I've been blogging long enough now that it's hard for me to keep track of what I have or have not written, and on which particular blog. I used to be pretty compulsive about digging up old links to my first blog (now in storage) or to denialism, or even to this blog, but this can be paralyzing. I still try to make sure to link to other writer's pieces, whether on denialism blog, or at other blogs that I like, but if I were to be overly compulsive about this, I'd never get any writing done.
And with that in mind, it's time for a review of alternative medicine (one that is a bit more extensive than my last similar diatribe). I get a lot of questions, mostly of the "DrPal, why are you such a hater?" variety. I'm not a hater. I'm a stickler. My ethics require me to do the best for my patients, which includes treating them with respect. Respecting my patients requires telling them the truth about various interventions---does the evidence support them, and if so, how well? This week, for example, I was going over a medication list with a patient and asked him why he took mega-doses of vitamin C. He said to prevent colds, cancer, and because it seemed like a good idea. I informed him that multiple well-done studies have failed to show significant benefit to taking vitamin C supplements, and he agreed to stop them.
But what's the harm? There may be none in this case (although the same can't be said for vitamin A). But there's lots of reasons to guide patients toward science-based therapies, not the least of which is your ethical responsibility. I have many patients who complain of taking "too many pills". Sometimes they are, and sometimes it's a doctor's fault, sometimes not. If I have a patient with hypertension and diabetes, the evidence clearly shows that certain interventions, including lifestyle modification and medications, will save them a lot of grief. But a patient may also be on a host of non-proven supplements, which, if dropped, would make the patient seem much less "over-medicated".
And this is one of those weird false dichotomies. Patients sometimes want to take something "natural" rather than a "medicine" (as long as natural doesn't mean eating better and exercising more). If something is physiologically active enough to affect a disease state, it doesn't much matter whether it's "natural" or not.
But I'm getting ahead of myself. Let's throw some organization on this post before it gets completely out of hand.
Alternative medicine can mean lots of things. There are some additional terms of note: complementary medicine usually refers to practices that integrate medicine with alternative medicine (and is often called "complementary and alternative medicine (CAM)"; and "integrative medicine", which largely means the same thing. According to the National Center for Complementary and Alternative Medicine (NCCAM):
Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.
What does that mean? What makes something "alternative" rather than "conventional"? Here's some proposed categories:
- Practices that lack of wide adoption by conventional doctors
- Practices that seem "weird"
- Practices without sufficient supporting data or putative, plausible mechanism of action
- Practices that are either hold-overs from pre-scientific times or whose "legend" makes them appear to be so
- Practices that sound "natural"
Admittedly I made this up, but it's no worse than what NCCAM came up with, and it allows us to examine some of these practices.
For the first category, there are many practices not widely adopted by real doctors. Some perfectly conventional therapies take a while to propagate through the community, for example, the use of ACE inhibitors in diabetics with proteinuria. Still, propagate they do. But why do some practices remain alternative? Why, for example, has acupuncture failed to be adopted by most conventional doctors?
Because it doesn't work any better than placebo, and if something doesn't work any better than nothing, then there's no reason to do it. It also doesn't have a plausible mechanism of action, being based on ancient ideas of astrology and elan vital (or more properly "qi"). It also carries a myth of ancient origin when in fact it was largely promoted by Chairman Mao as a nationalistic (and cheap) alternative to "imperialist" medicine.
One argument I sometimes hear is that there are alternative practices that work we-know-not-how and therefore cannot be measured by known methods. This is absurd. Any time a patient claims to feel better, a data point is established.
One of the gravest sins committed by proponents of altmed is the false dichotomy between "natural" treatments and real medicines. There is nothing special about something that is "natural", and many drugs are either natural products or derived from natural products. The unfortunate tendency in alternative medicine is to assume that "natural" is somehow better than "unnatural".
The fact is that most "natural" remedies are produced and marketed by big corporations, often the same companies that make "real" drugs. "Natural" appears to mean "not prescribed by a doctor and not subject to FDA regulation". There is no other difference.
