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Pediatrics & “CAM” I: the wrong solution

Oh no!  Not again! The venerable medical journal Pediatrics devotes an entire supplement this month to Pediatric Use of Complementary and Alternative Medicine: Legal, Ethical, and Clinical Issues in Decision-Making.

We sense from the very first sentence that we are in familiar territory:

Rapid increases the use of complementary and alternative medicine (CAM) raise important legal, ethical, clinical, and policy issues. (S150)

“Rapid increases”? And evidence of these “rapid increases?” None cited.

We do, however, see the same shopworn reference to popularity deconstructed elsewhere on SBM. What we learned by actually examining “the large 2007 US survey” which purportedly “revealed that ~4 in 10 adults and 1 in 9 children and youth used CAM products or therapies within the previous year”(S150) is that

…most hard-core CAM modalities are used by a very small percentage of the population. Most are less than five percent. Only massage and manipulation are greater than 10 percent. These numbers are also not significantly different from 10 or 20 years ago — belying the claim that CAM use is increasing.

We also find this definition of “CAM”:

a broad domain of healing resources …other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. (S150)

I’m not sure what it takes to become “intrinsic” to the “politically dominant” healthcare system. If it includes being legal, licensed or covered by public and/or private insurance, that would appear to disqualify dietary supplements, chiropractic, acupuncture, homeopathy, homeopathic products and naturopathy as “CAM” in some, or in some cases all, of the American states.

There are four main authors, one of whom will be familiar to SBM readers: Michael H. Cohen, J.D., a character in Dr. Kimball Atwood’s revelatory opus on the “CAM” shenanigans at Harvard Medical School. Cohen’s pro-CAM proclivities have been nicely set out in our friend Orac’s recent post over at Respectful Insolence: “Misinformed Consent rears its ugly head in Pediatrics,” which takes on one of the Supplement’s articles: Informed Consent: Advising Patients and Parents About Complementary and Alternative Medicine Therapies. (S187-S192)

Another author is Sunita Vohra, M.D., M.Sc., a Canadian physician affiliated with the “Complementary and Alternative Research Education (CARE) Program,” at Stollery Children’s Hospital in Edmonton, Alberta, Canada.

The authors acknowledge the contributions of the Canadian College of Naturopathic Medicine (S153) and an “anonymous pediatric chiropractic reviewer” (S204).

Cohen and Dr. Vohra have ploughed this ground before: in 2007, as co-authors of “Ethics of complementary and alternative medicine Use in children,” in Pediatric Clinics of North America. Dr. Vohra also co-authored “The use of complementary and alternative medicine in pediatrics,” as part of the Task Force on Complementary and Alternative Medicine, Provisional Section on Complementary, Holistic and Integrative Medicine, also in Pediatrics.

If you have read those articles, there is nothing new here, except an expansion of post-hoc rationalization for the use of “CAM.” As with CAM efficacy/effectiveness research, CAM legal and ethical research builds on the unshakable premise that CAM — whatever CAM is — must be included in the health care armamentarium, and then scrambles to tell us why the evidence — in this case law and ethics in addition to scientific research — mandates this conclusion, a topic to which I will return in a subsequent post.

DANGER: “CAM” in use

In the first of ten articles comprising the supplement, the authors state they

examined current legal, ethical, and clinical issues that arise when considering CAM use for children and identified where gaps remain in law and policy. (S150)

As a springboard for this examination, they construct various scenarios in which a pediatrician or other physician must deal with the unfortunate presence of CAM in his patient’s case.

(In light of Dr. David Gorski’s Monday post, Defining what a ‘physician’ is, please be advised that that when I say “physician” I mean an M.D., or, in the U.S., a D.O., a definition which will remain consistent throughout my posts until further notice.)

