Harms of alternative medicines: article in The Economist

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Just saw this article today. What do you guys think about this? I thought this seems a bit scary but also reveals a lot about patients needs and wants that are unfulfilled or underaddreessed in today's health system.

http://www.economist.com/node/21552554

Medicine and its rivals: The believers
Alternative therapies are increasingly mainstream. That means headaches for scientists—and no cure in sight
The Economist
Apr 14th 2012 | TUCSON, ARIZONA | from the print edition


THREE DOZEN doctors-in-training recently sat in a conference room in Tucson. Arizona sunshine streamed through open French windows. On the floor were votive candles and peacock feathers, symbols of healing. It was the closing ceremony in a month-long course at the Centre for Integrative Medicine at the University of Arizona, promoting the notion that doctors should use alternative treatments alongside conventional ones. Speaking to the students was Andrew Weil, a doctor and campaigner who heads the centre.

Dr Weil is a diminutive Santa Claus with a not-so-diminutive brand. He writes books and sells products (such as the Dr Andrew Weil for Origins™ Mega-Mushroom Skin Relief Soothing Face Lotion, for $61). Profits go to his foundation. On this occasion he was in his role as teacher, explaining the importance of nutrition in keeping patients well. That is a doctor’s task, he said, not merely treating the sick.

Few in mainstream medicine would disagree with such an approach. But Dr Weil continued by saying that evidence-based medicine, at its worst, “is exactly analogous to religious fundamentalism.” He urged the students to promote integrative medicine. Together, they would be the future of American health care.

They are well on their way. By one recent count four in ten American adults use some form of alternative therapy. If Dr Weil’s flourishing business and other programmes are any indication, these will grow even further. For six decades double-blind, randomised, placebo-controlled trials have helped doctors to sort science from opinion and to sift evidence from anecdote. Now those lines are blurring.

The evidence for alternative treatments varies wildly. Some herbal remedies broadly meet the test of mainstream medicine. St John’s wort has antidepressive effects (though quite how it works is not completely clear). Chinese herbs may improve chemotherapy for colon cancer. Acupuncture can relieve nausea and some types of pain—though for other ailments it seems no more effective than a placebo, according to Edzard Ernst, who led the study of alternative medicine at Exeter University. Homeopathy is more controversial. Believers say substances which in large quantities may cause symptoms of illness can cure them in highly diluted form, thanks to an imprint left on the water. Sceptics deride both that claim and the principle behind it.

An example is Oscillococcinum, a homeopathic treatment for flu symptoms made with extract of duck heart and liver. Once diluted 100-fold—with the process then repeated another 200 times—it purportedly gains healing properties. Boiron, a French firm that makes this and other such products, had revenues of €523m ($681m) in 2011. Whatever the scientific arguments (or lack of them) for such treatments, the commercial ones are striking.

Powerful supporters have helped the cause. King George VI helped to ensure that homeopathy would be part of Britain’s newly created National Health Service (his grandson, Prince Charles, is also a fan). Royal Copeland, an American senator and homeopath, saw to it that the Food, Drug and Cosmetic Act of 1938 authorised homeopathic products. Sixty years on another senator, Tom Harkin, helped to set up the National Centre for Complementary and Alternative Medicine (NCCAM) at the world’s leading medical-research outfit, the National Institutes of Health (NIH).

Small pills

The $1.5 billion that taxpayers have devoted to NCCAM has brought meagre returns. In 2009 Mr Harkin said it had “fallen short” and bemoaned its focus on “disproving things” rather than approving them. But it has spawned a new generation of research outfits. The University of Maryland’s Centre for Integrative Medicine has received $25m from the NIH for research. Separately it offers treatments such as reiki, in which a healer floats his hands over the patient’s body.

In 2003, with NIH funding, Georgetown University created a master’s degree in alternative therapies. The University of Arizona offers training in them for medical students and a two-year distance-learning course for doctors and nurses. The Consortium of Academic Health Centres for Integrative Medicine now has 50 members.

Such trends have vocal opponents. In Britain and Australia, horrified scientists are fighting hard against the teaching of alternative therapies in publicly funded universities and against their provision in mainstream medical care. They have had most success in Britain. David Colquhoun, a pharmacology professor at University College London, has shamed some universities into ending alternative courses. The number of homeopathic hospitals in Britain is dwindling. In 2005 the Lancet, a leading medical journal, analysed the evidence and declared “the end of homeopathy”. In 2010 a parliamentary science committee advised that “the government should not endorse the use of placebo treatments including homeopathy.” But the NHS still provides it, albeit to the modest tune of £4m ($6.3m) a year.

