Respectful Insolence

More credulous reporting on placebo effects

Now that Trine Tsouderos no longer works for the Chicago Tribune, there aren’t that many reliable generalist medical/science reporters around any more. For example, here in the U.S. there’s Marilyn Marchionne at the AP, Gina Kolata of the New York Times, and then there’s Sharon Begley, who used to be at Newsweek but is now at Reuters I’m having trouble thinking of others with national prominence, other than Nancy Snyderman, who has recently profoundly disappointed me with a fawning report on “complementary and alternative medicine” (CAM) that made it seem to be the greatest thing since sliced bread, and Sanjay Gupta. Unfortunately, although Marchionne is rock-solid reliable when it comes not to falling for the blandishments of quackademic medicine, Sharon Begley is less reliable. For every article in which she’s right on target (for instance, this one, where she explains why a study that purported to show that cancer survival is worse in Europe shows nothing of the sort or this one about Steve Jobs’ cancer), she churns out articles that come to very dubious conclusions. In particular, a few years ago she really annoyed me with a truly clueless article about doctors “hating science.” Unfortunately, her most recent article in The Saturday Evening Post, Placebo Power, is more like the latter than the former.

Very frustrating.

It’s been a while since I’ve written about placebo effects, at least as the main topic of a post. I must admit, my views on placebo effects have evolved over the last couple of years to the point where I now think much less of them than I used to. Not all that long ago, I used to buy somewhat into the current narrative that placebo effects are powerful. Since then, however, over time I’ve come to the conclusion that most doctors don’t really understand placebos. Unfortunately, CAM practitioners, who apparently have switched from “complementing” real medicine with quackery to “integrating” quackery into real medicine to produce “integrative medicine,” have seized upon placebo effects to justify their nostrums, having apparently started to realize that science and evidence are not showing any specific therapeutic effects attributable to their woo. “Hey!” they seem to be saying, “I know that acupuncture doesn’t really do anything, but it invokes the powerful placebo effect, and that’s what heals. Heck, you can even have placebo effects without deception” (except that, no, you really can’t.)

Don’t believe me? Then get the hence to some of my old posts, where I argue that this use and abuse of placebo medicine by CAMsters is in reality a manifestation of a very old aspect of medicine: Paternalism. It’s also more than a bit of magical thinking. Unfortunately, a lot of journalists eat this stuff up, basically doing the quackademics’ work for them and serving as mouthpieces for their messages. Sadly, that’s the function Begley’s most recent piece serves, and it doesn’t take long for her to fall for the “wishing makes it so” fantasizing that so often characterizes reporting on placebo medicine. After an example of patients feeling better after placebo interventions, Begley leaps to this speculation that could have come from Ted Kaptchuk himself:

It is tempting to say that “mere thought” or “mere belief” caused these patients to feel and function better, just as the child’s trust in her mother made her knee feel better and our belief that little white pills will relieve a headache made the calcium tablet do so, even though it contained not a speck of headache-fighting medication. But if doctors and scientists have learned one thing about the placebo response or placebo effect, it is this: There is nothing “mere” about how thoughts, beliefs, and the power of the mind affect the body.

As researchers find more and more conditions that respond to placebos, they are gaining new respect for the power of mind. They are also learning how a belief or expectation can travel from the brain to arthritic knees, asthmatic airways, hypertensive blood vessels, and sites of pain. Understanding these mechanisms holds out the promise of tapping the placebo response more systematically, so more illnesses can be treated not with pills and operations (which almost always come with side effects or other risks) but with the power of the mind. “What we believe and expect can significantly influence the outcome of a disease, how much pain we feel, even whether Parkinson’s symptoms diminish,” says neuroscientist Mario Beauregard of the University of Montreal, who examines the brain basis for the placebo response in his 2012 book, Brain Wars.

No, what we believe and expect can influence the subjective symptoms of a disease or condition. There’s no good evidence that what we believe and expect can have a significant effect on hard outcomes. For instance, there’s no evidence that placebo effects or expectation can result in prolonged survival or a better chance of a remission in cancer treatment. The only time one can reliably see placebo effects is for the measurement of more subjective outcomes, such as pain, nausea, and the like, but the effects are highly variable. Moreover, although Begley seems oblivious to components of observed placebo effects that are not magical or due to the “power of the mind,” such as observer bias and other undetected biases in clinical trials. Indeed, it has been said that much of what is reported as “placebo effects” is actually an artifact of how randomized clinical trials are carried out. Not necessarily all, but, let’s just put it this way: Although I’m not sure I’m ready to come to the conclusion that Mark Crislip has come to argue that there is no placebo effect, although I do agree with him that the placebo response represents “the beer goggles of medicine” in that much of what is being observed are changes in the patient’s perception of his or her symptoms rather than true changes in the underlying pathophysiology.

An excellent example of this was a study that we discussed at TAM a couple of years back in which placebos were tested in asthma, along with real asthma medicine. The studie’s been blogged about extensively; so I’ll cut to the chase, rather than explaining it in my usual Orac-ian detail. Basically, patients receiving the placebo acupuncture felt better, as good as those who received treatment with a real albuterol inhaler. However, the pulmonary function tests did not bear that out. Basically, the placebo intervention produced the illusion of improvement, which in the case of a disease like asthma, where it is function, not symptoms, that determine how sick a patient is. It is not hard to imagine a situation in which a placebo intervention falsely leads a patient to feel better, even though his pulmonary function hasn’t improved. Given the nature of asthma, such a false sense of confidence could easily lead to a patient’s death, because it’s not too uncommon for asthma patients to be reasonably functional up to a certain point of lung function deterioration and then be “tipped over the edge.” In other words, it’s not good to give asthma patients a sense of feeling better if their lungs are not actually functioning better.

Funny that Begley didn’t mention that study, although she did mention asthma as a disease that placeboes could effect. She does, however, mention a whole bunch of studies that, as you might expect, use subjective outcomes. Well, most of them discuss subjective outcomes. One of them is about Parkinson’s disease:

In Parkinson’s disease, production of dopamine in structures called the substantiae nigrae declines. That means dopamine, the very same molecule whose production is raised when we expect something good to happen to us, is AWOL in Parkinson’s. Scientists led by neurologist Jon Stoessl of the University of British Columbia gave a small group of Parkinson’s patients injections of a saline solution but told them it was medication. Sure enough, the patients’ brains began producing more dopamine and their movements became better controlled and less shaky—improvements equal to those in patients who received an actual Parkinson’s drug. In Parkinson’s disease, “the placebo effect is real, it’s huge and it’s got a physiological basis,” Stoessl told the journal Nature.

It’s true that Stoessl said this in a news article in 2011. What Begley fails to note is that in the very same Nature article, his assertion is questioned:

Many regard bias as a more significant confounder. “Investigators have a tremendous vested interest in seeing that their treatment is effective,” says Anthony Lang, a neurologist at the University of Toronto in Canada who has participated in several neurosurgical trials for experimental Parkinson’s therapies. In any trial, bias can affect how researchers assess patient responses and may inflate the patients’ expectations, further enhancing the placebo effect. Compounding the problem for Parkinsons’ research is the fact that there are no objective measures for how well a patient is doing. “It’s just a sort of perfect storm conspiring against our ability to see definitive changes in the underlying disease,” says Steven Piantadosi, a clinical-trials methodologist at Cedars-Sinai Medical Center in Los Angeles, California. “Sham surgery, properly done, can control for that.”

Throughout the entire article, there is very little in the way of anything that resembles significant skepticism regarding the statements made by the people she interviews, all of whom are clearly believers in placebo effects, in particular Ted Kaptchuk, whom we’ve met on multiple occasions before on this very blog. She even completely buys into Kaptchuk’s infamous study from a couple of years ago in which he claimed he had demonstrated that he could induce placebo effects without deception, describing it straight, as though, yes, that’s exactly what Kaptchuk had shown. As it turns out, he had shown nothing of the sort, having in fact used a bit of deception about the placebo, despite his spin.

In the end, Begley fell for nearly every trope that CAMsters who have co-opted placebo effects as the explanation how their woo allegedly “works” want people to believe. I’m hoping that she redeems herself with her next story, but I’m not counting on it.

NOTE: Steve Novella has also discussed the issues with Begley’s article.

Comments

  1. #1 Pris
    The Dark Side of the Force
    January 16, 2013

    Interesting. With my lay understanding of medicine I had always assumed that the placebo effect was entirely based in the subjective perception of symptoms with no actual change of objective measurable quantities and no physical changes.
    Are there actually medics who believe that the placebo effect actually leads to physical changes?

  2. #2 Pharmacist-in-Exile
    Just across the Post Office
    January 16, 2013

    I no longer use the term “placebo effect” for anything outside a study controlled by a supposedly non-active intervention (a placebo intervention). I try to be honest about my stand against implausible interventions and just talk about the power of suggestion, which in all its paternalistic glory usually is what people mean anyway.

  3. #3 WoefullyUnderEducated
    January 16, 2013

    I was just discussing this before I logged on to get my daily fix!( obviously Im psychic. I mean coincidence? Grow up)
    I seem to remember in Ben Goldacres fantastic book ‘Bad Science’ he mentioned that on occasion shrinking tumours have been attributed to the placebo effect. That confused me for a long time because I had less of an understanding than I do now of what gets labeled as the placebo effect. In short, simply because a person in the placebo group improved and had physiological changes, does not mean the placebo treatment was the cause but lacking specific evidence it must be included in the study.
    It seems to me that the whole concept and categorisation of the effect is very boring and a bit complicated, Im still not sure I get it (what I wrote above could easily be flawed but its my current understanding, correction welcome) but I feel that making more public and getting some media coverage of what the effect is and is not could really help unscientific people to make better decisions. Like wise with the structure, process and quality of studies. Dr Goldacre does a great job of that but we need more people sexing up these two basic concepts and making them common knowledge. I think it would leave less hiding places for quacks.

