Respectful Insolence

To say that I haven’t been much of a fan of the National Center for Complementary and Alternative Medicine (NCCAM) throughout the years is a gross understatement. If you want to see the depths of my—shall we say?—lack of enthusiasm for NCCAM, feel free to type “NCCAM” in the search box of this blog and in particular look for posts that have “NCCAM” somewhere in their titles. It won’t take you long to find posts by yours truly with titles as awesome as NCCAM: I say we take off and nuke the entire center from orbit. It’s the only way to be sure and NCCAM in the news: Why does it still exist? Trust me when I tell you that the articles are just as awesome as the titles.

As I have argued over the years, NCCAM is a misbegotten government agency whose activities have directly contributed to the rise of quackademic medicine over the last two decades in the U.S. Don’t get me wrong, it’s nowhere near all NCCAM behind the infiltration of so-called “complementary and alternative medicine” (CAM) quackery into medical schools and academic medical centers, but clearly NCCAM, wittingly and unwittingly, provides a patina of scientific plausibility to nonsense, not to mention the imprimatur of the federal government, much to the delight of quacks everywhere.

Amazingly, three years ago, criticisms by myself, Steve Novella, and Kimball Atwood led to an invitation to meet with Josephine Briggs, MD, PhD, the director of NCCAM. We found her to be earnest but also not understanding of what, exactly, the problem at the core of NCCAM as an entity. She is also a consummate politician who knows who her constituency is, because around the time she met with us she also met with an “international homeopathic team.” She then promptly produced a post on the NCCAM blog entitled Listening to Differing Voices in which she produced a false dichotomy between two groups of stakeholders, one of which consists of CAM advocates and the other of which consist of skeptics who reflexively dismiss CAM and want to eliminate it and then piously implied that NCCAM is the only reasonable position between them, proclaiming:

As I’ve stated before, our position is that science must remain neutral, and we should be strictly objective. There are compelling reasons to explore many CAM modalities, and the science should speak for itself.

The problem with NCCAM, of course, is that the science does speak for itself, saying that the vast majority of CAM is pure quackery, but NCCAM doesn’t listen any more than CAM advocates do. Modalities with little or no prior plausibility or convincing preclinical evidence, such as acupuncture, are studied as though they show great promise. Modalities that violate the laws of physics, such as “energy medicine” modalities like reiki and therapeutic touch, are studied as if they had plausibility. Sadly, Dr. Briggs is still at it, over three years later. Only this time somehow she’s gotten her views published in a top medical journal, JAMA, as viewpoint article co-authored with her deputy director Jack Killen entitled Perspectives on Complementary and Alternative Medicine Research. Accompanying this article is a press release on the NCCAM website, a new blog post by Dr. Briggs on the NCCAM blog entitled A New Conversation, and a video blog also entitled Perspectives on Complementary and Alternative Medicine Research:

In this blog, Dr. Briggs calls for a “a fresh, more nuanced and balanced conversation about research into complementary and alternative practices.” I don’t know what she’s talking about from our perspective as critics of CAM as unscientific, but we’ve always been “nuanced” when appropriate, particularly when discussing specific studies. We try very hard (and certainly I do too) to examine the evidence. The thing that disturbs Dr. Briggs about us is that we don’t find the evidence convincing and criticize NCCAM for being a massive waste of money that could be better used elsewhere in the NIH. In this, there is nothing in Dr. Briggs vlog, blog post, or opinion piece in JAMA that isn’t anything more than her 2010 message on steroids, wrapped up in a plea to reset and reboot the conversation. For example, in her NCCAM blog, Dr. Briggs writes:

Before I took on the role of Director of NCCAM, I worked as a kidney physician and researcher and regularly saw patients who were struggling with very difficult-to-treat symptoms. Now at NCCAM, I often have the opportunity to travel and meet people: consumers, health care providers, and researchers. These interactions have allowed me to hear a wide variety of insights, and I’m often struck at how strongly people react regarding the topic of complementary and alternative medicine. There are those who embrace these “all-natural” approaches and avoid conventional medicine completely. And there are those who completely dismiss anything labeled “complementary” as quackery.

I feel very strongly that this all-or-nothing debate does a disservice to patient care. The field of complementary and alternative medicine encompasses a very wide array of products and practices, with the only unifying factor being that we’re still exploring their safety and value. By embracing anything that is deemed “natural,” patients may put themselves at risk, falsely believing that natural equals safe. They may also forgo proven therapies that can help their condition. Likewise, by completely dismissing complementary approaches, we miss an opportunity to uncover and take advantage of promising therapies that can address very practical problems.

See what I mean about the false dichotomy? In this passage, she makes it explicit, even more so than she did three years ago. You have the “all natural” types who don’t want to use anything other than “natural cures,” and you have reflexive skeptics who, apparently so blinded by ideology, reflexively dismiss CAM as quackery. In between, apparently, NCCAM places itself as the adult in the room, the reasonable people who neither believe completely in CAM over science-based medicine (SBM) nor reflexively dismiss all CAM, as those nasty skeptics are portrayed as doing. If there’s a better example of the fallacy of moderation or the fallacy of the golden mean, I haven’t seen one in a while.