What I'm trying to tell you, dear reader, is that there really is no such thing as "alternative medicine"---only that which either works or may plausibly work, and everything else. Anything that really works doesn't stay alternative for long. Are there exceptions? Are there practices that should be widely adopted but that either are not, or are accepted only slowly? Sure, there must be. Medicine is fairly conservative, unless data is so overwhelmingly positive that to go slow would be unethical. But when they are adopted, there was always a plausible mechanism of action or data to support their use.
When you examine alternative medicine claims with even a bit of a skeptical eye, you quickly find that most are built on false premises, emotional attachment, misunderstandings, or outright lies. Non-anecdotal arguments in support of CAM are rarely positive, and usually resort to meaningless obfuscation ("well, medicine got it wrong before", "Big Pharma is only out to make a profit", "doctor's just wanna make a buck".)
If people eyed alternative medicine with even half the suspicion they have for real medicine, the CAM practitioners would be out of work by the end of the business day.
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but...why are you such a hater? Just kidding. This is a fabulous post. I'm emailing it to a bunch of people who need to read it. Thanks!
From the University of Michigan:
"In the study, researchers at the U-M Chronic Pain and Fatigue Research Center showed acupuncture increased the binding availability of mu-opoid receptors (MOR) in regions of the brain that process and dampen pain signals â specifically the cingulate, insula, caudate, thalamus and amygdala."
Here's the link
http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1246
You might want to do some research before writing articles like this. You sound very emotional.
From the University of Michigan:
"In the study, researchers at the U-M Chronic Pain and Fatigue Research Center showed acupuncture increased the binding availability of mu-opoid receptors (MOR) in regions of the brain that process and dampen pain signals â specifically the cingulate, insula, caudate, thalamus and amygdala."
Interesting...but clinical studies still show no difference between acupuncture and placebo.
You sound very emotional.
...and your point is?
True Skeptic, I read through the paper. Some observations:
1. pretty small sample sizes
2. no switching control & experimental participants midway through (probably due to small sample size)
3. no control for the validity of acupuncture points. This is the biggest one to me. If you really want to show that the needle insertion points are the real deal, why not have a sham group stimulating the 'qi' points? Why not have real needle penetration at the random points used for the sham group? (sample size again) The experiment was conducted as if these sites were established as meaningful in some way, which is not the case.
These findings are intriguing, but as they are contradicting many other, larger, prior studies, the authors should have made sure to cover their bases with respect to robust controls. As it is, there's more than a bit of "Tooth Fairy Science" to it.
From the same U of M article:
âInterestingly both acupuncture and sham acupuncture groups had similar reductions in clinical pain [...] But the mechanisms leading to pain relief are distinctly different.â
"One implication of this research is that patients with chronic pain treated with acupuncture might be more responsive to opioid medications..."
So real acupuncture is doing something different than placebo. And since acupuncture research is still in its infancy, this fact alone should be sufficient reason to withhold judgment and await more research.
> ...and your point is?
My point is that science is about the dispassionate analysis of meticulously gathered data. The author's emotions are getting in the way of his rational thought.
@True Skeptic. Science is dispassionate analysis of meticulously gathered data, but you also can't pick and choose studies to fit your idea of what works and what doesn't. One study with 20 subjects doesn't dismiss the overwhelming majority of (better controlled) studies that show that acupuncture is no better than placebo (i.e. Brinkhaus, 2006 N=298; or the meta-analyses with a total of 6736 patients).
Some time back Richard Dawkins was excoriated for condemning alternative medicine. The person who wrote the article said that some of the treatments might have some value, and Dawkins was wrong to condemn all of them.
But a careful reading of what Dawkins actually said showed that he considered part of the definition of "alternative medicine" the fact that it doesn't work. (or perhaps not any better than conventional treatments, I can't find the article I read and don't remember that detail) When or if a treatment is shown to be effective, it is considered "medicine," not "alternative."