What immediately strikes the reader of this series is the number of times the authors mention the lack of research supporting the use of CAM for pediatric patients. The articles are filled with statements such as:

  • Meeting [the need for ‘sound information’ about CAM practices] is made more difficult by the relative scarcity of pediatric research in the area. (S150)
  • This determination [of who should make treatment decisions] may be more challenging when considering CAM, because evidence may be lacking or less adequate than desired. (S152)
  • Relatively limited research on the efficacy and safety of CAM, especially in children, means that decisions must frequently be made in conditions of uncertainty. (S152)
  • [A suggested framework for advising patients about CAM] may be helpful when there is adequate reliable evidence but it is less helpful when evidence is lacking or limited, as is often the case with CAM. (153)
  • Information about the safety and efficacy of CAM therapies is increasing all the time, but there are still large gaps in knowledge. (S153)
  • [T]he lack of evidence about many CAM therapies and products can make assessing CAM options particularly difficult. (S153)

And that’s just the first four pages of text! (S150-S153)

Another curiosity is that the CAM used in hypotheticals designed to illustrate the authors’ points is described almost uniformly as ineffective and dangerous. Not curious in the sense that this would be unusual or surprising, but curious considering the authors’ recommendations, which we’ll get to later.

  • Jenny, an HIV-positive teen, takes (unbeknownst to her treating specialists) St. John’s wort for self-diagnosed depression. This results in the possibility that “a drug-herb interaction has led to her unstable indinavir levels and decreased CD4+ T-cell counts.” (S156-160)
  • Chris, who is 14 years old, is diagnosed with ulcerative colitis. His doctor recommends surgery and his parents agree that this is the best option, and all risks and benefits having been explained to both Chris and the parents. Chris, however, says he has “researched his condition and knows that other therapies, including homeopathic treatment, are available.” He is opposed to surgery and wants to consult a homeopath. (S161-S166)
  • Three-year-old Angela was diagnosed at 15 months with glycogen storage disease type IV and her gastroenterologist recommends a liver transplant. After initially agreeing to put Angela on a transplant waiting list, her parents want her taken off because “they have spoken with a Chinese medicine (TCM) practitioner, who recommended specific dietary treatment, mind-body imagery, and acupuncture.” (S176-S180)
  • The mother of Phoenix, age 24 months, doesn’t want him to get the MMR vaccination because “her chiropractor has discussed the issue of vaccination with her,” including the topic of vaccination safety. He discussed immune function as well and noted that treatments such as spinal manipulation and nutritional supplements, “although not an alternative to vaccination, may optimize her son’s natural immune function.” (S168-S172)
  • Lindy is a teen suffering from chronic recurrent headaches. After trying other treatments, her physician refers her to an acupuncturist. The acupuncturist uses unsterilized needles and she contracts acute hepatitis B. (S182-S186)
  • Michael, a 14-year-old, has “new-onset back pain with no known precipitating cause.” He goes to his mother’s chiropractor who concludes Michael has a “misaligned spine” and performs spinal manipulation on Michael twice a week for 6 weeks. Michael complains of increasing fatigue and pain, for which the chiropractor recommends nutritional supplements and relaxation techniques, having concluded that these symptoms are adverse responses to the manipulation. Michael then sees a pediatrician and is diagnosed with testicular cancer with lung and retroperineal nodal metastases. (S201-S205)

The point of these “case scenarios” is “to act as a practical anchor in the exploration of CAM policy issues and to illustrate the application of and shortcomings in existing guidance and intervention principals.” (S151) One of the purposes of these articles, the authors further explain, is to “act as a catalyst for policy development.” (S153)

A “job jar” for medicine

Their solution is to come up with a big “to do” list for pediatricians and other physicians who care for children. Here’s what the authors want you — the busy physician — and the larger medical community, including hospitals, to do:

  1. “Be aware of research regarding CAM use for those conditions [you treat, especially chronic health conditions] to help prevent the potential harm of adverse reactions.” (S156)
  2. If your patient insists on using CAM instead of “conventional” treatment, you “will need to closely monitor his condition by using conventional means.” As well, you should “attempt to ascertain whether there is evidence about its use for this condition, and assess the likely impact on his health.” (S164)
  3. When referring a patient to a CAM practitioner, “the physician should also learn about the proposed treatment plan to ensure that it is what was anticipated when referring and does not include practices known to be unsafe or ineffective. In addition, he should monitor the patient conventionally and treat as appropriate.” (S184)
  4. If the physician doesn’t want to refer a patient to a CAM provider he “should state his or her own view and reasons [and] refer the patient to another physician who may be more comfortable advising about the referral or to a regulatory authority [for the “CAM provider] or professional association [of CAM providers]. (S184)
  5. “There is a moral imperative [!] to develop good evidence through research into CAM therapies to facilitate informed decision-making and informed consent.” (S152)
  6. We must “incorporate more formal training about pediatric care into chiropractors’ education” to “reduce the risk of adverse events caused by delays in diagnosis or referral.” (S203)
  7. “Patient and public education campaigns” need to inform dietary supplement consumers of risks and adverse effects of supplements. (S158)
  8. Hospitals must institute credentialing for “CAM” providers. (S196-S198)
  9. And finally, because there are “divisions between …CAM practitioners and some physicians about the merits and risks of vaccination …educational programs …about vaccines and the diseases targeted should be developed.” (S168, S171). This recommendation comes in spite of the authors’ acknowledgment that “neither evidence-based teaching nor presentations from polio survivors changed chiropractic students’ perceptions of immunizations.” (S170)

It’s all your fault

And why the list? Perhaps because in the illustrative scenarios created by the authors, it isn’t the lack of sound public policy and adequate regulation which allows these CAM disasters to happen. In several of the scenarios it’s your fault, dear physician.

Thus:

Who are the parents of Jenny, our HIV-positive teen, mad at about her dietary supplement — drug interaction? The government for failing to adequately regulate supplements? No. Sen. Orrin Hatch? No. Perhaps a supplement manufacturer for making overly broad claims about St. Johns wort? No. How about the manufacturer for failure to warn about drug interactions? Wrong again. They are mad at her HIV specialist because, according to the authors, although supplement — drug “interaction data are still scant, particularly from pediatric populations” the specialist who treats Jenny “should make special efforts to explore CAM use with patients during history-taking.” (S156-S158)

We next learn that this has caused the parents to lose faith in their daughter’s specialist which (the plot thickens) leaves them with “limited options” because “there may simply be no one else to provide care to Jenny.” Thus, “the onus is on her physicians to take the steps needed to begin rebuilding trust and, more broadly, to alter their practice to take the increasing prevalence of various forms of CAM use into account.” (S157) Indeed, the authors argue that “practitioners are legally obligated to inquire about the use” of supplements. (S157)

In the case of Lindy, who contracted hepatitis B from acupuncture needles, we see that it is the physician’s fault for failing “to check to determine if the practitioner is licensed by a trustworthy body, such as a professional college or regulatory body.” (S182) Well, at least, according to this vignette, Lindy’s chronic recurrent headaches “that have not been relieved by any of the medications her physician has suggested” seem to have disappeared after two weeks of acupuncture. (S182)

Then there’s little Phoenix, whose mother doesn’t want him vaccinated based on her chiropractor’s dubious advice. In the authors’ view, this simply requires “different and unique educational strategies” for chiropractors about vaccination because “one reason for this failure [of educational efforts] may be that educational programs have not addressed practitioners’ concerns, such as questions regarding safety of adjuvants and preservatives used in vaccine preparation.” (S170) An odd recommendation, seeing as how that very information is readily available to everyone else.