The problem, of course, is the same problem that is encountered whenever science is juxtaposed with pseudoscience For some “debates” one position is clearly wrong based on science, such as when creationism is debated with evolution, anthropogenic global warming denialism is juxtaposed with climate science, HIV/AIDS denialism is debated with infectious disease science, or antivaccinationism is presented with vaccine science. In all these examples, there is a right answer and a wrong answer, and the right answer does not lie somewhere between the two “extremes.” Dr. Briggs’ argument is based on one massive logical fallacy, and that’s what we get in her JAMA article, even going so far as to reference an article by Paul Offit critical of NCCAM and declaring that “some criticisms betray a lack of understanding of scientific progress in this field and how it has shaped a compelling, sharply focused research agenda.”

As one of those critics standing with Paul Offit, I’d be lying if I didn’t say I wasn’t a bit insulted by such a characterization. I fully understand the scientific progress in this field. There hasn’t been any to speak of, all the smoke and mirrors laid down by NCCAM apologists and NCCAM itself notwithstanding. I’m also probably one of the few NCCAM critics who’s actually read the NCCAM strategic plan for 2011 to 2015 in its entirety, and I was not impressed. It amounts largely to a promise to do some real science for a change.

One statement by Dr. Briggs in her vlog stood out to me:

We also know a great deal more about the potential of complementary approaches to contribute to the management of chronic pain. Our current focus, on pain management, is driven by real world use data.

Our current research agenda reflects major evolution in research priorities. It recognizes that some of these practices are useful and can reasonably be integrated into care, some are not useful, some are dangerous and merit regulatory attention, and many are somewhere in between.

So it appears that NCCAM has found its niche, the one area where placebo effects confound SBM more than arguably any other area, chronic pain. It’s a savvy move. In what area are there probably the most seemingly “positive” acupuncture studies? Pain and especially chronic pain. The same is likely true for just about any CAM modality, be it “energy medicine” such as reiki or therapeutic touch, “mind-body” modalities, herbal medicine, or just about anything else CAM. It’s the one and only area of medicine where it’s really, really hard to differentiate true effects from placebo effects, other than perhaps psychiatry, particularly the treatment of depression.

As for the article itself, it begins with verbiage that is apparently mandatory for all articles of this type. (Heck, NCCAM even has an infographic for it!) It’s basically one massive appeal to popularity in which statistics are trotted out to show how many Americans use CAM. In this case, Briggs and Killen cite the 2007 National
Health Interview Survey, as all CAM apologists must, to come up with a figure of 40% of Americans using CAM. I swear, there must be a rule for these sorts of articles in which the author absolutely must cite this figure or the article is instantly rejected. The problem with this survey, as is the problem with many CAM use surveys, is that it lumps together modalities like massage (which is not really CAM) and prayer/spirituality, which is really not medicine of any kind but religion. If you look at the “hard core” CAM modalities, you’ll find that, for example, only 1.4% reported using acupuncture; 0.4% reported using naturopathy; 0.1% reported using Ayurveda; and 0.5% reported using reiki.

So what has NCCAM learned? Apparently, the most common use of CAM is for chronic pain, which is about as much a “Well, duh!” conclusion as I have ever seen. I could have saved them the money, time, and toil if they’d just asked me that question. Be that as it may, here are some of the major accomplishments of NCCAM as envisioned by Briggs and Killen:

For some mind-body approaches, however, there is mounting evidence of usefulness and safety, particularly in relieving chronic pain. A few examples include acupuncture for osteoarthritis pain; tai chi for fibromyalgia pain; and massage, spinal manipulation, and yoga for chronic back pain. Increasing comfort with this emerging evidence is reflected in practice guidelines from the American College of Physicians, the American Pain Society, and the Department of Defense.

Translational research is also elucidating effects of interventions like meditation and acupuncture on central mechanisms of pain perception and processing, regulation of emotion and attention, and placebo responses. Although not yet fully understood, these effects point toward scientifically plausible mechanisms—often unrelated to the traditional mechanistic explanations—by which these interventions might exert benefit.

No, acupuncture doesn’t work for arthritis. Tai chi is gentle exercise “rebranded” as mystical, “Eastern,” and mysterious. That it might decrease pain as repeated by patients with fibromyalgia is as unremarkable as it is disingenuous to lump Tai Chi in as a part of “CAM.” I’m pretty sure that over the years I’ve blogged about nearly all of these studies, both here and at my not-so-secret other blog, and I’ve been less than impressed.

The other accomplishments touted by Briggs and Killen include a string of negative studies of various supplements, such as St. John’s Wort for depression, glucosamine and chondroitin for osteoarthritis, silymarin for chronic liver disease, saw palmetto for prostatic hypertrophy, vitamin E and selenium to prevent prostate cancer, and gingko for early cognitive decline. Of course, doing studies on all of these supplements is nothing more than rebranding the old and respected branch of pharmacology known as pharmacognosy (natural products pharmacology) as somehow being “alternative” or “CAM.” It’s not. Testing natural products and trying to isolate active ingredients in herbs, for instance, is pharmacognosy. There is no reason to categorize such studies as “CAM.” They easily fall within the purview of science-based medicine. Another point: All of these studies were negative, likely because the preliminary data were so weak and the prior plausibility wasn’t so hot either.

So, after enumerating a bunch of not-so-impressive accomplishments, where do Briggs and Killen think that NCCAM should go from here? Take a look:

First and foremost, the conversation should reflect current realities, including the evolution of research priorities and the shifts in funding to projects that address them, rather than areas that have less scientific promise or less amenability to scientific investigation.

Translation: Ignore all that quackery we used to study in the past, like homeopathy distance healing, reiki, and the like. We don’t do that (much) anymore.