The problem with discussions about this is the definition and lumping everything into a CAM category. Things that are considered alternative consist of some things that are proven and some that are just ridiculous. For instance, some supplements (which would be considered CAM) do have double blind studies to back them up. I've read them. For instance studies were published back in the 1990s for using fish oil for rheumatoid arthritis. They were published in Arthritis and Rheumatism. The results showed a statistically significant benefit although it was mild. I've read these myself.
In addition, I haven't read them, but firmly believe that diet plays an important role in health. And, I do believe that it stands up to scientific scrutiny. That isn't to say that the grapefruit diet has any particular benefit. Same thing with exercise. That is not to say that all exercise is beneficial for all people.
Its like saying all drugs are good or bad.
The problem in my mind is lumping everything together. Then people are either for or against alternative stuff. I'm for some of it - that has evidence or personal experience (massage for muscle spasms). I'm suspicious of most other things.
Its better if each thing is addressed for what it is. Fish oil is proven for RA, heat and massage works to relieve muscle spasms, shark cartilage is shown to not help RA, etc.
DRPal,
Thank you for writing the least hater explanation of why altmed is really just woo.
The two points that struck home with me were, "Patients sometimes want to take something 'natural' rather than a 'medicine' (as long as natural doesn't mean eating better and exercising more)." (emphasis added)
And: "Any time a patient claims to feel better, a data point is established." Which applies to ANY claim of the variety "We don't know how it happened...!"
PalMD: ...there really is no such thing as "alternative medicine"---only that which either works or may plausibly work, and everything else.
I agree completely. And while some patients do favor remedies because they're "natural", some doctors seem to avoid them for the same reason.
A 2002 meta-analysis found that S-adenosylmethionine (SAMe) was as effective as NSAIDs for treatment of arthritis, but without the adverse side-effects. However SAMe is a dietary supplement and many doctors would shun its use for that reason.
However SAMe is a dietary supplement and many doctors would shun its use for that reason.
While I'm not a primary care physician and don't know anything about SAMe in particular, there is good reason to shun "dietary supplements" in general, even those which appear to be effective: Their manufacture is completely unregulated. So, if you tell a patient that s/he can buy this supplement for his/her arthritis you don't know if the product s/he will obtain contains the biologically active amount of SAMe and not an over- or underdose, contains other ingredients that might be dangerous (i.e. some preparations might be spiked with NSAIDs to make them more effective or just have byproducts or other junk in them), or even really contains SAMe at all. If the same product were produced at drug quality standards and evaluated positively by the FDA, then I'd be interested. Until then, it's just too dangerous to recommend.
Judy,
When scientifically valid research shows that a supplement can be effective, it is accepted into medicine. Until then, it is considered unproven and not used. Very simple. Proof, then use.
There is nothing "alternative" about proper diet and exercise. Our knowledge of the value of these comes not from what passes for CAM research, but from medical research and it is a focal point for standard medical care.
My doctor's office regularly has materials out on healthy eating and exercise. You would have to close your eyes to miss it. The worst you can say about medicine and diet/exercise is that many doctors do a poor job of convincing their patients to do the right thing.
I can tell by how delighted my doctor is that I've paid attention and have for the past three years, kept my type II diabetes under control entirely through diet and exercise. He wishes that more of his patients would do the same.
Also notable concerning SAMe: A second meta-analysis here concluded that the published studies on SAMe versus placebo or NSAIDs were few enough and low enough quality that definitive conclusions could not be drawn. This sort of evidence, while interesting (if a clean reliable version of SAMe could be produced a large randomized controlled trial would certainly be warranted), is not really enough of a basis to recommend a product.
Dianne: "While I'm not a primary care physician and don't know anything about SAMe in particular, there is good reason to shun "dietary supplements" in general, even those which appear to be effective: Their manufacture is completely unregulated."
This is simply not true. Here is an article from The Council for Responsible Nutrition detailing exactly how supplements are regulated. Included is information on Good Manufacturing Practices for supplement companies, recently implemented by the FDA.
Somehow, I don't think that the Council for Responsible Nutrition is the most unbiased of all possible sources.