A similar push in Australia has proved futile so far. In January a group of dismayed academics, doctors and scientists urged universities to renounce courses in alternative medicine. The universities’ leaders have yet to budge, although a leaked paper from the National Health and Medical Research Council describes homeopathy as “unethical” and baseless.

The future for the alternative-therapy industry looks particularly bright in America. NCCAM continues to pay for research. Josephine Briggs, its director, says she is neither for nor against alternative treatments; she just wants to test which ones work and which do not (she is also interested in the effect of medical rituals). But Steven Novella, a vocal critic at Yale University, argues that the centre’s very existence fuels the cause. “People say, ‘The government is researching that, so it has got to be legitimate’,” he complains.

Supporters of alternative medicine have two additional forces in their favour. Conventional health care has some clear failings. As Dr Weil points out, America’s health-care system excels at treating sick patients but is miserable at keeping them well. The pharmaceutical industry struggles to create good, long-term treatments for pain and other chronic conditions. Many doctors are hurried or come across as unsympathetic. Alternative practitioners spend time with patients, asking about not just their medical histories but their lifestyles. They may emphasise nutrition and exercise. Many such treatments, especially the hands-on ones, are soothing. It is unsurprising if patients feel better.

Second, arguments that insist on evidence and scientific rationales work only with those who think that these are all that matters. Many providers of alternative therapy say it is inherently unsuited to double-blind randomised trials.

The study of placebos does not jar with orthodox medicine. Harvard University (which employed Henry Beecher, inventor of the randomised trial) has now created a new programme in “Placebo Studies and the Therapeutic Encounter”. Ted Kaptchuk, its director, is studying how patients respond to sham treatments, as well as the importance of patient’s faith in a treatment. In a paper in the New England Journal of Medicine last July he described an experiment with asthma inhalers. The real ones improved patients’ lung function by 20%, compared with 7% for the alternatives: a dummy inhaler or acupuncture. But patients judged the effectiveness of the three therapies to be about the same.

The worries about the ethics of prescribing a placebo are real. But so are fears that alternative therapies may do harm—for instance, by tempting patients to shun real medicine. Steve Jobs, the founder of Apple, died from cancer last year after having first favoured acupuncture and fruit juices over conventional treatment. Misplaced faith has its costs.

from the print edition | International

"In a paper in the New England Journal of Medicine last July he described an experiment with asthma inhalers. The real ones improved patients’ lung function by 20%, compared with 7% for the alternatives: a dummy inhaler or acupuncture. But patients judged the effectiveness of the three therapies to be about the same"

This looks to be the real problem. How can we even begin to differentiate the merit of science-based medicine from that of complementary and alternative medicine (CAM) when patients themselves don't even realize when they are getting better? This may also come down to scientific illiteracy. A 2009 PISA (Programme of International Student Assessment) found the scientific literacy of the United States to be ~17th. Keep in mind that puts us behind former eastern block gems such as Poland and Estonia. If CAM outmodes science-based medicine we will have officially decayed from the Age of Information to the Age of Ignorance. Just my 2cents.

This hits way too close to home for me. My long distance girlfriend has a lot of anxiety, and she really is just avoiding psychiatry because of the stigma. She's gotten nausea issues that don't seem to respond to anything, and it just gets worse. I try to explain to her how bad stress can be, but to no avail.

She's likes the Naturopathic doctor because he basically spends time with her. It's too bad, because she gets great grades and is pre med.

Originally Posted by domnomnom

This hits way too close to home for me. My long distance girlfriend has a lot of anxiety, and she really is just avoiding psychiatry because of the stigma. She's gotten nausea issues that don't seem to respond to anything, and it just gets worse. I try to explain to her how bad stress can be, but to no avail.

She's likes the Naturopathic doctor because he basically spends time with her. It's too bad, because she gets great grades and is pre med.

Has she tried food intolerance testing? I was dealing with nausea and heart burn (among a host of other things), it was my body finally saying STOP EATING WHEAT! Again, that was me, but similar where Zantac and other stuff didn't even touch the problem and PCP looked at me like when I told her my symptoms.

Or she's knocked up. :P

As for the article, I think we need to understand these alternative therapies more. Even if not to prescribe them, but at least to understand what pts are doing to their bodies. If we automatically assume that researching something equals support for the therapy, we'll undermine our progress in science as well. These alternatives may have some interesting information that we can get to enlighten us even more about how our bodies function. I also think that these treatments are showing a lot more into what the population thinks of current medicine. There's obviously a disconnect between patients and their belief that modern medicine can really help them.