Second, although discussions about complementary and alternative medicine often imply a clear demarcation distinguishing a monolithic alternative domain from conventional medicine, this distinction breaks down in the realities of the pluralistic US health care system. The boundaries also shift—in both directions—as evidence changes.

Gee, did the director and deputy director of NCCAM just channel Tim Minchin and Richard Dawkins and tell us that that the word for alternative medicine that has passed scientific muster is “medicine”? Now there’s some chutzpah! I’d be insulted if my irony meter hadn’t exploded in my face. I will give the credit, though, for another false equivalency, namely the claim that the boundaries between alternative medicine and conventional medicine shift such that alternative medicine become medicine and medicine becomes “alternative.” I’d really love to know examples of alternative medicine that’s ever been scientifically validated to become “medicine.” No doubt they’d try to tell me that acupuncture is an example of such a medicine. I’d sadly tell them that it is not. It’s still quackery. However, I’d love even more to know an example of a conventional medical treatment where the boundary shifted to make it “alternative.” Maybe Stanislaw Burzynski’s incompetent “personalized gene targeted cancer therapy,” which in reality consists of various chemotherapy drugs used off-label. No, that’s probably not the example they meant.

Third, the conversation should recognize the state of current evidence indicating that some of these practices are useful and can appropriately be integrated into care, some should not, some are dangerous and merit regulatory attention, and many are somewhere in between.

You know, at this point I’d really love to know a few things. Which modalities, in Briggs’ and Killen’s opinion, have sufficient evidence supporting them such that they can be “integrated” into science-based medicine, much the way Mark Crislip describes “integrating” cow pie with apple pie? Yeah, yeah, I know. Acupuncture. Sadly, no, acupuncture does not have convincing evidence that it is better than placebo. It is a “theatrical placebo.” More importantly, I’d love to hear what CAM modalities are dangerous, in Briggs and Killen’s opinion. Odd that they don’t mention even a single example in their article. Which CAM modalities merit regulatory attention. Again, they don’t say, and I can’t find any calls for regulation of, for example, supplements on the NCCAM website. Of course, Killen and Briggs would never do that. The National Advisory Council for Complementary and Alternative Medicine (in essence, Dr. Briggs’ bosses) would react very badly such statements were ever publicized. After all, there are acupuncturists, chiropractors, naturopaths, and homeopaths on the council.

Briggs and Killen conclude with a plea for a more “nuanced conversation” about CAM. I rather suspect that what they mean is something akin to, “You quacks, quit pressuring us to study obvious quackery like homeopathy and distance healing! It’s embarrassing and gives our opponents ammunition to use against us!” and “You skeptics, stop being so mean to us, accusing NCCAM of studying quackery, and demanding that NCCAM be defunded and absorbed back into the NIH. In a way, I rather feel for Dr. Briggs. She’s in a no-win situation. If she tries to make NCCAM too science-based, she risks alienating her constituency on the National Advisory Council for Complementary and Alternative Medicine. They’re likely not particularly happy with her to begin with, given that she’s tried to deemphasize the quackiest CAM modalities. Meanwhile, nipping at her heels are those of us who realize that applying rigorous science to quackery and rebranding modalities that should be part of SBM as somehow “alternative” are not good uses of taxpayer money. Yes, I feel for her, but not enough to give her the “nuanced conversation” that she wants to hide behind.

Comments

  1. #1 Adam
    August 21, 2013

    What’s a more nuanced way of saying “if a treatment isn’t proven to work, it shouldn’t be used”?

  2. #2 Martin
    August 21, 2013

    Adam: How does “If a treatment isn’t proven to work, it shouldn’t be used outside of clinical trials unless and until it can be proven to work.” sound?

  3. [...] having a closer look at these publications. The JAMA-article has already been analysed skilfully by Orac, so I will not criticise it further. In the following text, the passages which are in italics are [...]

  4. #4 Antaeus Feldspar
    August 21, 2013

    To be fair, I can think of at least one example where an alternative medicine practice became medicine: the neti pot, which came out of Ayurvedic [sp?] “medicine”. Still, if that’s the biggest success that’s been achieved by mining the practices of “somebody thought of that and someone believed it” medicine, it’s obviously not a very fruitful research avenue.

  5. #5 Bryan
    Amsterdam
    August 21, 2013

    NCCAM regards colloidal silver as unproven and potentially dangerous:

    http://nccam.nih.gov/health/silver

    So there ;)

  6. #6 herr doktor bimler
    August 21, 2013

    less amenability to scientific investigation

    Some would translate that as “Grandiose claims to improve health disappear behind evasive clouds of bafflegab when testing is mentioned”, or “Practitioners maintain that ‘tests’ are part of a reductionist worldview which cannot be reconciled with their holistic paradigm”.

  7. #7 Chris Hickie
    August 21, 2013

    It’s basically one massive appeal to popularity in which statistics are trotted out to show how many Americans use CAM. In this case, Briggs and Killen cite the 2007 National
    Health Interview Survey, as all CAM apologists must, to come up with a figure of 40% of Americans using CAM.

    Just ’cause a big pie slice of people are doing it, that doesn’t mean it’s doing anything good for them. We don’t have national centers searching for the justification of tobacco use, driving over the speed limit or not washing your hands–but given we live in a representative democracy with an increasingly under-educated and gullible populace, who knows what our leaders may spawn next.

    The only “nuance” I believe is makes my voice recognition software for when my hands are too sore to type.

    It stinks when mudphud goes to the dork side.

