Respectful Insolence

While I’m on the topic of alternative medicine and NCCAM again, I’ve said on many occasions that I reject the distinction between evidence-based medicine and “alternative medicine” as a false dichotomy. To me, the only dichotomy that matters is between medicine that has high quality scientific evidence showing that it works and medicine that does not, a category that includes plausible treatments that might work but have not yet been shown to work and treatments, implausible treatments with little or no evidence of efficacy (a category that includes the vast majority of what is lumped together as “alternative medicine”), and treatments for which the preponderance of evidence shows that they do not work. The very concept of “alternative medicine” represents a double standard under which certain types of therapies labeled “alternative” are apparently either exempt from the normal standards of medical and scientific evidence or subject to a much looser standard that that evil “conventional” or “allopathic” medicine of whose medical-industrial complex I seem to be considered a tool.

It turns out that Steve Novella agrees with me and has made a compelling, almost Orac-length case (sadly, minus the usual Orac-style snark, but that’s OK) for the existence of this double standard. It’s well worth your reading in full. Particularly damning is Steve’s description of how “health care freedom” laws do nothing more than codify substandard care as acceptable as long as it covered under the rubric of “alternative” medicine. He also points out how physicians abandon treatments that don’t work. I often make the same point, but I also usually point out that this weeding out of ineffective treatments may take longer than we like. It does happen, however. In alternative medicine, as far as I can tell, there has never been a treatment that has been abandoned because it was found to be ineffective or unsafe.

Although this case has been used to attack the FDA and our drug approval system, the recent case of Avandia, the diabetes drug that has been linked to an increased risk of myocardial infarction and cardiac death. Whatever the flaws in our drug approval system this case may have revealed, the reactions of practitioners “in the trenches” that I’ve seen so far are quite instructive. They range from practitioners who plan on taking all their diabetic patients off of Avandia, to those who, seeing that a closer examination of the study does reveal problems but is not quite as dramatic as the press is painting it, plan on taking just their patients with heart disease off of it, to those who are taking more of a “wait and see” attitude while seriously considering cutting back or ceasing their use of Avandia for diabetic patients. In other words, when faced with evidence that a previously favored drug may not be safe, at least in some patients, most practitioners seem to be either abandoning it now or thinking very seriously about abandoning it in the near future. (Look for sales figures of Avandia to plummet, if the drug isn’t pulled by the FDA first.) Contrast this to the alleged anticancer drug Laetrile, which failed to show any efficacy in multiple trials 25 years ago but which is still pushed by alternative medical practitioners. Contrast this to chelation therapy, for which multiple trials have failed to show efficacy against cardiovascular disease, yet which is still used by thousands upon thousands of “alternative” practitioners for heart disease with the promise that patients can “avoid angioplasty or bypass surgery.” My guess is that, 100 years from now, even if no evidence of efficacy is ever found for these therapies (as is likely), alternative practitioners will still be using chelation therapy, Laetrile, qi gong, Reiki, and homeopathy. Now speculate about how many of today’s “conventional” medical treatments will still be in wide use 100 years for now or look back and determine what “conventional” medical therapies from 100 years ago that are still in use today, and the difference is clear. Alternative medicine simply does not stop using therapies that are shown not to work. Although the external trappings may change, at its heart it is stagnant and unchanging.

Whatever the faults of “conventional” medicine, it does change in response to new evidence. It does ultimately discard therapies that are shown not to work or shown to have an unfavorable risk-benefit profile in favor of therapies for which better evidence is found. It may take longer than we like and be a messier process than we like, but it does happen. A more stark contrast with alternative medicine I can’t imagine.

Comments

  1. #1 Rockstar Ryan
    May 22, 2007

    To sum up with my favorite question on the topic:

    Q: What do you call alternative medicine that works?

    A: Medicine.

    Well done Doc. Serious health practitioners are more concerned with making patients well then trying to prove their particular brand of woo-woo is better than Brand X.

    If [Woo] really works, then why don’t all doctors use it?

