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Dr. Simon Singh talks Alternative Medicines (pt. 2)

Published: October 22, 2010

Many Americans rely on “alternative medicine” treatments. There have always been doubts about the efficacy of such therapies. Studies have been undertaken in recent years to test them. In some cases the jury is in. A few years ago I interviewed the co-author of a book which summarized what can be said about such treatments. Dr. Simon Singh is a science journalist, and best selling author. With Dr. Edzard Ernst, the world’s first professor of complimentary medicine he wrote Trick or Treatment: The Undeniable Facts About Alternative Medicine. Here is the second half of that interview. For part 1 please see my blog on Oct. 9th, 2010.

It seems that acupuncture did not stand up to the best scientific analyses. As it turns out, studies done in China have to be regarded with suspicion. Could you comment on this?

The bottom line is that there is no convincing evidence that acupuncture actually works for fertility, asthma, or any of the conditions it is hyped for. The exception to this is of nausea and some types of pain. There is some borderline evidence for this [nausea and pain relief], but the jury is still out. If it works for you, the evidence is kind of on your side, so by all means continue. Just be careful when you are considering your options to start with. Going back in time we have to ask why are there is such a huge industry of acupuncture, and why are such claims made when the science doesn’t back it up. As you say, a lot of the research – at least the early research – was done in China. There is a thing called “publication bias”. What this means is that if you do some research and you get a positive result – which sometimes happens just out of pure luck – you go rushing to a scientific journal give it to them. They gratefully publish it because “hey you’ve got a positive result and this is really important.” If you get a neutral result, you think well this isn’t very interesting, so I won’t even post it to the journal. If you get a negative result, you think, oh why did I get a negative result? Maybe I was feeling ill myself and didn’t conduct the acupuncture very well or maybe my patients were just too sick. Then you don’t submit it to the journal and you become overly critical of your results. What this results in is that the published results are generally rosier than what the actual, genuine research would reflect.

When we look in China, there is a particular problem here because you very rarely see any negative research published about acupuncture, whereas if you look at the research in Europe and America you find a more balanced view, with some negative studies, and a few positive – at least in the area of nausea and pain. The other reason why it so widespread is that the people only get to read the positive research, the acupuncturists only talk about the positive results. Then we have things like tradition. People think that if something has been used for hundreds or thousands of years, it must be good and effective, otherwise it wouldn’t have survived to the modern age. This simply isn’t true. Earlier on the program we spoke about bloodletting, a practice that dates back to ancient Greece. It was dangerous, and it took us thousands of years to figure out it was dangerous. Now, acupuncture might not be dangerous, but just because we’ve been using it for thousands of years doesn’t mean it is necessarily good or effective.

Chiropractic is another alternative practice that many people think of as rather mainstream. I would like you to tell us about its rather colorful beginnings under Daniel David Palmer, and how, like homeopathy it has a cultish aspect to it, at least at the beginning.

It’s a very American treatment. Homeopathy started in Europe, acupuncture started in China, and it is America that has to take the blame or credit for chiropractic, depending on how you look at it. Most people think you will go to a chiropractor for back problems. They manipulate your spine, they adjust your back. They will tell you that the vertebrate need to be aligned, a claim which is true to some extent, and effective to some extent. If I had some back problems I would consider going to a chiropractor. There are some risks in manipulating the bones at the top of the neck, and I would ask the chiropractor to avoid that, but otherwise I might give it a go. They do as well or as badly as any other medical treatment. Back pain is notoriously difficult to treat, and chiropractors to just as well or as poorly as anybody else. What people will be surprised about is the origin of chiropractic. It dates back to Daniel David Palmer and the end of the 19th century. He believed that he could treat 95% of disease by manipulating the spine. The reason for this is that the spine carries the spinal cord and nervous system that taps out to every part of the body. He thought all disease was connected to an interruption of the neuronal signal between the brain and that part of the body. By fixing the spine and spinal cord you could ease the flow of information and cure disease. It sounds weird that you could treat a problem in your big toe by manipulating the spine, or you could cure a problem in your ear by manipulating the spine, but the first conditions Palmer tried to treat were deafness and heart disease. Today, many chiropractors have moved away from this notion and restrict themselves only treating back problems. There is a very significant fraction, however, still believe they can treat asthma, colic, ear infections and a whole host of what we call non-musculoskeletal conditions. There have been studies, and as of yet, there has been no evidence that chiropractic can treat anything that goes into this non-musculoskeletal territory.

When I was a medical student I treated a case of someone who had been very seriously injured by chiropractic neck manipulation.

With conventional drugs we know their adverse effects; we do a risk-benefit analysis. We know the hazards because they’ve been rigorously tested, even when they reach the market place, doctors look for adverse effects and report back, so there is continual monitoring. My worries about chiropractic and other alternative treatments is they still haven’t got on top of the adverse effects of their treatment. My co-author did a study looking at how many adverse effects had been noted. There were 700 cases of serious injury cases following chiropractic manipulation. There could be many more, we just don’t know. I think it is beholden to the chiropractic profession to investigate the safety of what it is that they are doing. That has to be taken into consideration by patients when they look into the benefits of whit chiropractic has to offer.

In your book, you list many popular herbs and what the evidence is for their effectiveness. Can we take a look at the herbal remedies which have the best evidence going for them?

