Wednesday, November 14, 2007

A Response to "Anonymous"

An anonymous poster commented on my entry about CAM and medical education, which I posted to give a little perspective on my experiences with CAM "infiltrating" schools of medicine--of course, mine is a school of pharmacy, but pharmacy is medicine, and it's my opinion that pharmacists have an ethical duty to uphold the use of scientific medicine. As I started to reply to Anonymous, I found myself writing quite a bit, and it seemed the most reasonable thing to do was to turn the comment into an entry. So, Anonymous, here's my take on what you said:

I focused on homeopathy in this post because it was the specific subject of discussion in the lecture I attended this week for one of my courses, and I wanted to address the way my university discussed homeopathy and "alternative medicine" in general.

In any case, I am not so hasty or ignorant as to "condemn CAM based solely on one modality." I am very familiar with naturopathy, chiropractic, acupuncture, ayurveda, and TCM. My girlfriend, for what it's worth, spent a summer in Mumbai studying the integration of ayurvedic medicine into Indian hospitals and analyzing the cultural impact of ayurvedic medicine on the Indian population.

You are correct in the sense that some CAM modalities may have plausible biological mechanisms of action. Naturopathy in particular; herbal medicine is not necessarily a placebo, and many "herbal medicines" contain biologically active compounds. The question, as you so astutely pointed out, is the level of evidence supporting the use of a particular modality.

The problem, then, is the fact that these methods are not abandoned when they are found to be ineffective. Acupuncture may relieve pain, but it will do nothing for immunological disorders. Chiropractic might be useful for lower back pain in some patients, but it certainly isn't going to do anything for diabetes, allergies, or inner-ear infections. You could drink willow bark tea for pain and fever, but you're also ingesting a bunch of other biologically active compounds that do nothing for your specific problem; it's safer and more focused to take aspirin.

There is no "alternative medicine." There is medicine that works and medicine that doesn't. Many experimental procedures are adopted into common practice once they are proven to be effective. And many "mainstream" therapies that turn out to be poor or ineffective options are discarded. Notice how Exubera, the inhaled insulin heavily marketed by Pfizer, was discontinued after only a two-year run? It was a novel idea, but a crappy drug. Dosing it was a pain in the ass, the inhaler was bulky and annoying, and it wasn't any better than using an insulin pen. The recent removal of infant cough and cold drops from pharmacy shelves was spurred by a lack of evidence for their safety and efficacy as well as concerns about overdoses. Many practitioners are arguing against the use of propoxyphene because it's a lousy painkiller and can have toxic side-effects in the elderly. Even aspirin is no longer recommended by many health care practitioners for analgesia; the much safer acetaminophen is recommended instead. When was the last time naturopaths said "quit using glucosamine, studies are inconclusive about its efficacy" or chiropractors suggested people should stop getting adjustments because they weren't doing any good?

I am inclined to dismiss any form of treatment not validated by scientific evidence. This doesn't stop me from learning about CAM modalities, especially herbal medicine, so that I can inform my patients about potential drug interactions or side-effects. It would be a terrible mistake for me to be ignorant of CAM. That doesn't mean I think it's generally useful. I don't recommend black cohosh or phytoestrogens for menopause. I don't suggest that my depressed patients start taking St. John's wort, even if it is potentially efficacious, because of the huge drug interaction profile (and if I ever see anyone purchasing it I always ask if their physician is aware that they take it and get a full list of their medications). I don't recommend men take saw palmetto or suggest cranberry tablets for urinary tract infections. I don't do any of these things because I don't have sufficient evidence that they are good treatments, even if patients swear by them. How many patients know whether or not saw palmetto is shrinking their prostate, anyway?