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Originally Posted by otggwmfs

Interesting article. I also found this - http://www.newyorker.com/reporting/2...a_fact_specter to be interesting. Sorry, it doesn't display the whole article, I read the entire thing on my kindle subscription, so I couldn't copy and paste.
I think the problem is, how do you have a placebo treatment for something like acupuncture? How can you discern whether it's the acupuncture itself that helps patients, or the idea that someone is taking care of them and the belief that they will get better because they are 'treating it? I guess I'm supportive of alternative medicine, if it makes the patient feel better, then fantastic. Even if we don't know what is truly working, or how it works. I think the biggest concern I have, as this article alludes to as well, is when patients shun evidence-based medicine in support of alternative treatment. Or when patients neglect to tell their physicians about alternative treatments that may interfere with standard care.

The placebo form of acupuncture is known as "sham acupuncture." It's basically acupuncture without using the "actual" acupuncture sites.

As an aside, I'd propose the more (yet far less well-studied/understood) side of the question is actually how placebos compare to no treatment conditions. That topic has important implications for how medicine really works and, perhaps, how we could improve patient care.

What do you call alternative medicine that works?

Medicine.

Originally Posted by otggwmfs

I think the problem is, how do you have a placebo treatment for something like acupuncture? How can you discern whether it's the acupuncture itself that helps patients, or the idea that someone is taking care of them and the belief that they will get better because they are 'treating it?

There are several good placebos that can be used for acupuncture. As music2doc states, sham acupuncture is a good one; it involves putting the needles at random sites instead of the official ones. Another good placebo involves sham needles. Acupuncture needles usually come in a small sleeve. Placebo needles come in a sticky sleeve that adheres to the skin, while the needles are shorter and duller, and don't penetrate the skin. From looking at the outside of the sleeve, there's no way to tell if the needle has gone in. Apparently the sensation is quite similar for the patient.

The general pattern with acupuncture studies is that the better the study design, the better the placebo control group, and the larger the number of subjects, the more likely the study is to find that there's no effect. The studies that do find a large effect are overwhelmingly small studies with poor control groups that are done by acupuncture proponents and/or come out of China. I don't think it's hard to look at this pattern and come to a conclusion about the efficacy of acupuncture.

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Originally Posted by TropicalKitty

Has she tried food intolerance testing? I was dealing with nausea and heart burn (among a host of other things), it was my body finally saying STOP EATING WHEAT! Again, that was me, but similar where Zantac and other stuff didn't even touch the problem and PCP looked at me like when I told her my symptoms.

Or she's knocked up. :P

As for the article, I think we need to understand these alternative therapies more. Even if not to prescribe them, but at least to understand what pts are doing to their bodies. If we automatically assume that researching something equals support for the therapy, we'll undermine our progress in science as well. These alternatives may have some interesting information that we can get to enlighten us even more about how our bodies function. I also think that these treatments are showing a lot more into what the population thinks of current medicine. There's obviously a disconnect between patients and their belief that modern medicine can really help them.

Yes and she has tried eating gluten free. It's also tough to get appointments with GI specialists, who even then hurry you through tests, so I can understand why some people are switching to a doctor that feels better.

Originally Posted by skiing

Just saw this article today. What do you guys think about this? I thought this seems a bit scary but also reveals a lot about patients needs and wants that are unfulfilled or underaddreessed in today's health system.

http://www.economist.com/node/21552554

The problem isn't predominantly that they are placebos. It's that some of these "alternatives" do have unstudied medicinal properties and lots of dangerous co-reactions with actual medicines, and so if a patient is on these and doesn't tell you about them,or adds them to their regimen, or they haven't been studied, the patient can get very sick/ you can hurt them. There is no FDA testing, no evidence based testing. Just because something grows in the ground or is part of an animal doesn't make it safe. Evidence based medicines get studied for safety and efficacy. Anything else should be presumed neither safe nor effective until proven otherwise.

Dr Weil continued by saying that evidence-based medicine, at its worst, “is exactly analogous to religious fundamentalism.”

f*** this guy. It's science, and it's exactly the opposite of religious fundamentalism. If alternative medicines actually work, studies will provide evidence of it and it will be incorporated into medicine and no longer be "alternative." If there are no options left for treating my patient's pain or something, then I will recommend accupunture or homeopathy...but I will do it knowing from study after study and multiple meta analyses and Cochrane reviews that those treatments are nothing more than a vehicle for providing an effective placebo effect to my patients.