I think the best and most impressive of the herbal remedies is St. Johns Wort. There have been clinical trials of St. Johns Wort and the evidence is mounting that it might have some positive treatment for mild depression. Some words of caution go along with this however, because as with any treatment, there will be adverse reactions. For this reason you must talk to your doctor is you are thinking about taking St. Johns Wort. People might think, “Oh but this is natural and natural must be good for me. Natural products can’t do me any harm.” That’s just not true. Plants are full of a chemical cocktail, some of them can be good for us, but many can be very bad. One of the side effects of the chemicals in St. Johns Wort is accelerating the function of your liver. This leads to quicker breakdown of other pharmaceuticals you might be taking, such as anti-coagulants, contraceptive pill, and so on. St. Johns Wort does seem to be effective in the treatment of mild depression, but you do have to talk to your physician and treat it with caution.

St. Johns Wort contains a chemical that acts as an MAO inhibitor, the same mechanism used in drugs that treat depression. MAO inhibitors are notorious for drug interactions.

The record shows St. John’s Wort interacts with about half of known prescription drugs. Immunosuppressants are a class of drugs that interact with it, and there is a recorded case about a lady who had a kidney transplant. She was taking immunosuppressants to allow the kidney to bed in. She took St. Johns Wort and didn’t tell her doctor, because she thought it was natural and safe. The St. Johns Wort interacted with, and rendered ineffective the immunosuppressants that she was taking and her body unfortunately ended up rejecting the kidney.

You and Dr. Ernst note that these products are not well regulated and so the things that they contain or don’t contain are not well controlled.

Yes it comes back to the idea of supplements being “natural.” Herbal healers will push the idea of natural being wonderful. Natural might mean having the original plant, drying it and mixing it into a tea. In the form of the pill, you will know the weight and dosage of the extract. The problem of taking it straight from a plant is, depending on where the plant grew, the soil, the amount of sunshine, you could have varying concentrations or dosages of the active ingredient. This is just one example of a situation where natural is not equivalent to good.

I like that you point out several fallacies surrounding alternative medicine. People call it traditional, natural, or holistic. Those words really don’t mean that much.

I find the holistic term a bit offensive. When you go to the doctor they look at your age, your background, your family history, your lifestyle. Good doctors always take a holistic approach to medicine, and it offends me that alternative therapists have hijacked this term and somehow think they are more holistic than medical doctors.

You have a great quote in your book saying, “If a doctor can’t make the placebo effect work then he should probably become a pathologist.”

Everything has a placebo effect. This explains why treatments like homeopathy seem to be effective. The simple act of taking a pill that you think will help you, will boost your psychology and possibly your physiology. On a short term basis it will help you with some kind of recovery. People think it is the homeopathy helping them, but really it is the thought of homeopathy helping them. Some people are say that if homoeopathy can help a patient through the placebo effect, what’s wrong with that? The fears I have around this issue are that in order to get the placebo effect to work, there has to be a level of deceit involved. The homeopath has to hoodwink the patient – whether accidentally or intentionally in a well meaning but ultimately misguided way – to be fooled to believe that the homeopathy is helping them. For years we’ve tried to have an open and honest relationship between practitioner and patient, so that patients know the real truths. If we are going to try and maintain that homeopathy is effective, we have to maintain a lie that it has passed some sort of test, which it has not done. There are several other reasons why I think placebos shouldn’t be used to justify alternative therapies, the most important one you have hinted at. Conventional treatments also come with a placebo effect. If I have hay fever, why would I use homeopathy that is only a placebo, when I could take an antihistamine which has real, actual effects – with a placebo effect thrown in for good measure.

You and Dr. Ernst have put together, in Trick or Treatment, the best and most comprehensive explanation of what goes into the placebo effect that I have read anywhere.

It is a really important part of medicine. Sometimes you hear people say, “Well it’s just the placebo effect.” Really though, it is not a minor thing or should be ignored. We should exploit the placebo effect by having good doctor patient relationships and trying to build a patient’s confidence in a particular treatment, but not by deceiving them about what their treatment actually is.

Could you mention a couple of the alternative therapies that your analysis has shown to be fairly effective?

I think some of the exercise therapies like tai chi or yoga are good. We know that exercise is helps ward off a whole range of conditions. Additionally, some of the massage techniques are good for reducing pain and some other conditions. By massage I mean the traditional types, not too fierce or rough, it just makes us feel better by increasing blood flow and so on. I would discourage the more esoteric forms of massage like rake, where your therapist might be talking about increasing you levels of “chi” or trying to add bells and whistles that really don’t exist. So massage is great, but massage plus mumbo jumbo is just very expensive I’m afraid.

In New Scientist Magazine, your co-author mentioned that alternative medicines are ultimately a triumph of advertising over rationality.

I think that rationality is a wonderful thing. It shouldn’t be seen as a wet blanket coming to spoil the party. Rationality has given us things like vaccinations. There are people listening to this program now that wouldn’t be alive if not for the medical techniques that have come to bear on our lives. A rational approach to alternative medicine will identify those that are effective that will bring them to the mainstream. If anyone can prove that their therapy is cost effective, safe, and effective for patients, that therapy will be embraced. This is how we will move forward.

The book is Trick or Treatment: The Undeniable Facts about Alternative Medicine. I highly recommend this book and I thank our guest co-author Simon Singh for coming to talk to us about it.

Thank you very much it has been great to talk to you.

Dr. Doug hosts the program Radio Parallax on Thursday evenings from 5-6pm on KDVS 90.3FM in the Davis/Sacramento area. You can follow Dr. Doug on Twitter @DougDesallesMD, or become a fan of Sacramento Men’s Health on Facebook by following the link http://www.facebook.com/pages/Sacramento-CA/Sacramento-Mens-Health/122723801091305 and as always be sure to check back to the Sacramento Men’s Health blog for the latest updates in science and medicine that affects you.