  4. #4 Dangerous Bacon
    January 16, 2013

    A classic example of credulous reporting over what almost certainly is placebo effect came this past week, when local and national media reported on “groundbreaking” treatments for traumatic brain injury (excuse me if I alluded to this in a previous post).

    A former Cleveland Browns quarterback, Bernie Kosar, held a news conference to promote the work of Dr. Marvin “Rick” Sponaugle, an anesthesiologist who runs a Florida drug detox clinic. Using unspecified “intravenous treatments” and dietary supplements, the doc claims to improve blood flow to the brain. Not only that, brain damage magically disappears:

    “Kosar said he started seeing almost immediate results. His positron emission tomography (PET) scans, which detect damage to the brain, are showing improvement….

    “Sponaugle, who also works with patients suffering from Alzheimer’s disease and multiple sclerosis, provided little detail about his therapy Thursday. He did reveal he has treated about 20 former and current NFL players.”

    ht_p://www.cleveland.com/browns/index.ssf/2013/01/former_cleveland_browns_qb_ber_1.html

    What elementary investigation (which the reporters didn’t bother with) would have shown is that Sponaugle, who claims to have been researching the brain for 15 years, has zero published papers on the subject indexed in Pub Med, but has co-authored a nutrition book with a naturopath (Brenda Watson, who is praised by Suzanne Somers as being a “one-woman crusade for gut health). Woo-meters go off scale.

    Credulous reporting indeed.

  5. #5 Mephistopheles O'Brien
    January 16, 2013

    I’m still waiting for the double blinded study that shows that a placebo has more effect than, say, a sugar pill.

  6. #6 Mu
    January 16, 2013

    MO’B, every trial of homeopathy fulfills that criterion.

  7. #7 tgobbi
    January 16, 2013

    Orac: “Now that Trine Tsouderos no longer works for the Chicago Tribune, there aren’t that many reliable generalist medical/science reporters around any more.”

    This is certainly true at the Trib itself. There are more-or-less frequent exceptions but, by and large, Ms. Julie Deardorff (whom I lovingly refer to as the Trib’s “pseudoscience writer”) is the paper’s health reporter. For better or for worse. Mostly worse. She writes an occasional column that presents a modicum of mainstream information but over the years I’ve seen a distressing tendency to print highly questionable “advice” as viable alternatives to science-based theories. Homeopathy doesn’t offend her senses and various naturopathic nonsense has appeared over the years, along with other egregious offenses to reason. She appears to adhere to the “science as democracy” principle – the one that accepts the possibility that there are multiple truths.

    I miss Ms. Tsouderos’ columns but, even though I found them scientifically tenable most of the time, we did exchange the odd email that showed we didn’t always see eye-to-eye.

  8. #8 Brian Deer
    January 16, 2013

    An aspect of the problem in journalism, I think, is that 99.9% of science journalism might reasonably carry the label “advertising”. It’s a branch of PR: aiming to mediate between science and the public, explaining one to the other.

    Very few journalists have the luxury of the time needed to understand something to the point where they can see the flaws and contradictions. Then there’s a bunch in the technical press who have Ph.Ds in something or other and can’t understand a field barely a cigarette paper away from their thesis topic. And I know of a Nature has a reporter who likes to write about science fraud, who plainly doesn’t even know what it is. She did one recently where she said that a Harvard panel had found “fabrication”, but was that really fraud? Duh.

    Since you can’t really have many medical doctors in journalism (the pay’s too poor and you wouldn’t expect doctors to be particularly critical anyway) you have depend on a few remaining media organizations that can give their people enough time to work up the background to find and understand stories. And there ain’t many such organizations left.

  9. #9 Jeffrey
    Ohio
    January 16, 2013

    So now CAMs claim that homeopathic pills work because of the placebo effect? Wow. That sounds like a total admission of fraud and deception on a massive level. I know from personal experience having mixed up my meds on occasion, that I’m susceptible to the placebo effect. For example, mistakenly taking my sleeping meds in the morning and my morning meds at night, and I didn’t notice any change from when I took them normally. Once I discovered that I just took my sleeping meds at 6am, I did start to feel quite tired despite having just slept 6 hours.

  10. #10 THS
    January 16, 2013

    @Dangerous Bacon: Thanks. I’d seen the Kosar article and the language suggested something shady. But I didn’t follow up as you did – just wondered if it would make RI.

    As usual, Orac’s post contains links to material to entertain & educate. (Still relatively new here.) – Placebo something – Elsewhere I noticed some commentary about the term “placebo effect” being too positive, as it suggests a significant physiological response to some people (I know that thought & mood are physiology but I’m thinking is about the course of the disease disease.) I do like the term “sham” as in sham surgery. One might consider substituting “sham effect” for “placebo effect” but that would be spitting into an ocean of established terminology,

    Placebos could have good utility, depending on your point of view. Example I’ve used before – the dude outside the Grateful Dead show: “get your placebos here…”

  11. #11 WLU
    January 16, 2013

    Placebo effects are about feeling better about your illness. Medicine is about your illness getting better.

  12. #12 Dave Ruddell
    January 16, 2013

    What happened to Tsouderos? Did she get another job? Was the Trib downsizing?

  13. #13 jane
    January 16, 2013

    Conventional medicine is frequently used simply to relieve symptoms – sometimes at the cost of increased risk to life – and nobody sees a problem with that use. Nobody says it is Woo or Quackery to put a person with arthritis on NSAIDs for years or decades, which obviously shows that the treatment is not curative in nature or intent. Nor do they say that it is unethical or bad to do so, even though NSAIDs increase the user’s risk of kidney failure, heart attack, or blindness. If in a clinical trial acupuncture produces better pain relief than a drug, while, like the pill, not curing the arthritis, this is a fact that you have to deal with, one way or another. Is the placebo-only effect of acupuncture capable of offering better benefits than the placebo-plus-drug effect of the pill? Then placebos do have a clinically useful effect in an area that is generally considered a legitimate aspect of conventional medicine. Are placebos ineffective by definition? Then acupuncture must have a biological influence on the nervous system that just hasn’t been figured out yet. Many patients, of course, are only interested in outcomes and could not care less about the mechanism[s!].

  14. #14 Mu
    January 16, 2013

    Jane, specifically acupuncture has been shown to be 100% placebo, with no difference between “real Chinese acupuncture”, random needle poking and sham acupuncture where the skin is not penetrated. As long as the patient believed in it it “worked”.

  15. #15 JustNuts
    January 16, 2013

    “As researchers find more and more conditions that respond to placebos…”

    Pretty easy to find – Self limiting and psychosomatic conditions!

  16. #16 Denice Walter
    January 16, 2013

    Amongst the reasons I focus upon the most egregious sources of pseudo-scientific mis-information I can find is because I flatter myself into thinking that I might help prevent the some of more serious damage people might inflict on themselves by following such *sage* advice
    AND it keeps me from squandering more time reading bad science from more legitimate sources.
    While the former often makes me laugh, the latter usually makes me want to cry.
    I suspect it won’t improve either.

  17. #17 Chris
    Neither here nor there...
    January 16, 2013

    jane:

    Conventional medicine is frequently used simply to relieve symptoms – sometimes at the cost of increased risk to life – and nobody sees a problem with that use

    Please tell why treating asthma symptoms that make it easier for a person to breathe is a bad thing. Also explain why treating the symptoms of my son’s genetic heart condition like high blood pressure and tachycardia with a beta blocker.

  18. #18 Science Mom
    http://justthevax.blogspot.com/
    January 16, 2013

    Nobody says it is Woo or Quackery to put a person with arthritis on NSAIDs for years or decades, which obviously shows that the treatment is not curative in nature or intent. Nor do they say that it is unethical or bad to do so, even though NSAIDs increase the user’s risk of kidney failure, heart attack, or blindness.

    A frequent attack on medicine but without merit. You see jane, while true on the surface, the reality is much different. These side effects are known and the patient informed of these but the patient prefers a better quality of life (we are rather myopic creatures) in the short-medium term rather than suffer. While yes, NSAIDs are not curative that doesn’t mean that there isn’t ongoing research into prevention and better treatments/curatives for chronic conditions such as arthritis.

  19. #19 Science Mom
    http://justthevax.blogspot.com/
    January 16, 2013

    What happened to Tsouderos? Did she get another job? Was the Trib downsizing?

    Alas she bailed for a more lucrative career in PR:
    http://www.mediabistro.com/prnewser/roll-call-syndicate-media-group-golinharris-buzzfeed-and-more_b45396

  20. #20 Denice Walter
    January 16, 2013

    I seem to have lost a comment- well, here goes…

    About 30 years ago, my friend E and I were in physio class with other students idly speculating upon possible mechanisms for accupuncture ( chemical, signalling etc): after what felt like hours, the prof summed up that perhaps eventually research would tell us how it works.

    Now we know.

  21. #21 Old Rockin' Dave
    January 16, 2013

    I am a former physician assistant who had a few placebo interventions as part of my “bag of tricks”. It has always been clear to me both as practitioner and patient that anxiety is a large component of the perception of pain and other symptoms, and sometimes a cause of symptoms in itself.
    The perception that something is being done, or is in the works, sometimes reduces anxiety and therefore reduces subjective perception of the symptoms.
    Here’s a little something on this:
    http://www.drmirkin.com/morehealth/9231.html.
    Note that I know nothing about this website other than what you see on the linked page.