  8. #8 herr doktor bimler
    August 21, 2013

    We don’t have national centers searching for the justification of tobacco use
    Isn’t that one function of the Senate?

  9. #9 jane
    August 21, 2013

    “I’d really love to know examples of alternative medicine that’s ever been scientifically validated to become “medicine.””

    Polysaccharide K. If you are a Japanese oncologist. Not if you are a white American oncologist. Or how about St. John’s wort, if you are a German psychiatrist; not if you are an American psychiatrist.

    You admit that pharmacognosy, defined as the study of “natural products”, i.e., “isolate[d] active ingredients”, is part of science-based medicine. Good of you to admit that, but the study of whole plant extracts can also be, and in many countries is, part of science-based medicine [science as practice, and science as body of knowledge, that is, not science as religion]. There is no reason that a clinical trial cannot be done on a plant product that has multiple active ingredients and can’t be boiled down to a single molecule; the Germans have been doing it successfully for decades. If your values oppose the use of such products, it does not nullify the fact that studies performed upon them using standard methodologies do indeed count as science.

  10. #10 Chris Hickie
    August 21, 2013

    All the nephrologists I’ve known relied a on history, exam, labs and other quantitative studies and not at all on “nuance” (hopefully Dr. Briggs wasn’t that way when she did real medicine). Maybe she meant to say “wooance”, as in vainly trying “to condense fact from the vapor of wooance” (w/ apologies to Neal Stephenson)

  11. #11 JGC
    August 21, 2013

    I’m not sure that the use of nasal irrigation for sinus congestion (i.e., neti pots) is really any more alternative medicine than are nutrition, massage or mild exercise such as Tai chi, and while neti pots may qualify as ‘eastern medicine’ to the extent that distincitions between eastern and western medicine are valid, nasal irrigation has been recommended in western medicine since the turn of the last century.

  12. #12 JGC
    August 21, 2013

    Jane, St. John’s Wort is an example of CAM treatmnet that’s been proven to be ineffective. See http://nccam.nih.gov/news/2002/stjohnswort/pressrelease.htm

  13. #13 Pareidolius
    August 21, 2013

    What if you’re Japanese and you think the study is たわごと? Does that make one not a True Japanese™? Racist claptrap Jane, racist claptrap.

    Dr. Miso Mysterious, Eastern M.D.

  14. #14 lkr
    USA
    August 21, 2013

    SJW for depression always struck me as being about as smart as Spanish fly for sex, for similar reasons. Having seen livestock poisoning by St.Johnswort ['Klamath weed' in western US], I’d never think of ingesting it. Nasty blistering of skin in cattle, sheep, goats, as a starter. Liver issues as well. Note that this is UV-activated, so it’s much worse in light-skinned livestock and in sunny climates.

    Of course, UV is Germany is about 10% of what you get in California or Colorado, so anyone who really wants to try SJW tea might knock the dose back and use lots of sunblock..

  15. #15 Flavius
    NC
    August 21, 2013

    ‘I’d love even more to know an example of a conventional medical treatment where the boundary shifted to make it “alternative.”’

    I don’t understand…wasn’t chelation standard medical therapy, albeit briefly? Wasn’t laetrile also considered valid therapy when first discovered? Now both are squarely in the “alternative” corner after being examined scientifically.

  16. #16 Mewens
    August 21, 2013

    @9 Nice straw man. The search for active ingredients doesn’t automatically rule out isolating multiple molecules that work in concert. But don’t stop tossing around those accusations of dogmatism – I’ve got eye-roll quotas to meet.

    And if you’ll excuse my self-indulgence: “whole plant extracts”? It’s like a line from a low-rent “Waiting for Godot.” What’s next, bleach dyes? Meritorious monarchy?

  17. #17 Alan Henness
    United Kingdom
    August 21, 2013

    You’d have thought that if she wanted a ‘fresh’ conversation on this, she’d at least have made the jama article free access…

  18. #18 Dr. Nancy Malik
    Gurgaon, India
    August 21, 2013

    First of all there is an ambiguity whether CAM stands for Complementary and Alternative Medicine or Conventional Allopathic Medicine.
    There’s no official position on this?

    Moreover, the term allopathy is official
    http://www.freezepage.com/1341259354QSYYDNIFPX

  19. #19 Shay
    August 21, 2013

    When I see someone use the term “allopathy,” that officially notifies me that they’re a crank.

  20. #20 Jamie Gegerson
    reston, va
    August 21, 2013

    @15, Flavius

    Chelation is STILL science based medicine when used properly for the treatment of heavy metal poisoning and whatnot. It’s being misused by the CAM community to treat things it hasn’t been proven useful for.

    Water is still a useful treatment for dehydration no matter how much it’s abused by the homeoquacks.

  21. #21 Calli Arcale
    August 21, 2013

    Since CAM isn’t a protected term, no, there is no official position, Ms Malik. The term “allopathy” is official insofar as it has a definition in the dictionary. It was coined by Hahnemann years ago to distinguish his new form of medicine, homeopathy, from everything else. It’s sort of amusing to me that so many modern homeopaths are happy to mix homeopathy with other treatments. By Hahnemann’s standards, acupuncture would clearly be allopathy, after all, as would chiropractic, reiki, moxibustion, aromatherapy, and more. (Though I could imagine reiki recast as homeopathic chiropractic, or a form of homeopathic aromatherapy. I haven’t seen it yet.)