You ask me if I've ever dispensed a prescription drug that was not "vetted by clinical trials." Of course I have, but I'm also not a pharmacist yet, and I don't have the power to refuse to dispense prescriptions because they're being dispensed for non-evidence-based indications. But that doesn't mean I don't see it happening. I cringe when I see quinine dispensed for leg cramps (which you'll note the FDA doesn't want you doing either). I don't recommend guaifenesin unless patients are absolutely desperate to take something for chest congestion because increasing water intake works just as well, and the long-acting guaifenesin-only products are incredibly costly. I don't care whether medicine is "alternative" or "western" because the distinction is meaningless. If it works, science will be able to demonstrate it works, and I'll support its use. If it were empirically demonstrated that standing on your head cured diabetes, I would build a jungle gym in my store's parking lot.

If science doesn't support use of a treatment modality, why should I support it? Because it makes people "feel" better? If it doesn't do anything to actually help the patient's condition, it does them no good, especially in serious conditions. And the "worried well," the people you're talking about that are involved in "wellness programs," the people for whom "CAM is most useful," aren't sick. What is a "wellness program," anyway? "You're already healthy, here's how you stay that way." And the answer to "how you stay that way" is "fork over lots of money for supplements, adjustments, and lab tests." That's a huge part of my objection. CAM practitioners are essentially making money off all their money off of "health conscientious" hypochondriacs and desperate people who'll try anything (i.e., cancer patients). People downing Airborne, zinc, and vitamin C for colds amaze me; a cold lasts maybe a week at most. You're willing to go to that much effort because it might decrease the duration of your cold by what, 24 hours? Maybe? And isn't it wrong--an outright lie--for me to tell my patients that they should try remedies that aren't supported by evidence just to placate them?

And I haven't even addressed the fact that many CAM practitioners hold and promote outright dangerous "health beliefs," such as the typical anti-vaccination rhetoric. Others support or "treat" fictitious diseases such as Morgellon's and "multiple chemical sensitivity." Physicians aren't necessarily honest, but no physician I've ever known has had to invent diseases to get more business. There are plenty of real diseases plaguing humankind to keep us occupied for a very long time.

What place does CAM serve? "Complimentary" medicine should do something above and beyond "the other medicine" in order to be worthwhile. If complimentary medicine can't stand on its own, what good is it unless it significantly amplifies the power of traditional medicine? During the Second World War, probenecid was used to extend the supply of penicillin to treat infections--THAT is complimentary medicine. Acupuncture may reduce required painkiller doses for surgery, but is that clinically significant? Does it really affect the patient in the long term, and is it cost-effective? And as I've already said, there's no such thing as "alternative" medicine. It works, or it doesn't. End of story.

Pharmacists are scientists, and even if medicine isn't a perfect science, it's foolish to abandon science for wishful thinking or to appease patient delusions. It is both logically and ethically inconsistent for me to endorse the use of CAM.


Anonymous said...

Interesting retort, somehow you read that I am a defender and a proponent of CAM. I think if you really go back and read my original comment you will find no where am I defending CAM. Your original post did not look at all aspects of CAM and it then implied that CAM therapies where �placebo� therapies, it was that statement that spurred me to post my comment. As a manager of one of the nations larger clinical pharmacy programs, yes I am one of those guys that spends the majority of my time reviewing trials and making sense of all the science, I would suggest that you become very comfortable with meta-analysis and if you have not already discovered the Cochrane web site ( I would suggest that you spend sometime with it. After 25+ years in clinical practice and research it is no longer surprising when I see an outcome in patients that does not jive with what the science supports. That doesn�t mean we ignore the science because evidence based medicine is really population based medicine, what has the best outcomes for the vast majority, but as long as you have genetics (polymorphism) involved you will always have that odd patient and that is when good clinical judgment comes into play.

I applaud you for dedication and enthusiasm and welcome you to the profession.


N.B. said...

I wouldn't say I necessarily thought you were a supporter of CAM. I did, however, want to illustrate that I was highly familiar with CAM and that I knew that many CAM therapies were not mere placebos. The question, as one who reviews many studies should know, is whether or not a therapy is clinically useful--and that's the bottom line. Even biologically active does not necessarily imply clinical usefulness.

Meta-analysis is no foreign game to me. And neither are idiosyncrasies, but I prefer to consider them something to deal with as they come rather than something to build my practice around.

And thanks for the welcome!