  22. #22 Narad
    January 16, 2013

    What happened to Tsouderos? Did she get another job? Was the Trib downsizing?

    The Tribune is in a state of disarray in the aftermath of Sam Zell. I’m pretty sure most everyone there would jump at a more stable gig.

  23. #23 Dangerous Bacon
    January 16, 2013

    Brian Deer said: “Since you can’t really have many medical doctors in journalism (the pay’s too poor and you wouldn’t expect doctors to be particularly critical anyway)”

    I think Brian is underestimating both the critical capacity of physicians and their willingness to aid in medical reporting. There are plenty of docs who, for instance, have little to no connection to pharmaceuticals in their practices, and when they have research interests, investigate matters far removed from the “breakthroughs” reported in the news media. It wouldn’t be so hard to recruit some of them (including retired docs with expertise but time on their hands) as consultants on news stories.* Apart from unwillingness to pay part-timers’ salaries, it seems likely that news organizations either don’t see the need for better medical reporting or perceive skepticism as a threat to ratings (it’s more appealing to announce a grand breakthrough than to suggest that it has limited application and that there are flaws in the research).

    *some of us even have a background in journalism (hint, hint).

  24. #24 Denice Walter
    January 16, 2013

    @ Dangerous Bacon:

    Actually, I see you more of a Dr Barrett type myself, oh dangerous one.

  25. #25 Mephistopheles O'Brien
    January 16, 2013

    jane – A difference is that when real medicine treats symptoms, it is stated as such and the medicine has been shown to have an effect on said symptoms. Thus there’s no trickery involved.

    If you were to give someone a placebo treatment and say, “we know this does nothing, but if you believe in it hard enough you may feel the symptoms less”, then I cannot see that there would be an ethical issue.

  26. #26 Mephistopheles O'Brien
    January 16, 2013

    jane – I would, though, appreciate some references to studies that show that placebos have an actual effect on symptoms rather than on the perception of symptoms. There’s an example above that placebo actually affect lung function (the symptom) but that people felt that it had (the perception of the symptom). Is there an example the other way?

  27. #27 Denice Walter
    January 16, 2013

    I think that there is a huge reservoir of interest for science-based material: one of the reasons that alt media ( like the crap I survey) manages to acquire an audience and sell books etc- is because people want to understand how the world operates, including their own bodies and minds, in order to make their own lives BETTER.

    Now alt med promoters utterly betray their audiences by providing fraud, prevarication and sugar-coated fantasies whilst posing as scientists, researchers and bold maverick paradigm-shifters. I have heard people sincerely ask a particular poseur questions about serious illness repeatedly and frankly, it makes me ill every time.

    But people are searching for answers and perhaps are taken aback by the complexity of recent developments in medicine and technology. Easy answers aren’t always possible. Woo-meisters take advantage of this by watering-down reality and substituting an attractive fiction which insures fame and fortune for themselves.

    I think that average people can handle reality.

  28. #28 Narad
    January 16, 2013

    Oh, for f*ck’s sake, All Things Considered just put Babs Fisher on the air.

  29. #29 Narad
    January 16, 2013

    (The topic being this.)

  30. #30 Mephistopheles O'Brien
    January 16, 2013

    Oh, for f*ck’s sake, All Things Considered just put Babs Fisher on the air.

    On the other hand, they stressed repeatedly that all the studies say that the current vaccine schedule was safe.

  31. #31 Denice Walter
    January 16, 2013

    @ Mephistopheles:

    But still ( I am assuming that NPR is somewhat legit), they provide a platform for BLF’s nonsense – it makes her look as though she has something of value to say.
    I’m sure that excerpts of this will be provided- meticulously editing out the criticism- by all of the usual suspects:
    ” BLF is SO respected as an expert and asked about vaccines on the radio” or suchlike.

    -btw- she is awful.

  32. #32 Science Mom
    http://justthevax.blogspot.com/
    January 16, 2013

    Oh, for f*ck’s sake, All Things Considered just put Babs Fisher on the air.

    Gotta present that “other side” right? All in all, a reasoned reporting on the IOM report and brief, shrill phone-in appearance by BLF.

  33. #33 Denice Walter
    January 16, 2013

    A question to whoever listened in to this:

    was BLF a scheduled guest appearing via the phone – or merely someone who called in, i.e. on her own?

  34. #34 S
    January 16, 2013

    A former Cleveland Browns quarterback, Bernie Kosar, held a news conference to promote the work of Dr. Marvin “Rick” Sponaugle, an anesthesiologist who runs a Florida drug detox clinic

    @Dangerous Bacon, I wrote a long comment about Rick Sponaugle on the ‘Joe Jackson’ post. He does a lot of questionable stuff.

    http://scienceblogs.com/insolence/2013/01/11/in-which-joe-jacksons-wisdom-about-cancer-is-apparently-not-validated/

  35. #35 Narad
    January 16, 2013

    was BLF a scheduled guest appearing via the phone – or merely someone who called in, i.e. on her own?

    It’s not a call-in program; this was an assembled report. She also might want to invest in a decent phone. The audio’s up; it’s four minutes.

  36. #36 Denice Walter
    January 16, 2013

    @ Narad:

    She probably should invest in a decent education as well.

  37. #37 Interrobang
    January 17, 2013

    As far as I understand it from what my doctor said, NSAIDs do things for arthritis; they’re not just symptomatic treatment. Curbing the inflammation helps slow the damage to the bones. Speaking as somebody who has had arthritis since the age of 28, I’d really rather take a pill now and again to increase the chances of being functional into my 50s and 60s than leave it to chance and quackery.

    Speaking from personal experience, NSAIDs don’t even do all that much for the pain from the arthritis, either, at least not once it has flared up…some “symptomatic treatment.”

  38. #38 Nomad
    January 18, 2013

    You’ve all pretty much picked up on the slight of hand Jane tried to pull, but I can’t resist piling on.

    Basically she tried to swap out “symptom” for “imagined effect”. If placebos that only make people think their symptoms are getting better are no good, then what good is a drug that has an actual effect on the symptoms? Surely the answer is self evident when the question is phrased that way.

    Jane, let’s go with a theoretical example. Let’s say you find yourself in the doctor’s office, about to undergo a root canal. You’ve been given the choice between Novocain, and a placebo local anesthetic. I think we can agree that Novocain is simply treating a symptom here. It certainly doesn’t do anything to treat the actual dental problems, it simply means that when harsh things are being done to your teeth you don’t experience pain from it.

    So, are you arguing that Novocain is the same thing as a placebo pain reliever? Would you happily turn away from the evil old pharmaceutical drug in favor of the all powerful mind-body effect? Or would you suddenly understand what you’re trying so hard to be oblivious to here?

    And come come, who do you think you’re fooling? You don’t actually believe those studies that were done on acupuncture. If you did, you’d be embracing “twirling toothpicks against the skin”, because studies have shown that to be just as effective as spearing needles into the skin. Somehow I never hear about “acutwirling” though. Why is that, Jane?

  39. #39 jane
    January 18, 2013

    Heh! The amount of bad logic around here is too great for me to debunk in detail; the two earliest messages attacking me offered blatant Straw Man Fallacies, which I thought would be adequately obvious to anyone who’s been trained to think. You, like Mephistopheles O’Brien, seem to be playing a different game in attempting to redefine “symptom”, though your message is incoherent enough that it is hard to tell. Many symptoms are, by definition, subjective: pain, fatigue, shortness of breath. If you feel less pain, then your pain is getting better. Period. If you want to argue otherwise, you will need to provide both a biological and a philosophical rationalization for your belief.

    Placebos and Novocaine both have been proven to relieve dental pain (did you know that?), but the latter relieves it more, so it is rational to prefer the latter. If for another condition acupuncture relieves pain more than the pharma drug, or provides similar relief without toxicity, it is equally rational to prefer the former. I have discussed acupuncture literature in comments before, and there’s no point in repeating myself in detail, but the Toothpick study is *totally worthless* by the definition that is applied to every positive acupuncture study, because it was not double-blinded. Also, if inserting needles into the skin has a biological effect on the nervous system, it would likely be possible to stimulate that effect by gouging people with toothpicks hard enough to make them think they’d been stuck with needles. The study, or at the very least its interpretation for propaganda purposes, is intellectually dishonest (and I use that term as a scientist, very deliberately).

  40. #40 AdamG
    January 18, 2013

    , if inserting needles into the skin has a biological effect on the nervous system, it would likely be possible to stimulate that effect by gouging people with toothpicks hard enough to make them think they’d been stuck with needles

    Why is this necessarily true?

  41. #41 JGC
    January 18, 2013

    if inserting needles into the skin has a biological effect on the nervous system…”

    And if my aunt had balls she’d be my uncle. That isn’t the case either.

  42. #42 Krebiozen
    January 18, 2013

    jane,

    Many symptoms are, by definition, subjective: pain, fatigue, shortness of breath. If you feel less pain, then your pain is getting better. Period. If you want to argue otherwise, you will need to provide both a biological and a philosophical rationalization for your belief.

    Of your three examples only pain is by definition subjective; there are objective ways of measuring fatigue (a continuous thumb pressing task, for example) and shortness of breath (spirometry). Placebos at best only affect subjective assessment, but not objective measures of symptoms.

    If for another condition acupuncture relieves pain more than the pharma drug, or provides similar relief without toxicity, it is equally rational to prefer the former.

    Acupuncture is not risk free; there have been cases of infection and even punctured lungs from acupuncture. There is also the matter of convenience; it is far more convenient to take a pill when required than to find an acupuncturist. Also, clinical trials are (or should be) carefully designed to eliminate placebo effects, whereas in clinical practice the effects of a pill will include placebo effects (in the popular sense of the term) i.e. in real life we are comparing a pill to no treatment, rather than to a placebo.