  2. #2 Bronze Dog
    May 22, 2007

    I loved that post of his. Was one of the reasons I gave him a “Sit! Stay! Good Blog.”

  3. #3 MarkH
    May 22, 2007

    I loved it too. It’s a classic.

  4. #4 HCN
    May 22, 2007

    I’ve noticed that many of purveyors of alt meds become chronic liars in order to convince their customers. One big example are those who sell laetrile to cure cancer… they lie, lie and lie some more claiming it is being suppressed when it is actually poisoning desparate sick people!

    The dishonesty of the anti-vax folks was noted at http://www.pathguy.com/antiimmu.htm … and it still continues with Wakefields lawyer financed study of 12 kids (most of whom were clients of the law firm) and the Geiers manipulation of information.

    Russell Blaylock, a fellow who writes a “wellness newsletter” and sells supplements in a strip mall used to claim on his website that he was on the faculty of the Medical School of Ole Miss (University of Mississippi). A search of their website never found him… and apparently Ole Miss got wind of his claims, so he had to change his website. He is on the faculty of a small religious school that teaches “Intelligent Design” in its biology department.

    I just caught Dana Ullman being extremely dishonest over in the Dr. Strange homeopathy posting. He is apparently hitting some blogs with a long bit on a paper in “Chest” where he does not properly identify the institution the study was done it… and then claims there are studies showing the effectiveness of super-diluted duck bit on influenza — but searching for them found nothing of the sort.

    Many large research universities have policies in place to keep down dishonesty (like http://www.umsl.edu/services/ora/compliance/resdis.html … I used Google)… What kind of enforcement is there to keep alt-med folks honest?

  5. #5 Michael
    May 22, 2007

    I don’t disagree with you at all, but there does at times seem to be an anti-holistic approach in medicine. “Health” is a concept that touches on a lot of areas: mental disposition, stress, diet, exercise, environmental conditions, heredity. It can seem incomplete when the response from a physician is to “take this pill”.

    I take great comfort in the concept of medicine as science. That’s why we’ve done so well. But I have experienced physicians who did not give me confidence that they were considering the big picture. I think this notion feeds the “woo”.

    The other notion that feeds the “woo” is that we have had successful treatments for various conditions for thousands of years (e.g. camphor as a mild topical analgesic). Unless some big institution studies it and verifies it and publishes it, it is considered “woo”. How much alternative medicine is really normal, valid medicine which has lacked formal study.

    I believe most alternative medicine is quakery, so don’t get me wrong.

  6. #6 HCN
    May 22, 2007

    Michael said “The other notion that feeds the “woo” is that we have had successful treatments for various conditions for thousands of years (e.g. camphor as a mild topical analgesic). Unless some big institution studies it and verifies it and publishes it, it is considered “woo”. How much alternative medicine is really normal, valid medicine which has lacked formal study.”

    Really?

    Actually, why don’t YOU tell us which alternative med is normal valid medicine that has lacked formal study? H

    Because for years many pharmaceuticals were actually taken from folk cures… but studying the solutions came up with better and more consistent forms of the active ingredient. Also, for anyone going for an advanced science degree looking for a research subject — folk remedies are ripe with possibilities.

    The problem is actually that there are alternative meds that HAVE been studied extensively, found to be useless… and yet are still being promoted as better. Examples include laetrile, colloidal silver, homeopathy, and on and on.

    So, again, I ask: Which alternative medicine do you feel is effective that has not been studied?

    Now to this strawman argument… you said: ” don’t disagree with you at all, but there does at times seem to be an anti-holistic approach in medicine. “Health” is a concept that touches on a lot of areas: mental disposition, stress, diet, exercise, environmental conditions, heredity. It can seem incomplete when the response from a physician is to “take this pill”.”….

    I find that is not at all true, especially from my sadistic family doctor. For my plantar fasciitis I was prescribed shoe inserts! For my back pain I was prescribed exercise! Now for my high cholesterol I have been prescribed a low fat diet and even MORE exercise!