    Flavius — chelation is a little more complex than that. Yes, it is a legitimate medical treatment for acute heavy metal poisoning. That hasn’t changed, incidentally — it’s still used for that. Using it to treat autism, or prevent heart attacks, though, that’s alternative. And yes, there are other mainstream medical treatments that have been coopted by alternative medicine providers, and there is also a pretty wide gray area between dubious medicine and alternative medicine. For instance, there are those who have been suggesting thyroid deficiency as a cause of all ills, particularly in women, and treating them with thyroid hormone. Thyroid hormone is very much a mainstream thing; my mother takes it after treatment for Grave’s Disease left her without a functioning thyroid. But it is not mainstream to give it to people without thyroid problems. Is that alt med, or just bad med? Hard to say, but the word “quackery” comes to mind for me in either case.

    Regarding neti pots: nasal irrigation has been done without neti pots as well for quite a long time. But only when a fashionably exotic method started being widely marketed to Americans did it become a common method of relieving nasal congestion; prior to that, nasal irrigation was mostly something done in hospitals to relieve the persistent congestion you get when you have to lie on your back for long periods of time while fluids are pumped into your body and you have to breathe very dry, air conditioned air. But people refused to do it at home, because ew. And then along comes the neti pot, and then it’s cool and exciting and fashionable and *new*!

    Meh. Kids. ;-)

  22. #22 Mephistopheles O'Brien
    August 21, 2013

    Dr. Nancy Malik – it was perfectly obvious from the first sentence of Orac’s post how the initials CAM were being used. The same initials could be used for any of a number of things, I suppose, which is why it’s important to spell them out if it’s not immediately obvious from context what the meaning is.

    Other possible meanings for CAM if you want:
    Computer Aided Manufacturing
    Contemporary Art Museum
    Christian Assistance Ministry
    Contract Audit Manual
    Certified Aviation Manager
    Center for Applied Mathematics
    Charles A. Manson (no, not that Charles Manson)
    Children Against Miasmas
    Can’t Argue Much

  23. #23 TBruce
    August 21, 2013

    I don’t understand…wasn’t chelation standard medical therapy, albeit briefly?

    Chelation is still used as treatment for heavy metal poisoning (mercury, arsenic and lead). AFAIK, it was never standard medical therapy for atherosclerosis or coronary heart disease.

    Incidentally, I am always amused by alties claiming that using herbs, rather than purified active ingredients derived from herbs, is better (for whatever reason). Why doesn’t the same hold for vitamin supplements as opposed to food?

  24. #24 SkepticalSlug
    Hiding from smoke.
    August 21, 2013

    Cuddle A Marmot
    Cats Are Misunderstood
    Cheetos And Manischewitz
    Confusing A Moron
    Choking A Mammothrept

  25. #25 Mark Thorson
    August 21, 2013

    Autointoxication and its treatment with colon cleansing was accepted by 19th century conventional medicine. The alkaline diet originated in conventional medicine. Chiropractic originated in its predecessor, osteopathy, which was a spurious outgrowth of conventional medicine.

    Going in the other direction, the anticancer drug camptothecin was isolated from the bark of a tree used in traditional Chinese medicine to treat cancer. The antimalarial drug artemisinin was isolated from the leaves of a plant used against malaria in traditional Chinese medicine.

  26. #26 Johnny
    127.0.0.1
    August 21, 2013

    Why doesn’t the same hold for vitamin supplements as opposed to food?

    Speaking only for myself, I’d say it would be better for me to get a full suite of vitamins from food, because I would then be eating more plant and less animal, resulting in an overall healthier diet.

    In my opinion, the best reason to use ‘purified active ingredients’ is controlled dosing. Is the (mythical) active ingredient in SJW grown in Germany the strength as SJW grown in Wyoming? How do you know?

    Where a plant grows, or even year to year variations in the same region, have tremendious impacts on a plants chemical makeup. Ask any wino or pothead.

  27. #27 jane
    August 21, 2013

    Whee. First, JGC, SJW has certainly not been “proven ineffective,” not with a couple dozen positive trials vs. placebo and a dozen or more head-to-head trials vs. SSRIs showing equal value. If those do not constitute proof of efficacy, then two American studies – one that found no benefit for either SJW or Prozac; one funded by Pfizer, grossly biased, and yet having to report clinically significant trends and a statistically significant tripled remission rate – do not constitute Proof of inefficacy. If you object to that statement, please explain the scientific evidence proving that your value judgement is correct.

    Second, Pareidolius, it’s racist of you to assume that controlled clinical trials showing a survival benefit in thousands of cancer patients are worthless “—-” because they were done by Japanese. Conventional MDs in Japan use the product to improve survival. Nobody’s making you use it – but if I had a family member with stomach cancer, I would make darn sure he used it.

    lkr, then you would think that there would be more reports of skin reactions among the hundreds of thousands of people who have used SJW. Turns out, amazingly, that a human who takes one capsule is not equivalent to a sheep or cow that eats ten pounds and stands outside all day. Onions are also lethally toxic, I read, when eaten in huge quantities by livestock; perhaps you think we should give them up? We should come up with a special Fallacy term for the belief that if a lot of a [natural] substance is toxic, so is a tiny amount.

    Mewens, if you think it is practically, legally, and financially possible to individually isolate 50 active ingredients from echinacea or hawthorn and then recombine them all into a patentable and approvable drug product, go for it; in the meantime, the choice is not between that imaginary product and the bad ole plant but between the bad ole plant and nothing. By the way, someone who has a tantrum over the term “whole plant extract” proves he has read nothing on the science of this subject. If you do not want to chew on bark, you can use a crude extract, which is a very different kind of product than a highly purified extract with high quantities of one or a few molecules. Think of the difference between a cup of coffee and “Water Joe.”