    Presumably you have in mind some condition in which acupuncture is reliably more effective than standard care, otherwise your argument collapses. What is it?

  43. #43 jane
    January 18, 2013

    I’ll just point out one more round of logical errors, then leave you to enjoy those to which you are emotionally attached:

    AdamG: “If” does not imply “necessarily”; neither does “likely”. It does not seem obviously implausible to me that one can affect the nervous system without breaking the skin. The subjective perception of being poked with a needle or Toothpick must arise from the stimulation of nerve endings, after all.

    JCG: “Evidence?” I wish I could enjoy such wonderful certainty about all of my opinions. I will check back in a couple of days to see if you have provided any citations that directly support this claim, and will follow up by reading them if so.

    Krebiozen – I have in the past listed some clinical trials that report acupuncture doing as well as or better than pills; you can use the search function, and you can look them up on PubMed, if you are genuinely interested..

    The idea that shortness of breath is identical to someone’s number on a spirometry test is not a standard use of language. (Attempting to impose nonstandard definitions is a Fallacy, by the way.) A patient’s complaint of shortness of breath is, in fact, a symptom, and it would remain their symptom even if their spirometry test was totally normal. Clinical trials do measure things like spirometry, but they also, if the investigators care about meaningful patient outcomes, ask patients to rate things like shortness of breath and fatigue. If patients are told that their Numbers are better but they feel worse, it is at best a value-laden statement to claim that they have been helped. It is also questionable to suggest that a thumb-pressing test is a better assessment of global fatigue than a numerical rating of global fatigue.

    It is also rather strange to see you apparently claim that psychological factors cannot influence how many times your thumb can push a button. In real life, if you feel stronger, you perform a little better physically; you would say that this is “subjective” and not worthy of interest. But you now want to assume that this effect doesn’t apply to your thumbs; why not?

    And finally, I will just note that where studies of herbal medicine are concerned, I have seen people yammer that “objective” effects such as walking distance, exercise tolerance, and left ventricular ejection fraction, or normalized liver enzymes or reduced hepatitis B viral loads, must be due to placebo effects – this though they derived from placebo-controlled clinical trials! It is no wonder that some people think placebos are magic panaceas when they see how many clinically significant objective trial results are dismissed as Just A Placebo.

  44. #44 AdamG
    January 18, 2013

    It does not seem obviously implausible to me that one can affect the nervous system without breaking the skin. The subjective perception of being poked with a needle or Toothpick must arise from the stimulation of nerve endings, after all.

    I didn’t say it was implausible, although in my opinion it’s highly unlikely. What I meant was that you have no evidence for that statement. Thus, we must accept the null hypothesis that sham acupuncture and real acupuncture do not have the same effect at the neuron level, if any at all.

  45. #45 Krebiozen
    January 18, 2013

    jane,

    I have in the past listed some clinical trials that report acupuncture doing as well as or better than pills; you can use the search function, and you can look them up on PubMed, if you are genuinely interested..

    That’s why I specified “reliably”, because the evidence is inconsistent, even in conditions like lower back pain (PDF) in which standard care isn’t very effective so acupuncture looks relatively good in comparison.

    The idea that shortness of breath is identical to someone’s number on a spirometry test is not a standard use of language. (Attempting to impose nonstandard definitions is a Fallacy, by the way.) A patient’s complaint of shortness of breath is, in fact, a symptom, and it would remain their symptom even if their spirometry test was totally normal.

    I think objective lung function is more important than subjective symptoms. No one ever died of subjective shortness of breath that could not be measured with a peak flow meter. If someone is reporting shortness of breath that cannot be measured, it seems likely their problems are psychological in nature.

    Clinical trials do measure things like spirometry, but they also, if the investigators care about meaningful patient outcomes, ask patients to rate things like shortness of breath and fatigue.

    I have asthma, and my health care provider is only interested in my peak flow measurements. I am quite happy with this, as I consider an improvement in this as the only important and meaningful measure of how well my asthma is controlled. I have never experienced shortness of breath that did not register on my peak flow meter. I am certainly not interested in a treatment that makes me feel better without improving my capacity to breathe.

    If patients are told that their Numbers are better but they feel worse, it is at best a value-laden statement to claim that they have been helped.

    Not really, since asthma can and does kill people.

    It is also questionable to suggest that a thumb-pressing test is a better assessment of global fatigue than a numerical rating of global fatigue.

    You seem to be suggesting that symptoms as reported by patients do not have any objective physical corollary. That’s an interesting philosophical position, but not very practical in the practice of medicine. These things have been studied, which is how various measures of fatigue have been developed.

    It is also rather strange to see you apparently claim that psychological factors cannot influence how many times your thumb can push a button. In real life, if you feel stronger, you perform a little better physically; you would say that this is “subjective” and not worthy of interest. But you now want to assume that this effect doesn’t apply to your thumbs; why not?

    As you wrote, you may perform “a little better”. The small improvements seen due to placebos like acupuncture are usually clinically insignificant, which is why I don’t think they are worthy of interest. The “placebo effect” is a much abused and misunderstood term.

    And finally, I will just note that where studies of herbal medicine are concerned, I have seen people yammer that “objective” effects such as walking distance, exercise tolerance, and left ventricular ejection fraction, or normalized liver enzymes or reduced hepatitis B viral loads, must be due to placebo effects – this though they derived from placebo-controlled clinical trials!

    Do you have any examples of this?

    It is no wonder that some people think placebos are magic panaceas when they see how many clinically significant objective trial results are dismissed as Just A Placebo.

    Again, do you have any examples of this? I have seen this argued many times, but whenever I have actually looked at the evidence, it doesn’t support the claims made. For instance, I have often seen the claim that sham knee surgery is effective due to placebo effects. When I looked at the studies involved I found that they were comparing real knee surgery with sham knee surgery, not with not treatment at all, and that neither real nor sham surgery led to any objective improvement in knee function. Also, you seem to misunderstand what is meant by”the placebo effect”. It refers to any apparent non-specific change in a control group, which may be due to natural variations in severity, or regression to the mean, or various other non-specific effects.

    I don’t think anything you have written challenges the view that placebos may make people feel better without affecting their underlying condition. Of course feeling better is important, but not as important as an actual objective change. In the case of shortness of breath, subjectively feeling better without an objective improvement in lung function could be dangerous. Placebo effects are mostly small, clinically insignificant and unreliable. In the case of homeopathy and acupuncture they encourage a belief in pseudoscience, which I think is unhealthy.

  46. #46 Chris
    January 18, 2013

    Jane, one symptom one my kids had when he young was seizures. So how does one use acupuncture on someone having convulsions?

    And I’m still curious on about how it would work for tachycardia.

  47. #47 jane
    January 19, 2013

    God, I don’t know why I keep trying, but – Chris, how do you use chemotherapy on someone with a broken arm? If acupuncture has been reported to treat seizures, either in a clinical trial or in clinical practice, I am not aware of it. You cannot *rationally* demand that any one modality must be useful for every possible medical purpose.

    I also can’t say whether or how acupuncture works for an unspecified “tachycardia”, but at least two clinical trials and a case report have reported it to have some benefit for atrial fibrillation. The individual I know who used it to stop the persistent atrial flutter he was allegedly doomed to suffer forever has no way of knowing for certain that he remains free of it because he continues to use acupuncture, but he doesn’t seem inclined to stop so long as he remains healthy. He says it makes his knees feel better too. Who am I to tell him that his knees don’t really feel better and he must be stupid or gullible to think they do? Nope, not going there.

  48. #48 Chris
    Neither here nor there...
    January 19, 2013

    You are making a claim that real medicine only suppresses symptoms like that is a bad thing. So I presented actual symptoms, and you don’t understand why treating them is a good thing.

    Also, anecdotes are not data.

  49. #49 herr doktor bimler
    January 19, 2013

    You are making a claim that real medicine only suppresses symptoms like that is a bad thing.

    I think you are misreading Jane’s comments.
    I understand her argument to be along the following lines:
    – Despite credulous reporting about placebo treatments, placebos are over-rated in that they only affect subjective states.
    – However, subjective states can be a real symptom (e.g. pain).
    – There is nothing wrong with treatments (including placebos) that address a symptom while leaving the underlying problem in place (case in point: insulin).

    Apologies in advance if I have distorted the argument.

  50. #50 jane
    January 19, 2013

    Herr Doktor Bimler – Thank you. I don’t know that it’s been proven that the placebo effect cannot have an influence on biological parameters that aren’t consciously perceived or currently understood to be affected by state of mind. But I agree completely with the two latter points, which are key. According to my value system, relieving people’s discomforts without imposing worse harm is generally beneficial to them, and the precise mechanism by which that relief is accomplished need not be the basis for judgement as to whether or not the relief is beneficial.

    Chris, another word for a blatant enough Straw Man Fallacy is “lie,” and you’ve crossed the line from offering nonsensical comments into being a simple liar. When did I suggest that symptom-relieving “real” [orthodox American-style Western] medicine was a bad thing? I said that it was a good thing, but that symptom-relieving treatments from other cultures or modalities could ALSO be good things – it needn’t be either-or!

