Student Finds Classical Reporting on "Holistic" Medicine Still Lacking Critical Rigor

The rise of "alternative medicine," if you can claim that it has risen at all, has mostly been due to word of mouth and unwarranted exposure by an uncritical press. Seeing as how CAM itself never actually changes, it should be no surprise to anyone that neither does reporting on it. We hear the same fallacies, the same appeals to authority and tradition, and the same overweighting of anecdotal evidence over and over again.

So I wasn't even a little shocked at this typical article on the common cold.

ABCNews.com asked four holistically minded doctors what they do when they feel under the weather. Their prevention and treatment advice might help you dodge or short-circuit the next bug that comes your way.

I'm not even entirely sure where to begin. "Holistically-minded doctors?" What does that even mean? Proponents are going to spout some gibberish about doctors that "treat the whole person, not just their symptoms," but let's see what these doctors recommend to "treat the whole person."

Let's start with Dr. David Rakel, MD.

There's no firm evidence that any medication or herb will prevent the common cold, said Rakel.

Hey, cool, he's actually concerned with whether or not there's evidence for the stuff he suggests!

At the first sign of symptoms, the goal is to attack the virus early because it replicates the most within the first 48 hours, pointed out Rakel. He might drink more green tea, which appears to have antiviral and antibacterial properties. And he would also drink three big glasses of orange juice to get more vitamin C...

...besides consuming more liquids, Rakel might take 20 to 30 milligrams of zinc acetate lozenges twice a day to improve his immunity. He takes zinc only for the first two or three days of a cold, when he feels it's most effective. He might add andrographis, an herb that's sometimes called "Indian echinacea." He would take 400 milligrams of this immune-stimulating herb three times a day.

That's why when it comes to his own health he takes a shotgun approach and tries everything that has ever been suggested for treating the common cold. Vitamin C, zinc, green tea (antioxidants), and "Indian echinacea," which must be better than "Western echinacea."

At least Dr. Rakel gets an annual flu shot, but he bemoans the presence of thimerosal in flu shots. I guess the fact that thimerosal-free flu shots is not important to him, or maybe he just thinks the CDC has it all wrong.

Strike one, MD's out. Who's next? Lynne Shinto, ND. You can probably guess where this is going.

She says she thinks that too much sugar can weaken immunity...when she gets a cold, her philosophy is to let it run its course. She'll turn to the usual suspects: bed rest, more fluids and chicken soup -- or because she's Japanese-American -- miso soup with shiitake mushrooms, fungi known for their immune-strengthening compounds.

Go Lynne! You strengthen that immune system! Is that the humoral or cellularly-mediated immune system? What do you mean you don't know? You're just sure it works? Well, as long as you're treating the real cause of disease instead of just addressing symptoms, like a good holistic doctor.

These approaches may make the symptoms feel better, she admits, but they likely won't make a cold go away faster.

Oops. I guess not. So you fail at both science and pseudoscience.

If Shinto's sinuses are congested, she turns to an "old naturopathic therapy" thought to stimulate the immune system. Called hydrotherapy, she might stick her bare feet in hot water for three minutes then in ice-cold water for 30 seconds, and she repeats this hot-cold sequence three times.

This is a fantastically plausible treatment for nasal congestion. Maybe the alternating peripheral vasoconstriction and vasodilation...no, this really is so implausible as to not warrant investigation.

What about another MD's perspective? Surely a second opinion is worthwhile. Dr. Kevin Barrows?

He's a big believer in meditation and has found this mind-body approach helps increase his awareness of subtle body shifts, a tip-off that he may be getting sick. For him, a sore throat is his early warning sign of a cold, his cue to start taking echinacea.

That's great, doc. I'm glad that you can recognize one of the most common symptoms of the common cold as...indicative of the common cold. But he didn't learn that in medical school. No, he figured it out through meditation! Once he determines that his chakras--er, his throat hurts--he knows it's time to start taking echinacea, the herb that a Cochrane review states "shows inconsistent benefit."

Sixteen trials including a total of 22 comparisons of Echinacea preparations and a control group (19 placebo, 2 no treatment, 1 another herbal preparation) met the inclusion criteria. All trials except one were double-blinded. The majority had reasonable to good methodological quality. Three comparisons investigated prevention; 19 comparisons investigated treatment of colds. A variety of different Echinacea preparations were used...

...there is some evidence that preparations based on the aerial parts of E. purpurea might be effective for the early treatment of colds in adults but the results are not fully consistent.

I know that whenever I have a problem, I'm willing to rush out and spend money on things that "might work."

Outside of a mental health context, I know that if I ever had a doctor who suggested "meditation" as a serious method for identifying or treating any illness I'd pull up my pants and walk out the door. Three doctors I'd never want to visit--assuming that their beliefs are being accurately portrayed in this article. Well, what about Dr. David Leopold, our fourth contestant?

