Sunday, March 17, 2013

The most recent "Anonymous" comment to my kefir post raised some interesting points that I felt required a more formal response.  Here is the text of the comment, without edit:

Anonymous said...
It is condescending attitudes like this that are driving patients away from mainstream medicine and toward charlatans. Just because medical labs have not adequately tested a treatment methodology does not mean there is no evidence for its efficacy.

What difference does it make whether the anecdotal self-reports are being published in medical journals or on amateur hobby websites? In either case you still have to take the patients' word when they say they feel better. And who cares if it's a placebo? Do they feel better or not?

By all means, critique foodsellers making untested medical claims. But don't mock the self-reports of patients who are proving more successful at treating their own illnesses than you are--especially when the treatment they have found has centuries of traditional use.

If they are saying that it works, then get in your lab and start testing.

I have been experimenting with kefir for the last two weeks. Despite the fact that I am a natural skeptic AND I hate plain yogurt, there is no question that my Crohn's, my ADHD, my chronic anxiety, and my restless limb symptoms are significantly improving, with a marked improvement in my bowel regularity. And the stuff tastes and smells absolutely delicious

I am indeed contemptuous and condescending regarding of the expounders of nonsense.  Nothing else seems to work as well when my goal requires drawing attention to quackery.  Besides that, its fun!

One of the important points raised in the Anonymous comment relates to "lack of evidence is not evidence of lack."  This appears to constitute the main point of Anonymous's first paragraph.  Great.  I get that.  But, understand that simply being ignorant is not an argument in favor of anything!  The fact that I don't know, simply means that I don't know!  It doesn't mean that I have to err in favor of this week's favorite quackery.  That would be an argument from ignorance--something that a skeptic, like Anonymous claims to be in his last paragraph, would understand.  The burden of proof regarding the efficacy of a treatment modality lies  with the purveyor.  Just because some crackpot claims he has a cure form an illness does not mean I need to break out the lab equipment.  The research dollars wasted by Anonymous's approach would be astounding.

Anonymous's second paragraph addresses, first, anecdotal evidence.  He implies that anecdotal evidence is an accepted, and even trustworthy, part of scientific research.  Medical and, more generally, science researchers, understand exactly the opposite to be true.  They understand that human beings are excellent at pattern recognition, but phenomenally terrible at statistics.  Anecdotal evidence is astoundingly error-prone.  That means that anecdotal evidence is considered untrustworthy.  In fact, one of the principle goals of a researcher in science is to bias-proof the research as much as possible.  In other words, the researchers work hard to eliminate sources of personal opinion and belief from their studies.

The second point in the same paragraph, regarding placebos, is more complicated.  I believe Anonymous means, essentially, that the "end justifies the means."  Hey, if a placebo works, what's the harm, right?  I believe this is a particularly paternalistic and dangerous approach to healthcare.  How would you feel if your physician recommended a treatment for you that he or she absolutely knew, worked no better than fake treatment, in other words, was just a placebo.  Worse yet, how would you feel if your physician, billed you, and your insurance, $130 for something he or she knew worked no better than that fake treatment?  In other economic areas like retail and auto repair, obtaining money by lying to customers is called fraud.

Patients have a right to expect that their physicians will tell them the truth about risks and benefits for tests and treatments, and that their physicians will not bill for services or treatments that the physicians know provide no benefit beyond that obtained by fake therapy.

Anonymous's last paragraph is just more anecdotal evidence.  "The plural of anecdote is anecdotes, not data."

Monday, October 8, 2012

Not here too!

I fly 3000 miles to further my medical education, in San Diego. $620 for the classes. In the exhibit hall, I find a booth hawking homeopathic remedies!

Can I not escape this blithering nonsense?! This quackery forces me to question why I bother paying dues to the AOA. Are they really so desperate for funds that they are willing to sell their collective souls for the price of a stinking booth on the exhibit floor? Homeopathic physicians are quacks! They promote nonsense that hurts our patients directly and indirectly. It doesn't belong anywhere near physicians who give a damn about their patients.
- Posted using BlogPress from my iPhone

Friday, September 3, 2010

Homeopathy: Part 3

Homeopathy: Part 3

Magical energy

Why do homeopaths bother going through such time-consuming machinations?  What possible benefit could there be to diluting a solution billions of times beyond the “nothing’s left” point?  Fantastically, homeopaths claim that the more dilute the remedy, the more powerful it is: "less is more."  They claim that a process they call “potentizing by succussion,” transfers healing energy to the, now, non-existent ingredient.[i]  Succussion involves ritualistic tapping of the remedy with each dilution.  This “healing energy” supposedly increases in concentration with each dilution.  The more dilutions performed, the more agitated the remedy, and therefore, the more potent the cure.