  28. #28 Mu
    August 21, 2013

    Cheetos And Manischewitz
    We’re used to a lot of gross things here on RI, but that’s beyond good taste.

  29. #29 Mephistopheles O'Brien
    August 21, 2013

    Jane – your comment to JGC would have more impact if you were to link to some of the actual studies you believe show the strongest evidence for the effectiveness of St. John’s Wort.

    Your comment to Pareidolius says (s)he said things I don’t think (s)he said. You might want to re-read and, if I’m right, possibly reconsider your comment.

  30. #30 dingo199
    August 21, 2013

    Most people know 2 plus 2 equals 4.
    However there is someone who claims 2 plus 2 equals 3.
    Clearly the truth lies in between. The answer must be 3.5

  31. #31 Mephistopheles O'Brien
    August 21, 2013

    2 plus 2 equals 3 for sufficiently large values of 3.

  32. #32 Dangerous Bacon
    August 21, 2013

    Careful, attacking NCCAM is just going to get Sen. Tom Harkin upset all over again. And he’s got enough to deal with, seeing as his sponsorship of legislation to replace dollar bills with coins is raising questions of ethics:

    “The advocacy group promoting the Coins Act has the same address as PMX Industries, a South Korean firm located in Cedar Rapids, Iowa, that supplies the U.S. Mint with the metal used to make dollar coins. Along with its CEO, Jin Roy Ryu, the company in 2011 donated a combined $500,000 to the Harkin Institute of Public Policy at Iowa State University (now at Drake University) named after the senator.”

    http://online.wsj.com/article/SB10001424127887324085304579011053541175182.html

    By the way, CAM also equals:
    Con Artistry Medicine
    Completely Asinine Methodology
    and
    Craptastic Advocacy by Malik

  33. #33 Denice Walter
    August 21, 2013

    And….
    Cooly Avaricious Malfeasance

  34. #34 Mephistopheles O'Brien
    August 21, 2013

    Cooly Avaricious Malfeasance will be the name of my next rock band.

    Actually, my next rock band will be named “Phillip” with the album “Milk of Amnesia”. I don’t know why – it’s an album cover I’ve envisioned since high school.

  35. #35 Mephistopheles O'Brien
    August 21, 2013

    My next fetish web site will be Cuddle a Marmot. They’re so darned cute, though, how could you not cuddle (if they didn’t run away)?

  36. #36 Denice Walter
    August 21, 2013

    For a band? I’m leaning towards Pyroclastic Flo and the Vents myself.

  37. #37 mike
    August 21, 2013

    Both the national organic program and nccam have boards populated with quacks to ensure the government agencies reject science.

  38. #38 Agashem
    Never under the influence
    August 21, 2013

    For my band, I always thought “Fletcherized” would be a sufficiently obscure name to garner interest. (Taken from the ‘Road to Wellville’ by T.C. Boyle – in which he lists the book ‘The New Nuts Among the Berries” as source material. A more interesting book on food fads, etc I don’t think I have encountered).
    As for CAM how about Christmas and mistletoe? Too holiday? How about Crush and mash? Too violent? OK maybe I should stop.

  39. #39 JGC
    August 21, 2013

    First, JGC, SJW has certainly not been “proven ineffective,” not with a couple dozen positive trials vs. placebo and a dozen or more head-to-head trials vs. SSRIs showing equal value.

    Citations needed, Jane. Exactly which clinical studies have shown s SJW to perform better than placebos or as well as SSRI’s ?.

  40. #41 Calli Arcale
    August 21, 2013

    Yes. Nasal irrigation in general should not be overdone. Studies found it works for short-term relief, which is completely unsurprising as it physically removes the blockage, but long-term use is associated with worse congestion and increased risk of infection, in part due to use of unsanitized pots at home or, as in the case that link cites, tainted water, but also because it can wash away *all* the mucus, and in fact you actually don’t want to wash it all way. You need some to protect the mucus membranes and provide a barrier for infectious agents and a way of ejecting them from the system.

  41. #42 Christine (the Public Servant Christine)
    August 22, 2013

    Conservatives Are Morons
    Copulation And Masturbation
    Cats And Moggies (inc)

  42. #43 Spectator
    August 22, 2013

    When do you hear
    “We need to have a conversation about…” ?

    Sounds familiar, yes? Yet vaguely ominous, and somehow suggestive of a conversation where your input goes, eventually, into a shredder.

    “We need to have a conversation”.
    Parents do that to their teens, when they are not able or willing to lay down the law but want to sorta sideways nag the teen out of a habit they should have never been allowed to acquire.

    “Let’s have a conversation” when announced by an official does not mean we, it means I, as in “I have an agenda which I have chosen to pursue. You may as well like it, because I’ve already set it in motion.”

  43. #44 Andrey Pavlov
    August 22, 2013

    (Formerly known as NYBGRUS)

    Dropped a note over at the NCCAM blog. Had a much nicer and longer one, but managed to lose it halfway through.

  44. #45 Antaeus Feldspar
    August 22, 2013

    Well, I didn’t say that neti pots were the greatest thing since sliced bread, or impossible to use wrongly to disastrous effect, I just said that they were an example of something which came from “alternative medicine” that was tested scientifically, and when it passed the testing, became just plain “medicine”.