At the first sign of a cold, Leopold treats his symptoms extremely aggressively. His goal is to support his immune system so that it helps clear the virus and slows down the spread of symptoms.

He takes zinc gluconate lozenges, drinks plenty of herbal tea and also uses a liquid tincture of echinacea. Despite research that questioned the herbs' benefits, "I'm convinced that most of the well-done studies of echinacea suggest it seems to be effective for reducing the severity and duration of a cold."

Just what I need, a doctor who flunked both statistics and immunology. No thanks.

The thing is, I'm not entirely sure that the blame is entirely on the doctors being quoted here. Now, granted, I don't think that their words (or positions) are being fabricated; I'm sure that, when interviewed about their "holistic medicine" use, all of these doctors (and the naturopath) volunteered honest information.

But here's the problem. This "sound-bite medicine" doesn't actually leave room for--or invite--serious discussion of anything beyond "some doctor said you should try this." And, in the interest of "unbiased journalism," the reporter behind this story didn't bother to fact-check any of the claims made by the doctors. After all, they're just harmless claims; the article isn't about "what is good medicine" but rather opts to provide some opinions by licensed medical practitioners.

Unfortunately, this approach is seriously misguided. Most people think of physicians of all stripes as having a good, solid understanding of medicine, and this implicit trust that doctors know what they're talking about is crucial. If patients think doctors are idiots, why would they ever solicit one for an opinion? The drawback to this is that off-the-cuff "opinions" about vitamin C, echinacea, or other various treatments that don't stand up as effective under serious scrutiny reinforce the misconception that these treatments actually work. Just try telling a patient whose doctor takes vitamin C that vitamin C doesn't treat or prevent colds. "If it doesn't work, why does my doctor do it?" What surprised me about this article is that it didn't even contain the "token skeptic" interview, but then, the article is subtitled "what alternative medicine experts do when they get sick."

Physicians who succumb to non-evidence-based thinking do more than harm themselves. They drag down patients with them, even patients they'll never meet, because their endorsement of unproven remedies assures that these treatments will never die out despite the immense evidence against their efficacy. As long as there are doctors promoting these remedies, no amount of double-blinded, well-controlled, properly randomized research is going to convince the public that they aren't effective--because their doctors, expected to be the gatekeepers of knowledge, are ignoring it.

Just Pissing It Away

It's been quiet in my corner of the blogosphere, but I lay the blame squarely on the fact that my latest round of exams has kept me extremely busy. Ths plus side of all this is that I get to come back to lots of news, all ripe for comment!

Like this article published today analyzing a couple studies from early 2000 about certain drugs prescribed for high blood pressure being potentially tied to bone loss, particularly in older men.

Most of the time, our sound bite-focused media doesn't get the whole story out there. This article is no exception.

Diuretics are commonly called "water pills," particularly by older people. I really, really hate that term. It isn't even remotely appropriate for describing how diuretics function. I suppose that the analogy comes from the idea that drinking more water causes increased urination, and taking diuretics causes increased urination; hence, diuretics are "water in pill form," except that that totally fails to explain how they work to lower blood pressure. Normally I don't think it's necessary for patients to know the mechanisms of action for the drugs they take--such details are excessively complicated. But we strive to explain things in the simplest way we can without sacrificing accuracy. Antidepressants, for example, are said to "balance or correct problems in brain chemistry." This is simple, but true at the base level.

Diuretics don't add anything to your body, and they certainly don't hydrate you. They have varying mechanisms of action, but what they really do is increase the body's excretion of certain elements that float around in the body in ion form. Sodium, potassium, and calcium are three good examples--they are commonly called "electrolytes," especially if you like reading the labels on your sports drinks. Generally, sodium loss is desirable in patients with high blood pressure. All of these ions must be present in proper concentrations for the body's various functions to work properly. Too much and too little are both bad. Diuretics are a convenient way to get rid of excess electrolytes.

The diuretic the article is talking about is furosemide, though there are other diuretics in the same family that have the same effect. Furosemide flushes out sodium, potassium, and calcium by preventing the kidneys from re-absorbing it at a specific point (the loop of Henle, if you're curious). Many patients on furosemide are also prescribed potassium supplements to counter the potassium loss. The calcium loss is not as frequently addressed, but it really should be; then again, most people don't get enough calcium anyway.

But saying diuretics in general are responsible for worsening bone loss is not only alarmist, it's false. Hydrochlorothiazide, or HCTZ, actually results in calcium retention. Sometimes this is a problem, as it can cause calcium levels in the blood to get too high. But for some patients with high blood pressure who are also at risk for osteoporosis, HCTZ is a great drug; it helps them retain extra calcium, improving bone density! This doesn't mean that everyone at risk for osteoporosis should be on HCTZ; increasing dietary calcium and vitamin D are a much better idea. But when treating patients with high blood pressure, it is often best to use drugs that "kill two birds with one stone." Likewise, it doesn't mean that patients at risk for bone loss shouldn't get furosemide. This is what trained physicians and pharmacists are for--evaluating the complicated mess of risks, benefits, and drug interactions that make modern medical therapy so difficult to manage.