An alternate source on the regulation of dietary supplements here. Critical point: "Under the provisions of DSHEA, manufacturers of dietary supplements are not required to provide evidence of efficacy or safety prior to marketing the product. Moreover, except for a supplement that contains a "new dietary ingredient," dietary supplements are not required to have FDA approval or to be registered with the FDA before they are produced and marketed." Seriously, do you want to be taking a product that has not been demonstrated to be safe or effective? Would you even consider taking a drug manufactured under these lax conditions?
Indeed not, especially as the document in question directly contradicts the FDAs information page on the DSHEA. (recapitulated with context in the link Dianne provided above). Supplement Manufacturers are on the 'honor system' regarding all safety testing, quality control, and labeling claims. The FDA will only regulate post-market, and they have really only started to do this in earnest in the past few months after--surprise!--a number of supplements were marketed with false claims or dangerous ingredients under the DSHEA guidelines. Further, the FDA currently has no say in enforcing truth in advertising for these products--that task falls to the FTC.
Well, its not a BAD article, I feel the sincerity in what you're trying to say. I think the thing you're missing..and missing badly..is that Alternative Medicine exists because of a hole in our current healthcare system. And it provides a new paradigm of health that you simply cannot, or will not, provide. You want to be the only tool in the box. Well, I'm sorry, but the complexity of our health issues in this world requires a much more and a much broader view. I prefer to use herbs over almost any pharmaceutical. I am educated in their use, and I think its a valid alternative for people. That's all there is. People like us need to be protected from people like you--who want to deny or restrict our access to vitamins/supplements/herbs/healing. Stop the ridicule--no matter how politely phrased, and start sharing the sandbox.
As a side note, megadoses of vitamin C can have an impact on the kidneys of elderly patients, or patients with pre-existing kidney conditions. Not a good impact, either.
Susan: I would say that even in this modern age of high-tech drug discovery, about 80% of drugs are plant-derived. They become mainstream medicine when they are tested, purified, and their preparation becomes controlled enough that dosage can be absolutely consistent. What you are advocating for is a return to the systems which necessarily existed before all that was available. What's worse, you are advocating a system which does not have any particular form of record keeping for evaluation of efficacy or safety or even effect at all, much less testing of interactions. Like, how many herbalists out there are required to warn people off St. John's Wort if the patient is taking the Pill? Or on antibiotics? Or, what systems exist to hold the herbalist who tells someone to take pennyroyal responsible for subsequent harm?
There is a reason to want people to stick with a system which is regulated and tested. All ways are not equal.
And it provides a new paradigm of health that you simply cannot, or will not, provide.
What is that paradigm and how can it lead to better health?
People like us need to be protected from people like you--who want to deny or restrict our access to vitamins/supplements/herbs/healing.
It's true that I would like to restrict your access to vitamins, etc. But only insofar as I want to restrict your access to drugs: I want to people to have access only to those drugs, vitamins, supplements, medical devices, herbs, etc that have been demonstrated to be helpful and tolerable. I don't think you should have access to unlimited quantities of foxglove extract or digitalis. Or bitter almonds or purified cyanide. And I want mandatory, independent quality control to ensure that if you take a pill labelled xeloda 500 mg it really contains 500 mg of capecitabine or when you take a herbal supplement labelled ginko balboa it really contains ginko balboa and not, say, aricept or synthetic hormones or arsenic. However, I'm not sure why that means that YOU need protection from me. Unless you're a drug company president and need your profits from the herbal market protected or something.
Susan,
There is precious little evidence that most of the thousands of herbs are effective beyond placebo. By definition, the few that do work are drugs, very dirty drugs. I prefer to just take the pure, active ingredients.
It is not a case of doctors wanting a monopoly, the rules are simple- demonstrate effectiveness under controlled conditions and you are in. As for your fear of being prevented from doing foolish things- not so much. The right way to look at it is preventing people from getting rich off you by scams.
You should read the book "Natural Causes" by Dan Hurley (Broadway, 2006). The title refers to the harm that is caused by natural remedies.