    And when did I say that it would not be a good thing for your kid with the seizures to have his symptoms relieved? Of course it would – whether by drugs, the ketogenic diet, or anything else that worked for him. I said only that I was unaware of any evidence that acupuncture would have helped him. You know, your original statement was irrational enough that I wonder if I shouldn’t interpret what at first seems to be blatant dishonesty on your part more compassionately. I suggested that acupuncture could be a safer alternative to NSAIDs, and you started yowling about acupuncture for seizures. Pause for a moment and think calmly about that, Chris. Did you give your kid NSAIDs for the seizures? Should I expect you to provide proof that ibuprofen cures epilepsy? Then what motivated your rant, really? Because it wasn’t me, so it must have been something within your own mind.

  51. #51 herr doktor bimler
    January 19, 2013

    I don’t know that it’s been proven that the placebo effect cannot have an influence on biological parameters that aren’t consciously perceived or currently understood to be affected by state of mind.

    The first bullet point in my previous comment was intended as a summary of the original post (which inspired or provoked Jane’s defense of the placebo), rather than as part of Jane’s argument. I take the blame for any confusion caused.

  52. #52 Alan Kellogg
    http://opines.mythusmage.org
    January 19, 2013

    Every time I hear sojmebody say there is nothing new to discover, I am tempted to ask; How then does the body repair the damage done by illness or disease?

  53. #53 Narad
    January 19, 2013

    According to my value system, relieving people’s discomforts without imposing worse harm is generally beneficial to them, and the precise mechanism by which that relief is accomplished need not be the basis for judgement as to whether or not the relief is beneficial.

    So your value system would consider ethanol and prescription calcium channel blockers to be basically equivalent treatments for Raynaud’s?

  54. #54 jane
    January 19, 2013

    Narad – According to my values, the costs and harms of a treatment – both those that may be statistically expected, and those that an individual is actually experiencing – can be deducted from the benefits [as defined by the patient's values] felt or seen to estimate the treatment’s net value. I know nothing about the relative efficacy of alcohol and CCB in relieving Raynaud’s syndrome, but let’s assume that they are similar and that enough alcohol to affect function is required. A person who felt that his Raynaud’s merited regular daily treatment would almost never consider alcohol to be an acceptable option. He wouldn’t want to have to drink every morning, smell of alcohol at work, or, if high doses are needed, have to choose between driving and taking his “medicine.” The vast majority of us, unless we are retired and really enjoy the sauce, would find the social harms of alcohol to outweigh the average health harms, even including the increased death risk, of taking CCBs. But that is, of course, a value judgement! [On the other hand, Teh Google tells me that some people find gingko, fish oil and/or niacin useful for Reynaud's syndrome, or can go through a process of acclimatization that reduces the problem. Perhaps a fairer question would be to ask whether those alternative treatments would be an equivalent to CCBs, since they're similarly burdensome assuming you don't have a major CCB side effect, and I would say that yes, if the alternatives worked for me, they'd be every bit as worthy of use as the prescription.]

  55. #55 Narad
    January 19, 2013

    let’s assume that they are similar and that enough alcohol to affect function is required

    Assuming that “affect function” is supposed to mean “cause intoxication,” as it doesn’t seem to mean much otherwise, let’s not.

    A person who felt that his Raynaud’s merited regular daily treatment would almost never consider alcohol to be an acceptable option.

    Might be right down with the nifedipine or diltiazem, though.

    He wouldn’t want to have to drink every morning, smell of alcohol at work

    You are again assuming intoxication. It takes a fair amount of consumption to get a smellable amount being put out by the lungs.

    On the other hand, Teh Google tells me that some people find gingko, fish oil and/or niacin useful for Reynaud’s syndrome

    Have you ever experienced a niacin flush? In any event, you’re just tossing out other chemical agents.

    or can go through a process of acclimatization that reduces the problem

    The hunting phenomenon? Allow me to remind you that you’ve previously brought up workplace concerns.

    I am not really seeing anything in this to suggest that the suggestion ought not to be (just makes you feel) warmly embraced by the analysis embodied by your value system.

  56. #56 Krebiozen
    January 20, 2013

    jane,
    I just wanted to pick up on something you wrote.

    Who am I to tell him that his knees don’t really feel better and he must be stupid or gullible to think they do?

    I’m sure his knees and his atrial flutter do really feel better, but that doesn’t mean that the improvements he experienced were caused by acupuncture. There’s an idea that placebos have an effect when frequently they don’t, and people make a post hoc error of thinking that they do. The changes that are attributed to placebos are often actually due to something else. If someone is subjecting themselves to the expense and risk (albeit small) of acupuncture when the improvements they have experienced would have happened without it, that can’t be a good thing, can it?

    Also, you don’t have to be stupid or gullible to be fooled by cognitive biases; we are all prone to them, they are a part of being human, and are the main reason double-blind clinical trials were developed.

  57. #57 LW
    January 20, 2013

    jane, why do you say that “acutwirling” with toothpicks does not work as well as acupuncture?

  58. #58 jane
    January 20, 2013

    Narad – Your “response” above, with its field of straw men, makes it clear that your original question was a setup. No answer I gave would be acceptable. Not knowing the dose of alcohol needed to alleviate Raynaud’s, I presumed that alcohol would not meet my standards of tolerability. I got bashed. Yet you strongly hint that if I had said yes, alcohol would suit, I would also have been bashed. If one sip of vodka in your coffee in the morning would prevent you from being uncomfortable on the way to work, I would indeed prefer that to taking a CCB for life. I don’t know much of anything about Raynaud’s, so can’t speak authoritatively on the relative merits of CAM treatments for it – though people take niacin voluntarily for “conditions” as asymptomatic as “high cholesterol,” so I certainly will not assume that niacin is unacceptable to everyone. Nor that anything involving sessions of soaking the hands in water must be intolerable – why you think that would interfere with someone’s work is beyond me.

    Krebioze, yes, that’s why we have trials, but then we can’t ignore the results when they show CAM working. The man I mentioned with atrial flutter had had it persistently and was seeking a cardioversion, but facing long delays. Almost immediately after his second session of the acupuncture that was shown useful for AFib in clinical studies, he reverted to sinus rhythm. He hasn’t had AFL again since, though he’d had it twice before and the last -ologist he saw told him he could never get better. Maybe it was just a coincidence that after all those weeks with flutter, he happened to be spontaneously cured just when he started acupuncture. He’s rationally playing the odds.

    LW – I said repeatedly that we don’t know. Some studies of acupuncture versus skin-stimulating non-penetrating acupuncture (called “placebo” acupuncture) show the former to be superior; others find them to be equivalent. It’s possible that transdermal stimulation of nerve endings by sharp poking, without penetrating, could have the same effect as traditional acupuncture. My objection to this study is that it is spun as the proof that all acupuncture is Worthless, when it in fact shows *nothing of any value* by the usual standards of scientism because it was not double-blinded. If the investigators were open-minded and hoped to see a difference between the two groups, they were morons, but at least honest in publishing their garbage results. If they were anti-acupuncture and deliberately using a very active placebo, then the lack of double-blinding represented scientific fraud. We are told constantly that the practitioner must not know or even be able to guess whether a penetrating needle was used, otherwise his biases will cause him to evaluate the subjects in the verum group better or subtly convey more positive attitudes to them. And here we have researchers smirking behind the subjects’ backs with toothpicks in their hands? Now, toothpick-twirling is more labor-intensive than inserting a needle, but it’s readily available at home, so if we could confirm that this really worked – with enough evidence to outweigh all the studies in which it doesn’t work equally – it would make some of the benefits of acupuncture available to people who don’t have access to professional services. But that’s a big if.

  59. #59 al kimeea
    January 20, 2013

    it would make some of the benefits of acupuncture available to people who don’t have access to professional services

    you mean pros who tell their marks their chronic lower back pain is a result of the liver processing gamma rays in the skull and so pokes their noggins?

  60. #60 LW
    January 20, 2013

    jane, thank you for your thoughtful response to me.

    I am not sure that an acutwirling vs acupuncture trial couldn’t be double-blind — you could have group A doing the acupuncture or acutwirling while group B does the evaluation of the effect. True, group A could subtly encourage or discourage the patient, but one thing you can do in such tests is to ask the patients which group they think they were in. If they can do better than chance on that question, your blinding may have had a problem.

    You comment that, ” It’s possible that transdermal stimulation of nerve endings by sharp poking, without penetrating, could have the same effect as traditional acupuncture.” It seems to me that this is actually a good possibility to follow up. Why, indeed, should actual penetration be more effective than poking (or acutwirling)? And if it isn’t, I think a lot of people, including me, would look more favorably on acutwirling, which doesn’t penetrate the skin and therefore doesn’t raise a risk of infection, than on traditional acupuncture — even if acutwirling and acupuncture have no real effect and just make the patient feel better.

  61. #61 Narad
    January 20, 2013

    Yet you strongly hint that if I had said yes, alcohol would suit, I would also have been bashed.

    No, you merely would have admitted that something followed from the principle you advanced that you didn’t like.

  62. #62 Narad
    January 20, 2013

    It’s possible that transdermal stimulation of nerve endings by sharp poking, without penetrating, could have the same effect as traditional acupuncture.

    Perhaps one ought to demonstrate that the “effect” of “traditional” acupuncture is due to “stimulation of nerve endings” in the first place, as this rearrangement of acupuncture by Cheng Dan’an was motivated simply to provide a veneer of modernity. And was ultimately renounced in favor of “qi.”

  63. #63 jane
    January 20, 2013

    LW – Where the two have been shown to work equally well by studies whose purpose was to demonstrate equivalency in a positive sense, I wouldn’t have a problem with toothpicking. However, since acupuncture is very safe in practice, I wouldn’t rush to adopt a novel and perhaps less potent alternative. Narad demands proof that the benefits of acupuncture have a basis in the nervous system. I would think that he would want to presume this, because people who do not believe that have only two other obvious choices. They can believe that acupuncture’s clinically proven or personally observed benefits are actually due to qi, requiring them to adopt a broader vitalist belief – surely unacceptable! – or to insist that those benefits must be due to The Placebo Effect – requiring them to believe that placebos can affect “hard endpoints” and offer symptomatic relief equal to pharma drugs, another belief that scientism forbids.