    It shows the point: if alternative medicine does show the goods, we do accept it as scientific medicine. This straw man, this fantasy world where alternative medicine actually works and is even more effective than “Western” medicine but we won’t accept it because it was Not Invented Here is just that – a straw man, a delusion of the alties.

  45. #46 jane
    August 22, 2013

    Mephistopheles O’Brien and JGC – It’s strange that the most amazing assertions that fit with your beliefs need no citation, yet elsewhere-uncontroversial statements of fact that contradict them, such as the mere existence of well-known literature, needs documentation. Well, this is not my blog and I’m working on an actual publication today, so I will refrain from writing an entire review paper for you. Instead, I suggest you check the most recent Cochrane review:

    Linde K, Berner MM, Kriston L. St. John’s wort for major depression. Cochrane Database Syst Rev 2008 Oct 8;(4):CD000448. doi: 10.1002/14651858.CD000448.pub3.

    On PubMed it is abstract # 18843608. (I am sure that you know what PubMed is and how to use it, right?) This review is based on 29 trials including 5489 patients. SJW was found to be significantly better than placebo and identical to pharma drugs, while having fewer side effects. You might start there for more information, but there have been several other systematic reviews and meta-analyses published.

    Otherwise, I might recommend that you begin with:

    Szegedi A, Kohnen R, Dienel A, Kieser M. Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St. John’s wort): randomised controlled double blind non-inferiority trial versus paroxetine. BMJ 2005;330(7490):503. This paper will be particularly informative for you because the full text is free online (cf. PubMed 15708844) and the study included over 250 patients who were not just “mildly” depressed. SJW both performed better and caused fewer side effects. This and a dozen or more similar studies with active comparators represent science-as-process in action. As a scientist, I feel obliged to accept that data reported by multiple teams of researchers are what they are reported to be unless contrary evidence is shown to me.

  46. #47 Pareidolius
    12 Miles East of Wooville
    August 22, 2013

    Polysaccharide K. If you are a Japanese oncologist. Not if you are a white American oncologist.</blockquote?

    Really Jane? Putting words in my mouth? The racism came from your own use of the word "white" in your quote. Who cares what ethnicity the researcher is? To assume that "white" American doctors aren't able to hold your misguided view of CAM is racist. As racist as the very term "eastern medicine." It's the appeal to the exotic. It makes asians The Other, oh, so mysterious and possessed of a "different way of knowing." I know of what I write, Jane. I was a new ager and worried well consumer of all things CAM for years. I finally had the riot act read to me by a Native American who took umbrage with my notion that he was possessed of some kind of spiritual quality that I didn't have. I thought I was honoring his culture and people. He saw it quite differently. I'm grateful to Charlie (a medicine man, ironically) for being a part of the long process of my waking up from magical thinking.

    I'll leave it to the pharmacists and researchers to clean up the rest of your mess.

  47. #48 Pareidolius
    Blockquote Fail, but I stand by the content . . .
    August 22, 2013

    Polysaccharide K. If you are a Japanese oncologist. Not if you are a white American oncologist.

    Really Jane? Putting words in my mouth? The racism came from your own use of the word “white” in your quote. Who cares what ethnicity the researcher is? To assume that “white” American doctors aren’t able to hold your misguided view of CAM is racist. As racist as the very term “eastern medicine.” It’s the appeal to the exotic. It makes asians The Other, oh, so mysterious and possessed of a “different way of knowing.” I know of what I write, Jane. I was a new ager and worried well consumer of all things CAM for years. I finally had the riot act read to me by a Native American who took umbrage with my notion that he was possessed of some kind of spiritual quality that I didn’t have. I thought I was honoring his culture and people. He saw it quite differently. I’m grateful to Charlie (a medicine man, ironically) for being a part of the long process of my waking up from magical thinking.

    I’ll leave it to the pharmacists and researchers to clean up the rest of your mess.

  48. #49 Mephistopheles O'Brien
    August 22, 2013

    jane – you completely misunderstood my intent. I was merely trying to help you make a stronger point. JGC listed a study that you stated did not make JGC’s case. In my view, your comment would have been more effective if in addition to saying that you had also said “and here is a study that shows how effective SJW is for condition x”.

  49. #50 Mephistopheles O'Brien
    August 22, 2013

    jane – and by the way, thanks for the citations.

  50. #51 JGC
    My opinion proceeds from citations
    August 23, 2013

    It’s strange that the most amazing assertions that fit with your beliefs need no citation, yet elsewhere-uncontroversial statements of fact that contradict them, such as the mere existence of well-known literature, needs documentation.

    Jane, in my original post @12 I included a link to the NIH NCCAAM website, which discussed one such study demonstrating that SJW is ineffective at treating major depression. ( Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John’s wort) in major depressive disorder: a randomized, controlled trial. JAMA, 2002; 287:1807-1814.) The discussion included a link to the full-text of the article available on the JAMA website.

    The evidence does suggest that extracts of SJW may contain active ingredients effective at treating depression (hypericin, hyperforin, etc. have been suggested) and in time effective compounds may be derived proceeding these lead molecules, just as apirin was derived from willow bark extracts.

    Which of course places the use of SJW firmly within the realm of conventional rather than alternative medicine (pharmacognosy).

  51. #52 ebrillblaiddes
    August 26, 2013

    Creeping Along Mildly
    Camping At Mars
    Coat And Mittens
    Cold And Moist
    Chocolate Almond Macadamia

    And the rush to give out pills for depression would not be made much less problematic by making the pills out of plants. The real problem there is that mental health is a low priority even among healthcare in this country, so the solution that takes least office time wins by default.