"It is not a case of doctors wanting a monopoly,..."
Weeellll. The regulatory environment has that effect, even if doctors claim otherwise. And thise statement is an extreme over-simplification "...the rules are simple- demonstrate effectiveness under controlled conditions and you are in."
If it was only about the science, I'd have zero criticism of the FDA. In fact, if it was only about the science, we'd have no need for a government regulatory agency, we'd have a few private companies providing third party testing and evaluation, then publishing results for all to see. Much like the "Comparative Guide to Nutritional Supplements" http://comparativeguide.com/cgi-bin/plugins/MivaEmpresas/miva?plugins/M…
(which, by the way, adresses most of Dianne's concerns).
However, because there is much more involved than just science, then a political entity, the FDA, has control over which drugs get released to market and which do not. Influencing this political entity requires much more than being a good doctor or good drug manufacturer who is concerned with helping people fight off illness.
Alternative Medicine exists because of a hole in our current healthcare system.
I completely agree with this bit. There are many things that exist because of holes in our current healthcare system: black market pharmaceuticals, internet pharmacies that don't require prescriptions, illicit drug abusers, prisons being used in lieu of mental hospitals, high rates of malpractice insurance, high nosocomial infection rates, etc.
Lack of access (financial or otherwise) to actual, real medicine is probably a biggie--how many women would risk poisoning themselves with pennyroyal if they could get an abortion from a licensed doctor for an affordable price without having to travel far, lose much work, take a raft of shit from friends/family, sit through waiting periods, or go to multiple mandatory "counseling" sessions to have looney-tunes state-scripted statements read at them?
Per this NIH study, people mostly use herbs and such for musculoskeletal diseases, especially back pain--which real medicine doesn't do well with. Docs are, understandably, skittish about prescribing serious pain control for chronic non-lethal conditions, and treatment options tend to be either hideously expensive or very limited. I suppose $20 worth of placebos is an improvement on negotiating the black market drug trade for Darvocet.
Lora, excellent points.
Nice post, Pal!
IMO, CAM is glorified by calling it medicine - hey, my insurance company might pay for it!
Some of these procedures feel good (massage therapy), and others may act as placebo, but none have been subjected to the same levels of scrutiny of medicine.
Supplements are also iffy - despite GMP, there is no compulsion for manufacturers to provide standard formulas with consistent levels of the supposed active ingredient(s). Any practitioner who sells supplements is making a lot of money at the patient's expense, and providing their patients with at worst, harmful side effects and interactions with drugs, and at best expensive urine.
In honor of the media hype for the 40th* anniversary of Woodstock, I've created a 60's style chant: Hey hey, ho ho - DSHEA has got to go!
*Disclaimer: Wasn't born yet, and I hate crowds anyway.
"Big Pharma is only out to make a profit", "doctor's just wanna make a buck"
I am so tired of hearing this argument from CAM supporters--economically it makes absolutely no sense at all. I am positive that "big Pharma" would love to get its hands on something found in an alternative medicine that it could make millions from. I am also certain that insurance companies would be especially happy to stop paying for expensive medications if a few sessions of acupuncture would do the job. I am also convinced that the overwhelming majority of doctors would love to be able to give their patients something that would help their suffering, as doctors are pretty dedicated folk as a whole, wanting to HELP people and not make a buck off the suffering of another. Maybe I am naive about this, as the President seems to think doctors need "incentives" to keep diabetics from having amputated feet. I don't see any "incentives" in the self policing methods of the CAM industry, nor do I see much in the way of ethics. No matter how much "proof" is ever provided that something doesn't work--it remains on the shelf, and it takes a death or two or ten to ever get it off the shelf. And what of the effects of the CAM treatments that no one ever finds out about? What of the people that take all kinds of things behind the backs of their doctors, thinking its "safe because its natural" and then winding up in the ER because they took too much, or it interacted with another drug they were taking, or even worse they got a dose of something in the bottle that wasn't supposed to be there in the first place? Can we ever know how many of these instances took place, as many people won't even fess up that they took something they shouldn't have?