As for all the supplements and junk out there, they may or may not work; again, if they have an active ingredient then I hope they are studied further and become a part of medicine. If they work, they can become part of medicine period, not alternative medicine. Unlike what this douchebag doctor says, no one fundamentally discriminates against a compound that is actually proven to be efficacious just because it's from a plant that has been used in central America for hundreds of years or something. But this moron makes a fortune through miseducation and lies, telling the scientifically illiterate public that traditional medicine is discriminating against his products because they are alternative? No, we discriminate against it because every meta-analysis on it shows no significant difference from placebo. A******.

This is the same guy who got a smackdown from the FDA for selling some of his products by telling the public it would treat or cure their H1N1 flu.

I've worked with CAM treatments for a while, not to promote them but rather to see which ones actually have scientific evidence backing them and which don't. Since I'm more involved in the field of psychiatry, treatments that I've looked at pertain to different psychiatric illnesses ie. generalized anxiety disorder, major depressive disorder, bipolar disorder 1 and 2. Some DO have literature backing them, such as omega-3-fatty acids which can be used to treat mild-to-moderate depression, or some forms of yoga which have the same effects. However, they're still classified as complementary and alternative treatments simply because they're not fully yet integrated in modern Western medicine. Since adherence to many standard medication regimes is (unfortunately) low, it's good to see what CAM works and what doesn't so that we can spread this scientific information to the masses and not have the whole "hurr I don't want to see my MD cause they're all about the money" and whatnot.

That all being said, yes, there are many forms of CAM which are complete and utter bull****. It's time that we actually look at the ones that don't work/may even have adverse effects in patients and inform them of their inefficacy.

Just food for thought

Originally Posted by domnomnom

Yes and she has tried eating gluten free. It's also tough to get appointments with GI specialists, who even then hurry you through tests, so I can understand why some people are switching to a doctor that feels better.

I hear ya! It's frustrating when you have an issue, but traditional medicine can't help you, or won't in my case.

At least with these alternatives someone is there to hear and offer support for the patient.

Vous desirez some snake oils?

taking shots at fanatical devotion to double-blind randomized prospective studies is fair.

translating that distaste into acceptance of the healing power of wizard farts is not

Originally Posted by QuizzicalApe

taking shots at fanatical devotion to double-blind randomized prospective studies is fair.

translating that distaste into acceptance of the healing power of wizard farts is not

If you don't trust placebo controlled double-blind randomized trials, what would you rather go on, personal anecdotes?

Oh great, you've just summoned the f-guy.

Originally Posted by phltz

There are several good placebos that can be used for acupuncture. As music2doc states, sham acupuncture is a good one; it involves putting the needles at random sites instead of the official ones. Another good placebo involves sham needles. Acupuncture needles usually come in a small sleeve. Placebo needles come in a sticky sleeve that adheres to the skin, while the needles are shorter and duller, and don't penetrate the skin. From looking at the outside of the sleeve, there's no way to tell if the needle has gone in. Apparently the sensation is quite similar for the patient.

I've also heard of anesthesia being administered, then the acupuncture (or not) done while the patient is asleep, thus upon waking they have no idea whether or not they received treatment.

Originally Posted by Coffee Machine

I've also heard of anesthesia being administered, then the acupuncture (or not) done while the patient is asleep, thus upon waking they have no idea whether or not they received treatment.

Or whether they were sexually abused while under the gas.

Originally Posted by kami333

If you don't trust placebo controlled double-blind randomized trials, what would you rather go on, personal anecdotes?

That's not what the objection to RCT-fanaticism is about. Some people dismiss anything that's not a RCT - even though many things can't be studied using RCT because of logistics and/or ethics. Focusing solely on the RCT as the be-all and end-all of evidence is stupid. Science can have rigor without rigor mortis.

Also, homeopathy:

http://www.youtube.com/watch?v=HMGIbOGu8q0

Originally Posted by kami333

If you don't trust placebo controlled double-blind randomized trials, what would you rather go on, personal anecdotes?

Smith GCS, Pell JP. (2003). Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ, 327(7429), 1459-1461.

real article

Originally Posted by O2Doc

That's not what the objection to RCT-fanaticism is about. Some people dismiss anything that's not a RCT - even though many things can't be studied using RCT because of logistics and/or ethics. Focusing solely on the RCT as the be-all and end-all of evidence is stupid. Science can have rigor without rigor mortis.

yup, this