  52. #53 Shay
    who is cat-sitting
    August 26, 2013

    We could issue everyone a kitten. No office time and it would clear out the animal shelters as well.

    (I’ve just learned that the state where I reside has the second fewest # of residental beds for behavioral health patients. It’s very levelling to find out that we’re just one step ahead of Alabama).

  53. #54 ebrillblaiddes
    August 26, 2013

    A pair of kittens would be more effective. They can do more amusing antics together, especially when their human doesn’t feel like doing anything, which has to be figured in since we’re talking about depression.

  54. #55 Calli Arcale
    August 26, 2013

    Not for me. I am very allergic to kittens. I would gladly accept puppies instead. ;-)

  55. #56 Alison Cummins
    Montréal QC
    August 26, 2013

    ebrillblaiddes:

    Love love love.

  56. #57 Dorothy
    Oz--the other one
    August 26, 2013

    @Calli Arcale

    Alas, I’m deathly allergic to cats AND dogs…and horses, cows,insects, and any other creature of the animal world that I am tested for from time to time. Bummer. They haven’t tested me yet for primates, but I suspect that that will be positive as well. :-)

  57. #58 Krebiozen
    August 27, 2013

    I have somehow overlooked this thread recently, but I do have some thoughts on “whole plant extracts”. The idea that different chemicals in plants act synergistically to better treat human disease is rooted in medieval (and earlier) belief systems. It used to be thought that God created plants (and everything else) to be used by humans, so they were specifically designed to be effective in human disease. They were also made to look like the organ they were supposed to treat – the doctrine of signatures. Lungwort, for example, which has leaves that a lung-shaped, is still used to treat pulmonary disorders.

    We now know that in many cases the chemicals we use as medicines are ‘designed’ to repel or poison animals (like us) that would otherwise eat these plants. It isn’t impossible that some chemicals might work together in this way, but there is certainly no good reason to expect them to as a matter of course.

    A similar idea is that bioflavonoids are provided along with vitamin C in fruits for human benefit. When you realize that animals capable of synthesizing ascorbate don’t make bioflavonoids as well, this looks less plausible.

    BTW, SJW was believed to repel demons, and its use to treat depression comes directly from that, a legacy of the idea that mental illnesses are manifestations of supernatural interference by malevolent non-human entities.

    A lot of CAM is about rationalizing behaviors derived from irrational pre-scientific beliefs.

  58. #59 Calli Arcale
    August 27, 2013

    Dorothy — I remember seeing a story on Animal Planet about a dog (a golden lab, IIRC) who was deeply devoted to humans, and unfortunately also violently allergic to them. He was also allergic to pretty much everything else in his environment. They moved him to a rescue in the Southwest, where the clear air and general lack of pollen would remove most of the allergic insults, fed him constant Benadryl, and made sure all the humans who worked with him bathed and put on fresh clothes before playing with him. I felt so sorry for that dog — compelled to be with humans, but sickened by them.

  59. #60 ebrillblaiddes
    August 28, 2013

    @Calli Arcale #55 They keep saying that hypoallergenic kittens are just around the corner…

    @Allison Cummings #56 Thanks :)

    @Krebiozen #58 OTOH given the extent to which pre-scientific cultures attributed mental health issues to demons, it’s at least possible that if something did improve mental health, they would label that observation as “it chases their demons away” so I can see how it was at least plausible to consider whether an herb with a reputation for chasing demons might have some effect on a person’s actual mental health. Likely, maybe not, but plausible enough to investigate, sure.

  60. #61 Krebiozen
    August 28, 2013

    ebrillblaiddes,

    I can see how it was at least plausible to consider whether an herb with a reputation for chasing demons might have some effect on a person’s actual mental health.

    I wondered about that, but the earliest references to SJW I can find don’t mention ingesting it, they refer to macerating it in oil and using that to treat wounds, or hanging bunches of it above pictures of saints to repel evil – the Latin name Hypericum comes from the Greek ‘hyper’ meaning ‘above’ and eikon meaning ‘picture’. The idea that it is somehow holy comes from its leaves which have oil glands that show up as transluscent red dots, which are supposed to be from the blood of St. John that splashed on its leaves when he was beheaded, since it flowers around the time of St. John’s day on 24 June.

    So, I don’t believe the idea that SJW can treat depression comes from the observations of herbalists at all, but in a convoluted way from superstitious beliefs based on its appearance and the time of year it flowers.

    As we know, depression is extremely susceptible to placebo effects, and I suspect that the clinical trials that found SJW as effective as convention antidepressants say more about the efficacy of conventional depressants than they do about the efficacy of SJW.

  61. #62 ebrillblaiddes
    August 28, 2013

    @Krebiozen You make a valid point. I only found antidepressants to be particularly effective the first time I was on them, and even that, only for a week or so at the beginning (two weeks in, they raised my dosage because I couldn’t rate my life a 10, and they wanted to do it again a while after that but I put my foot down and pointed out that it’s a pill not a life transplant and I still had a wide variety of real and practical problems so they’d have to break out the narcotics to get me to rate my life a 10). I found out afterward that a strong but quickly tapering response is typical for a placebo effect, which I would’ve been OK with except they also left me a little fuzzed and feeling like the good days weren’t really me, the really bad days got through the filter just fine though. I can easily imagine that a plant that doesn’t do much at all still might come out better than that on balance.