I have several objections to this rubbish.  No solution or solvent has ever demonstrated any type of objectively measurable memory.  Wouldn’t this theoretical basis for potency mean that the solution would remember anything it had ever met, no matter how insanely dilute?  In fact, wouldn’t the tiniest impurities in the solvent get “potentized” to insanely powerful and unpredictable degrees?  Wouldn’t that render the remedy worthless--or perhaps even more potent?

The concept of increasing potency with lowering concentrations simply makes no sense.  It contradicts the laws of chemistry and physics.  The intended concentrations are so low that any real effect identified likely reflects a previously unknown property of the alcohol or water solvent.[ii] 

Legislated ignorance and sacred cows

In 2003, over three thousand homeopathic physicians practiced in the United States, with thousands more in Europe.  If homeopathy is such nonsense, why does this industry generate hundreds of millions of dollars in annual revenue for homeopathic practitioners and remedy manufacturers?[iii] The answer is complex.  Let’s first look at why it is legal to sell this garbage at all.  This makes for an excellent case study in American special-interests politics. 

In 1938, Royal Copeland, a Senator for the State of New York, sponsored a piece of legislation, the Food, Drug, and Cosmetic Act, to protect the American public from dangerous or worthless drugs and patent medicines.  Senator Royal Copeland also happened to be Dr. Royal Copeland, a homeopathic physician.  He managed to carve out an exemption in the new law for his homeopathic remedies by legislating that any product listed in the Homeopathic Pharmacopoeia would automatically receive full recognition as a drug without having to meet most of the rigorous standards that conventional prescription drugs must meet.  The new law exempted manufacturers of homeopathic remedies from proving their products contained the labeled ingredient, proving that the strength of the remedy as listed was accurate, and proving that the remedy effectively treats any medical condition at all.  Homeopathic products also do not have to carry expiration dates, and can legally contain far more alcohol than the ten percent usually allowed in standard medications.8 

However, homeopathic products must comply with some FDA regulations.  Over-the-counter preparations can only be marketed to treat self-limited disorders, in other words, disorders that would go away on their own if not treated at all.  As such, homeopathic remedies occupy a protected niche created by special interests. 

Drawing back the magic curtain

Some, like Dharma, ask, “Well, it must do something, right, even if they don’t understand it?”  On the contrary, the data so far shows that homeopathy works no better than placebo.[iv]  Virtually all of the studies purporting to show benefit from homeopathic treatments are fatally flawed.[v], [vi],[vii], [viii], [ix], [x]  No adequately designed, sufficiently powered study has ever demonstrated that any specific homeopathic remedy works better than a placebo for treating any specific disorder.11

In one study, the effects of homeopathic remedies on hot flash severity and frequency in menopausal women clearly revealed no statistically significant benefit for menopausal symptoms.[xi]  Unfortunately, the authors of the study went on to crunch the numbers from one angle after another until they found a way to present a positive result about the research. “If you can’t find something good to say about something, don’t say anything at all.”  In this case, they noted that the overall health of patients was better a year after initiation of the study protocol in the treated group than the placebo group.

A well-publicized and controversial analysis of 186 studies of homeopathy published in The Lancet, a well-respected medical journal, in 1997, concluded that a “trend existed for homeopathy to be more effective than placebo.”[xii]  However, a thorough review of the data conducted by the editors of the journal revealed that, of those 186 studies, not even one showed a significant benefit for any homeopathic remedy over a placebo.  The analysis also revealed a strong inverse relationship between study quality and homeopathic benefit: the better the study design, the poorer homeopathy fared.[xiii]  

I suspect any appearance of success for homeopathy is likely due to the placebo effect.  A more recent article published in the 27 August 2005 issue of The Lancet seems to confirm that notion.[xiv]  The authors matched over a hundred studies on homeopathy with comparable studies on traditional medications.  They found bias colored many of the studies.  Taking that bias out of the equation they found that traditional medications work considerably better than placebo while homeopathic remedies performed no better than placebo.

So tempting, the Ring of Power

If the benefit of homeopathy is all placebo, so what?  What’s wrong with that?  Why not prescribe homeopathic remedies with the knowledge that they are placebos?  After all, the patient feels better.  Isn’t that the final objective, anyway?  Is that not why patients seek out doctors in the first place?  This is the single most dangerous and insidious aspect of this phenomenon.  In this particular case, the ends absolutely do not justify these fraudulent means.  The ideal of patient autonomy that drives me to defend a patient’s right to choose some treatment other than what I perceive as rational, makes this choice impossible for me. 

To pass on to my patient, under false pretenses, something I know has no intrinsic therapeutic merit would be paternalistic, unethical, and personally abhorrent.  Homeopaths are not generally in the habit of informing their patients that the treatment being offered is a placebo.  To smilingly lie as I hand Dharma a bee’s wax pellet that I know contains nothing that will help her, robs her of her autonomy.  Dharma has a right to make well-informed decisions about her own care, drawn from the best possible information.  Remember, Dharma pays to get my medical advice.  Dharma has the right to expect she is getting her money’s worth in the form of my considered medical opinion, not intentional deception.  Otherwise, Dharma’s autonomy is meaningless. 