    Narad, you are bizarrely warping my stated beliefs. Treatments that do more good than harm, as defined and experienced by an individual, are okay in my book; treatments that do more harm than good are not. I believe that people who are suffering have the right to select whatever option will offer the best ratio of benefit to harm according to their personal values and experiences, including the option of taking no action whatsoever. It is logically contradictory to claim that this view could ever lead to the conclusion that X treatment was as good as Y treatment for an individual whose personal needs or values made X and not Y totally unacceptable. How could that ever be possible? If X was not in truth so burdensome, for some individuals or for all, then for some it might well be superior to Y. X and Y could be anything, so your personal beliefs about alcohol are not relevant. But I am happy to concur that small daily doses of alcohol could be just as acceptable as CCBs for many fully informed people.

  64. #64 LW
    January 20, 2013

    @jane, “to insist that those benefits must be due to The Placebo Effect – requiring them to believe that placebos can affect ‘hard endpoints’ and offer symptomatic relief equal to pharma drugs, another belief that scientism forbids.”

    This discussion has been quite civil so far, I think. Throwing around accusations of “scientism” will make it less so.

    It is entirely possible for placebos to affect certain endpoints, and scientists admit this. For example, in the asthma study, patients did feel better but — and this is the key — objective tests did not show that they were better.

    If we’re talking about pain then I agree: if the patient feels better that is a sufficient result. If we’re talking about asthma, where the patient can die without treatment, then just feeling better without actually being better is not a good outcome.

    It is certainly true that a mere placebo can work as well as some pharma drugs — that’s why drugs are tested against placebos: to see if that is the case. But it’s difficult to be certain about the effects and sometimes, indeed, drugs are released that are no better than placebos. Nothing forbids scientists — or anyone else — to acknowledge this.

    However, there are other drugs — such as albuterol — where the objective measures clearly show that the drug is better than a placebo.

    Acupuncture — and acutwirling — do have physical effects, unlike Reiki or homeopathy. It is therefore not impossible that they have something more than a placebo effect. It would be great if that were proven, but so far it has not been.

  65. #65 Narad
    January 20, 2013

    Treatments that do more good than harm, as defined and experienced by an individual, are okay in my book; treatments that do more harm than good are not.

    If you are asserting that “harm” and “good” are purely subjective, you bump into the problem that to be meaningful, this assertion essentially forces the “eternal now” of Augustine and Thoreau as an operating principle, although you plainly don’t adopt it. It’s also a well-known recipe for allowing bipolar disorder to spiral out of control.

    But I am happy to concur that small daily doses of alcohol could be just as acceptable as CCBs for many fully informed people.

    Duly noted.

  66. #66 Denice Walter
    January 20, 2013

    @ LW:

    I think it’s important to always realise that there is a difference between *feeling* better and *being* better: SBM would hope to accomplish results beyond that of placebo.

    However the effects of *feeling* better may more accuately be called part of ‘self-care’ ( or what I call ‘mother’s’ or ‘spa’ medicine) which consists of simple measures people take to manage symptoms – both physical and mental. So if you hurt your leg, you might rub it or put ice on it. If you have a cold, you might drink hot tea or soup. If you have a headache, you might lie down or apply a cold compress. If you feel stressed, you might talk to a friend, have a drink or get a massage. Many of these activities have physiological effects and can be recommended by doctors. Sometimes injuries and illnesses require more.

    Barrett says that alt med often focuses upon these transient measures that traditionally were what you did for yourself ( or for another family member or child) but are offered as medical treatments by practitioners.

    Alt med/ woo procedures often might make a person feel better temporarily but do not actually change things. The promise of help offered by alt med often has a psychological effect as well.

    Alt med that has been shown through replicated trials to be consistently better than placebo is called SBM.

  67. #67 LW
    January 20, 2013

    @Denice Walter, oh, I entirely agree. I was making a clear distinction between feeling better and being better. But I was also acknowledging that sometimes drugs slip through that really aren’t any better than a placebo.

  68. #68 Mephistopheles O'Brien
    January 20, 2013

    According to some people there are certain symptoms, such as perceived pain, which can be affected by suggestion or hypnotism (some would argue the two are the same).

  69. #69 jane
    January 20, 2013

    LW – It’s hard to avoid noting that there’s an ideology active here that requires certain opinions to be held without proof, and other things to be disbelieved no matter what, and the rules for yet other things to vary according to circumstances. Had this acupuncture study for asthma shown that spirometry was improved as well as symptoms, for example, we would no doubt be hearing that that was surely only due to a Placebo Effect and therefore using acupuncture for asthma would be Unethical. Acupuncture studies that report improvements in apparently objective endpoints are dismissed out of hand with just such rhetoric. Yet because this particular study showed no improvement in the biomarker measured, we are told that this somehow proves it was only a placebo, because “of course” placebos can’t affect such parameters.

    If you desire to focus further on asthma, I point out firstly that many people diagnosed, even correctly, with asthma have only mild occasional symptoms and do not require any treatment to keep them from dying of it, and secondly that our society tolerates the sale of a category of pharma drugs for asthma that have been shown in randomized controlled trials to increase death from asthma – something that acupuncture has not been shown to do. If you tell people that it is bad to relieve their symptoms with acupuncture and in fact they may DIE!!! if they do it, then you need to tell them the same thing about using LABAs. Do I think it’s wrong to use LABAs? Not at all, if an informed person makes a voluntary choice to do so for the sake of quality of life, so I hope nobody will be foolish enough to erect that straw man.

    Finally, with regard to your general point about “some drugs” being no different than placebos: It has been shown beyond reasonable argument by good clinical trials as well as human experience that pharma drugs are better for pain relief than sugar pills, though not infinitely better. It has been shown that the effect of real drugs has a placebo component. And lastly, there are multiple studies in which acupuncture provides as much symptomatic relief as pharma drugs or more. So you must somehow deal with the fact that science-as-practice indicates either that acupuncture is not “just a placebo”, or that some placebos are so powerful or so reliable as to deliver a better average effect than the placebo-plus-drug effects of a pill. If the latter is presumed to be the case, I regard the blanket assertion that the use of such placebos is still wrong for all persons as a type of dogma that can reasonably be viewed as a religious belief.

  70. #70 LW
    January 20, 2013

    @jane,

    Had this acupuncture study for asthma shown that spirometry was improved as well as symptoms, for example, we would no doubt be hearing that that was surely only due to a Placebo Effect and therefore using acupuncture for asthma would be Unethical.

    You do not know that without doubt. Asthmatics want cures. Pulmonologists want to cure them. I know this; I am an asthmatic who sees a pulmonologist. If the study had shown that acupuncture produced better objective outcomes then, yes, there would be initial resistance but there would also be interest and the studies would be repeated. If the results held up (and this has been the problem with acupuncture results in the past — they don’t hold up), then acupuncture could be accepted as a treatment.

    But there are a couple of problems with acupuncture even if it is proven to work. One is, acupuncturists are thin on the ground. I live out in the country, ten miles from the nearest doctor of any kind. It is much more convenient for me to take my Big Pharma drugs than to try to track down an acupuncturist for … what? daily treatments? Another problem is the risk of infection. That is why, even if acupuncture were proven to work, I would prefer acutwirling for safety’s sake.

    I point out firstly that many people diagnosed, even correctly, with asthma have only mild occasional symptoms and do not require any treatment to keep them from dying of it

    And some of us have had entirely too many near-brushes with death due to asthma, and as a result cannot afford to fool around with ineffective or unproven treatments.

    secondly that our society tolerates the sale of a category of pharma drugs for asthma that have been shown in randomized controlled trials to increase death from asthma

    Why, yes, and do you know why they increased the risk of death? Because they made people feel better even though they weren’t better. So you have to have two drugs that work together so you both feel better and are better. I’ve taken the combined therapy, by the way. It helps a lot. My pulmonologist was quite firm about the need for both drugs together.

    It has been shown beyond reasonable argument by good clinical trials as well as human experience that pharma drugs are better for pain relief than sugar pills

    There are drugs and then there are drugs. That was my point. Some drugs work really well and others perhaps do not. And some are effective in most people but ineffective or contraindicated in others. You can’t just point to “drugs” and make a meaningful statement.

    It has been shown that the effect of real drugs has a placebo component.

    That’s why double-blind tests are so important, to tease out the real effect from the placebo component.

    there are multiple studies in which acupuncture provides as much symptomatic relief as pharma drugs or more. So you must somehow deal with the fact that science-as-practice indicates either that acupuncture is not “just a placebo”, or that some placebos are so powerful or so reliable as to deliver a better average effect than the placebo-plus-drug effects of a pill.

    Again, there are drugs and then there are drugs. There are symptoms and then there are symptoms. And, unfortunately, there are studies and then there are studies. Some studies are poorly run and produce the desired results, but when rerun properly, they don’t.

    You don’t seem to get what I am saying. Acupuncture and acutwirling actually touch the body and could, therefore, have some effect on some symptoms, in the same way that pressing between the upper lip and the nose can suppress sneezing. If that can be proven, then that would be great because there’d be another weapon in the arsenal against disease though, as I pointed out with asthma, it may not be as useful as drugs. But it has to be proven first.

    I regard the blanket assertion that the use of such placebos is still wrong for all persons as a type of dogma that can reasonably be viewed as a religious belief.