And that's the bottom line--medicine is complicated. One 200-word article in a newspaper is never going to explain all the ins and outs of any particular treatment or drug; that's why scholarly journal articles are long, detailed, and extensively referenced. So consider very carefully where you get your information; chances are that if it was packaged for the general public and sold at the newsstand, you're not getting the whole story.

Alarmist Media Soundbites Annoy Pharmacy Student

Let it be known that there are few ideas that cannot be expressed in a more entertaining way by using AP-style headlines.

There's been a lot of talk about how common medication errors or overdoses occur in hospital settings, particularly in children. A good bit of this can be attributed to the recent heparin mix-up involving Dennis Quaid's children. This particular error, fortunately, caused no deaths, unlike some previous errors in Indiana a year or two ago. The Quaids have every right to be upset--and they have every right to campaign to make the issue more visible. Medication errors are serious business, and hospitals should do everything in their power to prevent them from happening.

That said, the issue is being way over-hyped by the media.

According to the first link, one in fifteen children admitted to a hospital--about 7.3%, or 540,000 children across the United States each year--is harmed by a medication error. These are the figures that are being pitched around by the media in multiple places.

But these figures are misleading and alarmist. What a shock! Here's the study they're citing.

Part of the issue is the definition of an adverse drug effect. According to the Washington Post:

More than half of the problems cited involved overdoses or allergic reactions to painkillers.

The "or" in that sentence complicates the issue, but here's a simple statistic. The two biggest classes of pain medication are NSAIDs like ibuprofen and opioids like morphine or codeine.

True opioid allergy is exceedingly rare. In fact, less than 1% of the population is estimated to be allergic to opioids. Likewise, only about 1% of the population is estimated to be allergic to NSAIDs (though NSAIDs may precipitate problems in some patients with asthma).

This means that if the numbers reported are accurate and 11 out of 100 children hospitalized experience an adverse effect, only one of those is truly allergic to the drug in question--and there's nothing that can be done about that, short of avoiding the drug. Unfortunately, patients without a history of an allergic reaction are not going to discover the allergy without being exposed to the drug. This seems largely unavoidable. So what about the other ten kids? If the Post is correct, all of them recieved some kind of overdose.

Let's take a look at the actual study:

Twenty-two percent of all adverse drug events were deemed preventable...ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. [emphasis mine]

Mild, temporary harm? What kind of harm?

The most common adverse drug events identified were pruritis [itching] and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics

Huh.

Even patients not truly allergic to opioids may react with what is called a pseudoallergy. Where a true allergic reaction is a result of inappropriate overactivity of the immune system, pseudoallergy reactions are a result of sudden histamine release, causing flushing, itching, sweating, or hives. This is a well-documented side-effect of opioids. Is it totally preventable? Sure--by not giving opioids! Of course, this is why using the lowest effective dose of a drug is always a good idea--unlike true allergies, opioid pseudoallergies are dose-dependent, so higher doses increase the probability of a reaction. The good news is that antihistamines can be used to reverse the majority of these symptoms.

Antibiotics, conversely, wipe out friendly bacteria in the digestive tract, which is commonly accepted to be a cause of antibiotic-induced nausea and diarrhea. Other factors include the direct effect of the drug on the digestive tract, but decimating gut flora isn't doing anyone any favors. Some antibiotics are worse than others, but nausea is extremely common with antibiotic therapy--and, again, there's basically nothing that can be done about it.

At this point, the question should not be "how many children suffer adverse drug reactions?" This statistic is too simple to have any predictive power, especially when including mild or easily reversed side-effects that are extremely common (and predictable) or associated with the use of particular drugs. We should be more concerned with medication errors than minor adverse reactions. A patient getting a thousand-fold overdose of heparin is serious. A child getting a stomachache as a side-effect of antibiotics is not. So let's turn the statistics around--only 3% of adverse reactions were serious. A full 97% were mild and/or reversible. That sounds like good news to me!

I've come to expect that the media is going to spin everything they report to make it sound infinitely worse than it actually is--bad news sells. But the last thing we need is parents panicking about medication errors and being afraid to take their children to the hospital. Vigilance on the part of both parents and healthcare providers is good. Panic--and subsequent distrust--is not. Distrust of medical professionals is one of the main factors that turns patients to supporting woo.

And since I can't resist plugging my own profession, let's not forget that well-trained pharmacists are crucial players in reducing medication errors.