    Not one blasted pill.

  7. #7 andrea
    May 22, 2007

    In reality, there’s no such thing as “alternative” medicine. There’s good (proven useful) medicine and bad medicine (unproven, useless, and/or dangerous). It doesn’t really matter where the original material came from if it can be proven useful.

  8. #8 Michael
    May 22, 2007

    You just answered your own question when you said, “many pharmaceuticals were actually taken from folk cures.”

    When we study things like aloe or camphor we find that some “folk remedies” work. They even lead us to better stuff, as you just said.

    (Did you know that “a bitter powder extracted from willow bark… [can] ease aches and pains and reduce fevers”?)

    I had also mentioned camphor which is “found in wood of the Camphor laurel…[and] acts as slight local anesthetic and antimicrobial substance.”

    So the notion that something like St. John’s Wart or Echinacea might work is not irrational. Some don’t work. I’m not disagreeing with the insanity of not judging things by their result.

    (Quotes from wikipedia.)

  9. #9 Bronze Dog
    May 22, 2007

    There’s nothing wrong with ‘might work’. In my experience science doesn’t do impossible.

    I’m willing to see studies on herbs and such, but they have to go through the same hurdles everything else does before I’ll spend money on them as a treatment. Doesn’t matter if it comes from a pharma company or Big Altie.

    As for the holistic thing, I once received a ‘prescription’ for Fiber One cereal. Woos, from my experience, however, often seem to think that everything has one cause and one cure, regardless of your overall health and circumstances.

    As for pill-popping: I haven’t seen too many doctors recommending that. Mostly it’s woos taking advantage of our sloth. I remember one badly-acted commercial for some kind of diet coffee, and they show one guy drinking it and watching TV while his wife’s on the treadmill. He wins the weight-loss contest. Americans want solutions that are easy, even if they don’t work, and woo is much happier to oblige than any doctor, who’ll typically tell you to eat more fruits and vegetables and get more exercise, at least until he gets tired of not being listened to.

    Sorry for the ramble. I get like that at times.

  10. #10 HCN
    May 22, 2007

    Michael, you did NOT answer this question: Which alternative medicine do you feel is effective that has not been studied?

  11. #11 Tracy W
    May 22, 2007

    “Health” is a concept that touches on a lot of areas: mental disposition, stress, diet, exercise, environmental conditions, heredity. It can seem incomplete when the response from a physician is to “take this pill”.”….

    What doctor have you been going to? I ask because I’m getting sick of having my blood pressure taken, refusing to have my weight taken, asked about my emotional life, smoking, etc, whenever I go to get a refill on my contraceptive.

    Okay, the blood pressure thing makes sense. The rest gets rather boring.

    And it’s not just my current doctor either. I remember once, when at uni, going to the health centre to get a sicknote as I had the flu and looked like missing a test, and finding myself being tested for issues ranging from glandular fever to diabetes.

  12. #12 sailor
    May 23, 2007

    “For my back pain I was prescribed exercise! Now for my high cholesterol I have been prescribed a low fat diet and even MORE exercise!
    Not one blasted pill.”
    Now that HMO is raking it in….

    Placebo is such a strong effect that it is the standard against which every new drug must be tested – even if the measure is purely physiological. It seems to me we need to know more about the placebo effect – are some placebos more effective than others (pills vs needles). If the placebo involves the patient doing something to control his condition, is it more effective than a passive placebo?
    If a placebo is ADDED to a drug test and compared with the drug alone is there an effect? How much is real belief in the placebo a factor?

    If we explored these fields a little we might come up with the most effective placebos and ways to administer them. These could replace our current woo wizards as more effective and lest costly.

  13. #13 HCN
    May 23, 2007

    sailor, are you saying that exercizing is a placebo? I know that my strengthened back muscles have stopped my back pain… but you see to be saying it is a placebo.

    If not, please clarify.

    Also, Michael… please answer this question: Which alternative medicine do you feel is effective that has not been studied?