    Who said it is wrong for all persons?

  71. #71 jane
    January 20, 2013

    I don’t know why we are focusing here so heavily on asthma, except that this is one acupuncture study with a putatively non-subjective endpoint that did not show benefit for that endpoint. I am sure you would not appreciate diversion into discussion of an unrelated study that showed benefit for some other endpoint. But asthma is not one of the conditions for which either placeboes or acupuncture are usually considered most useful, and I really cannot say much more about the subject. I will only say that the question of whether to try complementary medicine as well as any appropriate conventional medicine for asthma must be, like so many things, only answerable by reference to individual values and circumstances – including the availability and affordability of practitioners, as you note, as well as one’s level of satisfaction with the efficacy of conventional medicine alone, the degree to which one fears the real or imagined risks of complementary treatments, and the number and type, if any, of scientific studies one wants to see for a given type of treatment before trying it. The latter three all require value judgements; a given number of positive studies that would satisfy me that it was worth trying such a low-risk modality as acupuncture clearly would not satisfy you. Your view isn’t provably wrong, but neither is mine;I believe we each have the right to make decisions based on our own values.

  72. #72 Narad
    January 20, 2013

    I believe we each have the right to make decisions based on our own values.

    From where I sit, it appears that you wish to silently extend this position to the assertion that there isn’t really any such thing as bad decisions in this regard.

  73. #73 al kimeea
    www.quackademiology.com
    January 20, 2013

    I believe we each have the right to make decisions based on our own values.

    My values have nothing to do with whether a treatment works or not and I pay taxes that are to be spent on healthcare not quackery that has been shown repeatedly to be no better than a sugar pill.

    The only people who use the term scientism have no idea what science is.

  74. #74 al kimeea
    January 20, 2013

    But asthma is not one of the conditions for which either placeboes or acupuncture are usually considered most useful, and I really cannot say much more about the subject.

    Well, if you check out Wendy’s Acupuncture and Herbal Clinic there isn’t anything they can’t treat including asthma. There is a convenient “Who pays” link that will help you needlessly drive up private insurance premiums “for now” for the sake of Tradition!!

    Over at North York Acupuncture under the heading “Acupuncture and Natural Therapies for Asthma” we find:

    In Chinese medicine, asthma can be caused by a variety of factors including stress, diet, allergies, candida infection and constitutional weakness. All of these factors are related to different internal organs that are causing the lungs to constrict. Acupuncture theory involves combining the patient’s symptoms with pulse and tongue diagnosis to get a clear picture of the body’s inner workings. Acupoints are used on the corresponding meridians that will balance any energetic or functional disharmonies. Adjunctive therapies are also very helpful for asthma, such as cupping and gua sha.

    Cupping, AKA healing hickies.

    Asthma is the first respiratory ailment listed at “The Best of Chinese Medicine Acupuncture & Holistic Clinic”

    The fourth link is from asthmapartners.org and says this in regards to asthma:

    This sort of scientific experiment has been done at least four times, including in the United States, Canada, Australia, and Sri Lanka. In each case the results were the same: no benefit from the “real acupuncture,” no difference in effect for the two groups of patients. The “real” acupuncture did not help the patients feel better, improve their lung function, or reduce their need for traditional asthma medications.

    About.com says this aboot quackupuncture for asthma:

    Acupuncture may help some people with asthma breath better, but the evidence supporting this procedure for the treatment of asthma is significantly lacking.

    Then we woo again:

    Acupuncture treatment for cold asthma should focus on sedating the Lung and eliminating the phlegm. The points should be sedated and left in place for 30 minutes. Renzhong REN 17 should be stimulated until the needling sensation disperses to both sides of the chest. Chize LU 5 should be needled against the flow of the channel. Feishu UB 13 and Fengmen UB 12 should be sedated for 2 minutes. For best result, cupping may be applied with acupuncture for these two points.

    Supplement Points: Shenzhu DU 12 and Dazhui DU 14 may be added for patients with headache and body ache. Yingxiang LI 20 and Shangxing DU 23 may be added for stuffy nose and runny nose.

    That’s for asthma from cold, from heat is different.

  75. #75 al kimeea
    www.quackademiology.com
    January 20, 2013

    oh dear, I may have italicized the intertubes

  76. #76 al kimeea
    heavy sigh of relief
    January 20, 2013

    :)

  77. #77 LW
    January 20, 2013

    It’s a good thing woo-mongers use words in non-standard ways, otherwise I’d be really worried about someone who thought it was a good idea to “sedate the Lung”, for thirty minutes no less.

  78. #78 Denice Walter
    January 20, 2013

    @ LW:

    If the phrase comes from TCM, “lung” might well refer to the organ itself or to the lung meridian** ( lu) wherein the accupuncture points lie, extending from the clavicle down the arm.

    And yes, woo-meisters have their own set of idiosyncratic word definitions which vary to suit the incident.

    -btw- I was expanding what you wrote , not correcting you. Perish the thought,
    Oh, are you related to me? DW, LW? Or are you, Lawrence ( Brian)?

    ** which is non-existent

  79. #79 LW
    January 20, 2013

    No, I don’t think I’m related, though my sister is also DW. And also a psychologist … um, wait …

    But I am Lawrence. And Brian Deer. And Bonnie Offit, Kathleen, and Spartacus. Oh, and Krebiozen, too. The iDJiT has found out my secret identities!

  80. #80 Denice Walter
    January 20, 2013

    On a totally serious note- ( which I can manage, believe it or not):

    This has been bothering me: I don’t think that anyone should regard Atrial Fibrillation in such a cavalier manner- it’s not something to experiment upon with alt med. AF can be life threatening or can lead to strokes and other CV incidents; although it might be transient or relatively benign in SOME CASES, it’s nothing to fool around with or with which to play guessing games with pseudo-scientific ideas in the hands of woo experts. It is also not a rare condition.

    I frequently hear a well-known woo-meister( on internet radio) telling concerned listeners who have serious conditions like this – or have family members who do- to follow protocols of his own while casting aspersion on what SBM teaches, research, calling doctors “behind the times”, pharmaceuticals poisons etc…. even though he may technically say ” see your doctor” after he insults what doctors know and do.

    A family member of mine had a very serious incident with AF after the age of 80: simple tests and a simple, generic medication enabled him to live with the condition for nearly 10 years.

    SBM can demonstrate that controlling AF leads to better outcomes as well as what meds or procedures make that control more likely. That’s nothing to scoff at.

  81. #81 Bill Price
    January 20, 2013

    The only people who use the term scientism have no idea what science is.

    Al, I don’t find that to be true. I’ve seen this fraudulent term used by people who do know what science is, well enough to know that reality is sufficient to destroy the con-game they’re trying to play on the rest of the world.
    I wonder about Jane…. She does seem to understand science, at least to the cargo-cult level.

  82. #82 Narad
    January 20, 2013

    Nor that anything involving sessions of soaking the hands in water must be intolerable – why you think that would interfere with someone’s work is beyond me.

    I was remiss in failing to note that Raynaud’s does not just affect the hands (going to sit around with your tongue in ice water?), nor is it only triggered by cold. I would, however, appreciate seeing a reference to this “desensitization” technique to ascertain whether it is in fact anything different from CIVD.

  83. [...] Orac has also weighed in on Begley’s [...]

  84. #84 lilady
    January 20, 2013

    I’ve been ignoring “Jane” but this statement of hers caught my eye…

    “Krebioze, yes, that’s why we have trials, but then we can’t ignore the results when they show CAM working. The man I mentioned with atrial flutter had had it persistently and was seeking a cardioversion, but facing long delays. Almost immediately after his second session of the acupuncture that was shown useful for AFib in clinical studies, he reverted to sinus rhythm. He hasn’t had AFL again since, though he’d had it twice before and the last -ologist he saw told him he could never get better. Maybe it was just a coincidence that after all those weeks with flutter, he happened to be spontaneously cured just when he started acupuncture. He’s rationally playing the odds.”

    I’m calling bullsh!t on that statement Jane. Certainly you could provide more details about the case.

    Why was the man seeking a atrial ablation for intermittent episodes of A-flutter?

    What medication was the man prescribed by a cardiologist, before the cardiologist referred him to electrophysiology cardiologist?

    Did the man undergo cardioversion?

    Where are the studies that you claim show acupuncture to be effective in restoring normal sinus rhythm?

  85. #85 al kimeea
    www.quackademiology.com
    January 21, 2013

    @ Bill Price

    ya, that smug comment of Jane’s made the BP rise. It’s the whole idea of informed choice when one of the choices is a scam, spouting nonsense as healing wisdom – supported by the tools of the opposition to further guile the mob. I like to think only a small number fit your description.

    Jane seems all newage sciencey. If she wants to pray for healing fine, but not on my dime.

    Unfortunately insurance, both private and public cover this crap and our Minister overseeing Science & Tech is a double quack – chiroquackupuncturist – and quite possibly a Creationist too boot…

  86. #86 jane
    January 21, 2013

    Heh! What a lot of ad hominems (with the usual pathetic misunderstandings by lilady, who I am so glad to know is retired and not harming patients with her ignorance of medicine). I suspect I have more scientific (small-s) publications than most of you, so I don’t much care if you think me an untermensch. My friend with the formerly *persistent* atrial flutter remains in sinus rhythm without cardioversions or anti-arrhythmic drugs (which have been shown to *increase the death rate* for people with AFib, by the way – do your own research and don’t be buffaloed), so I don’t suppose that he much cares if you think him an untermensch. PubMed is available for those who want to know more about placeboes, acupuncture, AFib, and many other subjects.