My ire is especially directed at the BILLIONS of dollars people spend on alternative treatments under the guise of "what the heck, it might work" like the recent zicam debacle that proves some of the harm that can be done when snake oil is permitted to be sold over the counter.
Billions of dollars wasted on these unproven, suspect, and possibly harmful substances--billions of dollars that could be channeled toward research of real cures, or toward actual doctors that maybe might actually treat someone's condition. Billions of dollars that alternative treatments rake in--- and people think the drug companies are the ones trying to shill us?
When drug companies are the ones that have to spend millions on clinical trials, prove efficacy, and jump through FDA hoops to get something to market? Is that even fair?
Every dollar someone spends on some ridiculous placebo costs society in lost time and opportunity to do the right thing and get the money where it needs to go--to real treatments and REAL research.
Billions of dollars spent on treatments that DON'T WORK. If we want to save money on health care, perhaps we should start by regulation of an industry that has gotten away with far too much for far too long. Make the CAM manufacturers prove efficacy, before they can peddle anything in a bottle. Start by making them PROVE that what is IN the bottle IS IN THE BOTTLE. Make them STOP the snake oil, once and for all.
It's not a matter of hate. it's a matter of alt-med is an unproven and often harmful alternative to real, science-based medicine.
The claim is that there is nothing to CAM medicine, because if there is, then medicine will do research to confirm the efficacy of the treatment and adopt it, and it will become standard medicine.
The real world issue that is not mentioned is how long will it take for the conventional researchers get around to doing the research? Years? Decades? CAM practitioners have been promoting wheat free trial diets for thirty years as a way to test for wheat sensitivity or celiac disease. Doctors are still way slow to look for possible wheat problems in patients. They used to say it was totally rare. Then it was one in 150. Then one in 100. Now one in 33, and you still hear almost nothing about it. How many millions or billions and trouble and pain would be saved by proper conventional diagnosis of wheat problems?
Same with dairy. Alternative practitioners have called attention to the link between dairy and chronic ear infections for years. Still, the first thing a kid gets with an ear infection is antibiotics. And the second and the third.
But conventional doctors don't like avoidance diets, so afraid of reducing nutrition.
The real issue seems to me to be lack of respect for anyone who hasn't been through medical boot camp, and obsession with one kind of research, the controlled study, which they have arbitrarily labeled as the only valid one. However, all the pharmas have learned how to game the controlled study to the point where its scientific merit is losing credibility, which unfortunately spreads to the really good controlle studies. But clinical research is also valid.
Oh, jane, jane, jane...
I hope you can see that this argument is, well, dumb. What if engineers thought this way? "Well, we could build a bridge right, but people would be stuck on the other side for a long time while we figure it out, so, what the fuck, lets just toss something up and let them cross." This is a very, very dangerous approach to medicine.
I'm not sure if you really understand this. Celiac disease is pretty common in some ethnic groups--about 1% in caucasions, and about 5-10% in first degree relatives of those with the disease---doctors are not unaware of it. We deal with it often enough. The fact that you don't hear about it very often doesn't impress me---I hear about it every day. And it's not diagnosed via test diets. That's bad medicine, and tells you nothing specific about someone's condition. It's...dumb.
Huh?
I think your ideology is blinding you, including making you confound "clinical research" for "ideas I pulled out of my ass".
Jennifer, how did you get a copy of the paper (U-M Chronic Pain and Fatigue Research Center)? It doesn't seem to be published yet.
Unless I'm mistaken, the biggest claim from the article is: "It is imaginable - - but not demonstrated - - that acupuncture with morphine might be more effective than morphine alone". Slightly short of earth-shattering.
I also had some objection to the claim that "both acupuncture and sham are proved effective" - - are they saying the sham acupuncture is really a Great Breakthrough in Treatment?!?
I would like to see the paper - - not just the press release - - before I compose my carefully-worded response to my local community.
The press release says nothing at all about a control. Last time I checked, an experiment without a control is not an experiment at all.