  14. #14 sailor
    May 23, 2007

    No Michael, I don’t think I mentioned exercise except in the humorous aside about HMOs.

    Placebo is a major effect – so major we cannot do a drug study without it. It has been around for years and is very real. It is almost certainly a major reason for the popularity of many woo cures. Is it not time we started to find just how and why placebo works and see if we can maximise its advantage, instead of letting woo doctors maximise their profits?

  15. #15 sailor
    May 23, 2007

    Sorry that should have been “No HCN”
    And I too think my back got better through stretches, which could be called exercise, except I do it before I even get out of bed in the morning so it aint that strenuous.

  16. #16 sailor
    May 23, 2007

    And let us see if we can give orac high blood pressure with this one:
    Dental healer finds share of faithful believers

    http://www.heraldtribune.com/apps/pbcs.dll/article?AID=/20070520/FEATURES/705200841

    I partiicularly like this quote:
    “It’s two years since we’ve known him; we’ve never gone to the dentist since,” said Sarasota resident Mary Raber, who believes that Jones’ prayers have transformed five of her filings to gold or silver. “

  17. #17 kamagurka
    May 24, 2007

    Q: What do you call alternative medicine that works?
    A: Medicine.

    Fucking brilliant.

  18. #18 HCN
    May 24, 2007

    sailor, would those exercises be something like that described on this page, http://familydoctor.org/online/famdocen/home/common/pain/treatment/117.html ?

    You can also increase your back strength by walking for almost an hour each day (walk to the store, park further away, take a walk around where you work after lunch or in your neighborhood after dinner). I also swim between 1000 to 2000 yards a few times a week.

    Michael, I still want to know which alternative medicine do you feel is effective that has not been studied.

    I am imagining you plugging in a the name of an alt-med into http://www.pubmed.gov and coming up with more hits than you thought were available. Hey, I just found one that compares Reiki to rest for cancer parents!

  19. #19 Michael
    May 25, 2007

    Michael, I still want to know which alternative medicine do you feel is effective that has not been studied.

    You are very persistent. If you scroll back you’ll see I was asking a question: “How much alternative medicine is really normal, valid medicine which has lacked formal study?”

    Then I went on to add that things like aspirin, aloe and camphor, among many, many others, are pharmaceuticals that were derives from “folk remedies”.

    I am not claiming I have knowledge of an alternative treatment which is effective but has not been studied. I stand by the implication in my question, though: I suspect that there are valid treatments, currently considered “alternative” which are effective, in the same way that aspirin is effective. Aspirin was a folk remedy. Now it is medicine. What else is there out there like that? Do you have some problem with this notion?

  20. #20 HCN
    May 28, 2007

    Michael said “Then I went on to add that things like aspirin, aloe and camphor, among many, many others, are pharmaceuticals that were derives from “folk remedies”.”

    AND… they have all been studied extensively. Aspirin is NOT a folk remedy. The willow bark tea is a folk remedy, the refined pharmaceutical is similar but not the same:
    http://www.medicine.mcgill.ca/mjm/v02n02/aspirin.html

    So you still have not answered my question.

    You did answer by saying “I suspect that there are valid treatments, currently considered “alternative” which are effective, in the same way that aspirin is effective. Aspirin was a folk remedy. Now it is medicine. What else is there out there like that? Do you have some problem with this notion?”

    What is wrong with that notion is that aspirin is NOT A FOLK REMEDY… nor has it ever been considered “alternative”.

    Now try again: List a real “alternative” med that you feel is effective and has not been studied. Just be sure it is actually a “folk” med or “alternative”, and not one of the compounds that helped launch a pharmaceutical giant.

  21. #21 HCN
    May 28, 2007

    More on the history of aspirin:
    http://www.bayeraspirin.com/pain/asp_history.htm

  22. #22 Michael
    May 30, 2007

    Umm…learn to read:

    I am not claiming I have knowledge of an alternative treatment which is effective but has not been studied.

