearly defined how the substances will be used.
    He said chiropractors have cooperated with the board, making it unlikely the legal case will proceed.
    Anderson said he hopes the Medical Board will look closely at the qualifications of chiropractors to dispense prescription and injected drugs.
    Perlstein received a certificate in September as an "advanced practice" chiropractor from the state Board of Chiropractic Examiners that allows him to perform the injections, he said.
    To obtain the certificate, Perlstein completed about 90 hours of training that included pharmacology and toxicology, and passed an examination offered through the American Chiropractic Physicians Credentialing Center, he said.
    Schmidt said only advanced-practice chiropractors would be allowed to use prescription and injectable drugs.
    New Mexico has 26 advanced-practice chiropractors, who must be certified by the state Board of Chiropractic Examiners, he said.
    "We're making sure we have all of our bases covered as far as our background studies and qualifications," Schmidt said.

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