  87. #87 lilady
    January 21, 2013

    Heh, what a lot of nonsense being promulgated by “Jane”.

    “…The man I mentioned with atrial flutter had had it persistently and was seeking a cardioversion, but facing long delays….”

    Was the “man’s” A-flutter diagnosed by a medical doctor?

    Were lifestyle changes, including smoking cessation and ETOH intake discussed by his medical doctor?

    Which tests did the “man” undergo to determine that his A-flutter was “persistent”?

    Which monitor was provided to him to track the course of the disorder?

    Which electrophysiology testing was done?

    Which medications were prescribed to regulate the “man’s” heart rhythm…before “the man (went) seeking an ablation”?

    Why would the “man be seeking an ablation”, when a medical doctor would make a referral to an electrophysiology cardiologist?

    http://my.clevelandclinic.org/heart/disorders/electric/arrhythmia.aspx

    Heh, I’m not, nor have I ever claimed to be, a registered nurse who is a specialist in cardiology or interventional cardiology. And, your “credentials”, Jane?

  88. #88 LW
    January 21, 2013

    @jane: “What a lot of ad hominems”

    I warned you: “This discussion has been quite civil so far, I think. Throwing around accusations of “scientism” will make it less so.”

    Also, you should try to learn the difference between insults and ad hominems. An ad hominem is an attempt to discredit the opponent’s argument on the basis of the opponent’s character, instead of on the basis of its logical validity.

    You may have felt insulted by speculation on why you would use the insulting term “scientism”, but no one has engaged in ad hominem arguments. Except you, perhaps.

  89. #89 jane
    January 21, 2013

    LW – No, there have been both ad homs (by the orthodox use of the term) and straw men among the above messsages. But there’s not a lot of point in bickering about it; the right to use Fallacies is contingent upon the conclusions drawn, yes?

    Lilady, I’m not able or willing to post any of my friends’ and family’s medical records online, so you can go on pretending, e.g., that the “man” I spoke of – why the scare quotes on man, of all things? – was not seeing an electrophysiologist if you like. But I want to say only one more thing, very seriously. You may not want to accept that I mean this sincerely, because you surely know that I don’t like or respect you any more than you like or respect me – but I am serious. During your working days, you might have been equally willing to spout scattergun insinuations against people whose experiences did not fit with your beliefs – but you almost certainly would not have done it by repeatedly and explicitly treating “cardioversion” and “ablation” as the same thing. These are utterly different procedures, and anyone who knows anything whatsoever about cardiology knows that. You have said you were not a cardiology nurse, but if you worked in proximity to any of them or on a general medical floor, it is very likely that you used to know it, and would have known that many of your audience would know it. I have an elderly loved one who is losing his grip on knowledge related to his former career that he once would have known in his sleep. This can be, as it is in his case, a sign of a very serious medical problem (or it can be a drug side effect). I sincerely encourage you to consult your MD for a checkup if you are having difficulties of this nature in other contexts.

  90. #90 Lawrence
    January 21, 2013

    @jane – you’ve certainly nailed the “passive-aggressive” insult….though, if you’re going to question someone’s grip on reality, I would suggest being more direct & less with the dripping sarcasm and over-the-top explanations.

  91. #91 lilady
    January 21, 2013

    @ Jane: You have now misinterpreted or misread both of my comments…

    “During your working days, you might have been equally willing to spout scattergun insinuations against people whose experiences did not fit with your beliefs – but you almost certainly would not have done it by repeatedly and explicitly treating “cardioversion” and “ablation” as the same thing. These are utterly different procedures, and anyone who knows anything whatsoever about cardiology knows that.”

    I think you ought to reread both of my posts. Where did I state that cardioversion and cardiac ablation are the same procedure?

    You, OTH, have confused A-flutter and A-Fib in your prior posts.

    Wanna provide your “credentials” and some of the topics where you claim *expertise*?

    ” I suspect I have more scientific (small-s) publications than most of you, so I don’t much care if you think me an untermensch. My friend with the formerly *persistent* atrial flutter remains in sinus rhythm without cardioversions or anti-arrhythmic drugs (which have been shown to *increase the death rate* for people with AFib, by the way – do your own research and don’t be buffaloed),…”

    Wanna go another round with me, Jane?

  92. #92 al kimeea
    www.quackademiology.com
    January 21, 2013

    From the Pacific College of Oriental Medicine we have:

    In traditional Chinese medicine, asthma is considered not just a disorder of the lungs but also of the kidneys and the stomach. This explains why the acupoints that correspond to the treatment of asthma are located along the lung, kidney, and stomach meridians. Acupoints along the bladder meridian are also treated since bladder function is also considered important for the overall health of the body’s organs. Once the energy blockages in these areas are corrected, optimum health is hopefully achieved.

    I could go on Jane, but it seems you’re the only person on the planet who says quackupuncture isn’t really useful for asthma even though there are quackupoints to treat it.

  93. #93 al kimeea
    www.quackademiology.com
    January 21, 2013

    other than those who doubt it is efficacious for anything other than anxiety aboot illness

  94. #94 Denice Walter
    January 21, 2013

    Reversion to normalcy occurs “without cardioversion and anti-arrhythmic drugs ( which have been shown to *increase the death rate* for people with AFib, by the way, do your own research and don’t be buffaloed).”

    Notice that suspicion is cast upon meds- they cause death!
    ( “increase the death rate”)
    This is strikingly similar to the material I survey on a regular basis: the drugs, not the illness, cause death. Yet I don’t see any references that illustrate just how dangerous these drugs are. I don’t see any listing of the benefits that might accompany this ‘risk’. Where is this material?

    Then there is the admonition to “do your own research”- which I infer suggests that advice SBM offers is also suspect. How can she judge this?
    “Buffaloed” suggests that someone is telling tales. Evidence?

    So drugs and those who advocate for them are suspect. Now her advice goes entirely contrary to consensus in SBM.
    To overturn that, wouldn’t quite a lot of new data- peer-reviewed and replicated- be necessary?

    Or are the rules different outside SBM?

  95. #95 jane
    January 22, 2013

    Okay, for the sake of any reader who might suffer AFib or AFL, ONE more. Denise, I don’t know if you’re faking it or genuinely ignorant, but there are two forms of pharma drug treatment for these conditions. Rhythm control drugs attempt to keep the heart in sinus rhythm. Most don’t work very well and most are super-toxic. Rate control drugs, primarily beta blockers and digoxin (which is claimed by some, out of ignorance, not to be useful), don’t affect the arrhythmia but lower the ventricular rate so the heart is not overly stressed and one hopefully feels better. (There’s a balancing act there, as some MDs promote extreme rate control without evidence, causing more side effects.) Many electrophysiologists treat the EKG rather than the person and consider only rhythm control or ablation[s] to be acceptable. However, large randomized clinical trials have shown rate control to be just as good in terms of patient outcomes as rhythm control. (That is called EVIDENCE-based medicine, and I prefer to base decisions on evidence, which is published and can be checked by anyone, than on Science, whose dictates so often seem to be culturally biased.) For those who need any of these treatments (not all do), the choice among options must always be made by the individual patient, taking into account his symptoms, risks for drug side effects, activities he wants to engage in, and values regarding these things. Of course, if you can get rid of the arrhythmia through lifestyle change (and acupuncture?) you might not need any of that stuff any more.

  96. #96 Narad
    January 22, 2013

    (That is called EVIDENCE-based medicine, and I prefer to base decisions on evidence, which is published and can be checked by anyone, than on Science, whose dictates so often seem to be culturally biased.)

    Do go on.

  97. #97 Denice Walter
    January 22, 2013

    @ Jane:

    You’re disparaging the use of meds for a serious condition:
    ” Most don’t work very well and most are super-toxic”. You make leading suggestions:” if you can get rid of the arrhythmia through lifestyle change…” and criticise experts, “some MDs”, “Many electrophysiologists”, ” Science, whose dictates…” You advocate personal choice :”the choice among options…” .

    You speak ‘ex cathedra* – like many woo-meisters do- in critique of an entire field – in which you do not appear to be not educated, trained or employed. (Anyone can read general material on the internet and copy it ). You don’t have the background to do this. What is your background, -btw-?

    RI is a public place and you’re playing doctor- albeit in a sneaky way. Unbeknownst to you, many readers and commenters here have professional and/ or personal experience in the area. Off hand, I can name a few.

    Professionals don’t disparage medical treatments over the internet.

  98. #98 Mephistopheles O'Brien
    January 22, 2013

    Jane,

    I doubt anyone here would argue with well researched data. That’s what science is all about. Do you have links to the evidence for the statements you made about treatments for AFiB and AFL (e.g. the toxicity of one class of drugs and the large clinical trials about treatment)? Thanks.

  99. #99 LW
    January 22, 2013

    So long as we’re emphasizing evidence here, jane, would you mind clarifying the difference between super-toxic and toxic? I would interpret super-toxic as meaning that anyone exposed will promptly drop over dead, as opposed to merely toxic, where they might survive with proper care. What’s your definition?

  100. #100 lilady
    January 22, 2013

    @ Mephistopheles O’Brien: I’m already aware of one particular drug which can be “toxic” in a an exceedingly very small number of patients, and I have links to a retrospective patient outcomes studies about treatment guidelines for A-Flutter and A-Fib.

    (Repeat Disclaimer) I never implied and I never stated that I am a nurse who specializes in cardiac care. However, my husband underwent a right atrial ablation procedure to treat persistent A-Flutter…and a left atrial ablation procedure to treat persistent A-Fib. I am a quicker learner; after researching thoroughly the medications prescribed pre and post ablation procedures and the procedures themselves.

    Where’s Jane?