    Aspirin was studied because it was previously a folk remedy. From your link, it was known to be effective 25 centuries ago, 1900 years before formal study. What else might be like that? A promising compound that has not yet been studied yet is used effectively today?

    Do you understand? This is a question, not an answer, a question.

    From your response my guess is your answer to this question is that it is impossible that any such substance exists. I think that is idiotic.

  23. #23 HCN
    May 30, 2007

    Your reading comprehension is severely lacking… First sentence of the first link: “Aspirin is a product of the late-nineteenth-century laboratory, pharmaceutical industry, and medical community. ”

    A further sentence: “In contrast, much of the current literature on aspirin (2,3,4) attempts to trace the compound back to antiquity through the Ebers papyrus, the Hippocratic writings, and the works of Galen. Such histories tell a simple, linear tale of the numerous “discoveries” proposed to have led to the use of certain salicylate-containing plants, such as willow bark and wintergreen, or salicylate-related compounds, including salicilin and salicylic acid, as cures for a variety of ailments.”

    Note the word “attempts”.

    Then it continues: “However, the history of aspirin is not as straightforward a tale as conventional histories suggest, but rather is a complex narrative of the people and circumstances involved in transforming a simple chemical compound into a popular pharmaceutical product that has remained one of the most widely consumed drugs for almost a century.”

    Basically, while there is such a thing as willow bark tea… it was very nasty to the stomach. Aspirin is NOT the same as willow bark tea.

    From the SECOND link: “Greek physician Hippocrates prescribes the bark and leaves of the willow tree (rich in a substance called salicin) to relieve pain and fever. ”

    Followed by in 1832: “A German chemist experiments with salicin and creates salicylic acid (SA).”

    In two simple sentences you should learn that the “folk medicine” was salicin… but aspirin is salicylic acid. They are not the same.

    Try working on your reading comprehension.

    The rest of your comment is incomprehensible. You have not yet answered my question: Which alternative med do you feel is effective that has not been studied?

    Don’t use aspirin as an example because:

    1) It was never a folk medicine.
    2) It launched a large pharmaceutical.
    3) It has been studied extensively.

  24. #24 HCN
    May 30, 2007

    I would also suggest that you look up which modern pharmceuticals in present use were actually refinements of plant matter. Like what pharmaceutical is derived from foxglove? (hint: look up its botanical name).

    Check out this picture to see what drug research involved in the early part of the 20th century:
    http://content.lib.washington.edu/cdm4/item_viewer.php?CISOROOT=/uwcampus&CISOPTR=768&REC=3

    (By the way, that garden almost became plowed under… but was saved by a group called “The Friends of the Medicinal Herb Garden”. The Biology Dept. is trying to get graduate students organized to provide tours of the garden… which is near their greenhouses, somewhere between the School of Medicine and Chemistry buildings… oh and the football stadium…. and right off of a major regional bike path that I use when I visit it).

    The object of Orac’s blog post is why do purveyors of alternative medicine like Hulda Clark, Kevin Trudeau, sellers of laetrile, homeopaths and others can get away with more than those who practice real medicine.

    So you asked “How much alternative medicine is really normal, valid medicine which has lacked formal study.”

    To which I asked YOU… tell me which alternative medicine do you feel is valid but has lacked formal study.

    To which you answered “aspirin”… Since that is an extensively studied chemical (which is derived from an old folk med, but not a folk med), I will now surmise that the answer you now will give is: Nothing.

    Not Reiki, not laetrile (which has been studied), not homeopathy (cue the entry of Brave Sir Dana with his poor comprehension of studies done in Austria), not applied kinesiology, not cranialsacral therapy, not chelation therapy for autism or cardiology, not ear candling, not bloodroot salve (which removed the nose of one victim) and on and on and on.

    By the way I am presently reading:
    http://www.amazon.com/Natural-Causes-Politics-Americas-Supplement/dp/0767920422/

    Which goes to the heart of Orac’s and Dr. Novella’s postings on the double standard of alternative meds versus real medicine.

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