The magic mirror

The quackery that is homeopathy exists because of the quackery found in conventional medicine.  Healthcare has too many special interests feeding on the trillions of dollars in the healthcare budget.  The same defective reasoning that causes patients to accept homeopathy also causes many more patients and physicians to use questionable practices in conventional medicine.  The modern equivalents to leeching, purging and mercury poisoning still exist.  New medications and interventions get far more exposure, and aggressive direct marketing than their 19th century counterparts did.  The recent withdrawal of several high-profile drugs from the market, probably with thousands of deaths to their credit, reinforces the wary public’s opinion that medications are dangerous things.

Inherent in the use of homeopathy is the search for something safer than what modern medicine has to offer.  That being said, the problems in the current system do beg for changes, but do not justify fraud.  The trend towards science-based medicine promises slow, but steady improvement in treatment.  One could argue that not treating is better than treating with many of the medications currently in use. With homeopathy, that is precisely what patients get: nothing, in the guise of treatment.

People pay a lot of money for homeopathic therapy.  Our collective tax dollars find their way into government-funded research programs on this codswallop to the tune of tens of millions of dollars each year.  Not all claims to therapeutic benefit have equal standing. Homeopathy is based entirely on extraordinary, magical reasoning.  Extraordinary claims require extraordinary evidence. Therapeutic modalities based on extraordinary claims should meet the extraordinary evidence standard before qualifying for large research grants—and especially before they see the light of day as treatment for adults and children.

[i] Davenas E, Beauvais F, Amara J, Oberbaum M, Robinzon B, Miadonna A, Tedeschi A, Pomeranz B, Fortner P, Belon P, et al.; Human basophil degranulation triggered by very dilute antiserum against IgE.
Nature. 1988 Jun 30;333(6176):816-8.
[ii] Shealy CN, Thomlinson RP, Cox RH, Borgmeyer V; Osteoarthritic Pain: A Comparison of Homeopathy and Acetaminophen;American Journal of Pain Management; 1998 Jul; 8(3): 89-91
[iii] Stelin I; Homeopathy: Real Medicine or Empty Promises?; FDA Consumer Magazine. 1996 Dec
[iv] Shipley M, Berry H, Broster G, JenkinsM, Clover A, Williams I; Controlled Trial of Homeopathic Treatment of osteoarthritis; 1983 Jan 15; 1(83160:97-8
[v] McCarney R, Warner J, Fisher P, Van Haselen R; Homeopathy for dementia; Cochrane Database Syst Rev. 2003;(1):CD003803
[vi] Walach H, Haeusler W, Lowes T, Mussbach D, Schamell U, Springer W, Stritzl G, Gaus W, Haag G; Classical Homeopathic Treatment of Crhonic Headaches; Cephalalgia. 1997 Apr;17(2):119-26
[vii] Reilly DT, Taylor MA, McSharry C, Aitchison T; Is Homeopathy a Placebo Response?; Lancet. 1986 Oct 18; 2(8512); 881-6
[viii] Reilly D, Taylor MA, Beattie NG; Campbell JH, McSharry C, Aitchison RC, Stevenson RD; Is Homeopathy Reproducible?; Lancet.; 1994 Dec 10; 344(8937); 1601-6
[ix] Jacobs J, Jimenez M, Gloyd SS, Gale JL, Crothers D; Treatment of Acute Childhood Diarrhea with Homeopathic Medicine: A Randomized Clinical Trial in Nicaragua; Pediatrics. 1994 May; 93(5):719-25
[x] Hill C, Doyon F; Review of Randomized Trials of Homeopathy; Rev Epidemiol Sante Publique. 1990; 38(2):139-47
[xi] Jacobs J, Herman P, Heron K, Olsen S, Vaughters L; Homeopathy for Menopausal Symptoms in Breast Cancer Survivors: A Preliminary Randomized Controlled Trial; J Altern Complement Med.; 2005 Feb; 11(1):21-7
[xii] Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas WB; Are the Clinical Effects of Homoeopathy placebo effects? A meta-analysis of placebo-controlled tirals. Lancet. 1997 Sep 20; 350: 834-43
[xiii] Linde K, Scholz M, Ramirez G, Clausius N, Melchart D, Jonas WB; J Clin Epidemiol. 1999 Jul;52(7):631-6
[xiv] Shang A, Juwiler-Muntener K, Nartney L, Juni P, Dorig S, Sterne J, Pewsner D; Are the clinical effects of homoeopathy placebo effects?  Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet 2005 Aug 27;366(9487):726-32