Jake, a six-year-old with medulloblastoma, in the case covered by Orac, suffers from chemotherapy-induced nausea and vomiting (CINV), which drugs either do not relieve or cause unpleasant side effects. His parents are also mad at their son’s oncologist because they learned on the internet about acupuncture for CINV and “are delighted to see that his nausea and vomiting are much improved after each acupuncture session.” Not only that, but “Jake begins to regain his appetite, gains weight, and generally has a better sense of well-being.” (S188)

The parents could be forgiven for attributing this positive effect to acupuncture, an effect that goes way beyond what the studies indicate would happen, even taking the most optimistic view of the authors’ evidence (S190),  which Orac reviewed.  We should be far less forgiving of the authors’ coming to the same conclusion when they state, in a different article following up on Jake’s progress:

We continue with the example of 6-year-old Jake’s success with acupuncture for chemotherapy-induced nausea and vomiting, described in the preceding article ….” (S194)

We’ll return to Jake’s “success with acupuncture” in the next post, when I’ll examine why the authors’ ethical, legal and medical arguments don’t support the their recommendations and offer “alternative” ideas about the locus of the solution to the CAM problem.

The authors are apparently of the view that these very serious problems with CAM — lack of evidence, incompetence of CAM practitioners and their overly-broad scope of practice, safety issues, intransigence to public health measures, ineffective treatments — are solvable if only the medical community would get off up its collective derriere and embrace CAM — monitor it, study it (post hoc), alert the public to its dangers, provide it with some additional education and training, overcome its resistance to proven public health measures, credential it, waive the usual level of evidence required to recommend therapies and forget plausibility as a basis for medicine.

They don’t ask for much, do they?

 

 

Posted in: Acupuncture, Chiropractic, Herbs & Supplements, Homeopathy, Legal, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine, Vaccines

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32 thoughts on “Pediatrics & “CAM” I: the wrong solution

  1. Intraneural says:

    I do take responsibility at educating myself on many CAM treatments, but that is simply do to the fact that I have been extremely interested in it since having to shadow a chiropractor once in medical school. From that time forward I have taken every opportunity given me to educate patients of the nonsense that is out there. I am an anesthesiologist and when working in the OR the opportunities are scarce. But every so often when a patient admits to taking different herbal therapies or homeopathic remedies I do kindly educate them if time allows. Half of my time is devoted to running the acute pain service (nerve blocks, perioperative pain management). It is during this time that I am able to educate on rounds more effectively to not only patients but my residents and fellows. Although this is interesting to me and I enjoy whittling away at the faith of my colleagues and patients in SCAM, I definitely feel that the expectation that all physicians should be responsible for educating patients on worthless therapies is garbage. It is obvious that the patient’s and family members’ feelings of anger are misdirected. It is unfortunate that in the litigious climate that is US healthcare we must add SCAM to our list of daily concerns.

  2. lordshipmayhem says:

    I see all of those caveats about CAM from the article and come to the conclusion not that one should be careful about integrating CAM treatment, but that one should dump CAM treatment for science-based ones.

    I have to wonder yet again as to how it is that supposedly learned and scientific medical educators are permitting CAM a foot in the door.

  3. JB quoted “Rapid increases the use of complementary and alternative medicine (CAM) raise important legal, ethical, clinical, and policy issues. (S150)”

    JB “Rapid increases”? And evidence of these “rapid increases?” None cited.

    We do, however, see the same shopworn reference to popularity deconstructed elsewhere on SBM. What we learned by actually examining “the large 2007 US survey” which purportedly “revealed that ~4 in 10 adults and 1 in 9 children and youth used CAM products or therapies within the previous year”(S150),” etc

    I keep reading comments about the risks or threats of the increased use of CAM, and they are seldom if ever questioned. But when a CAM proponent suggests there is an increased use of CAM, then there is criticism.

    It can’t be both way folks. The use of CAM in the U.S. is increasing, decreasing or steady. If someone is making a call to action based on the assumption that CAM use is increasing, then that assumption should be questioned regardless of whether they are an opponent or proponent of CAM.

  4. RE: “ Relatively limited research on the efficacy and safety of CAM, especially in children, means that decisions must frequently be made in conditions of uncertainty. (S152)” et al

    It seems relatively simple to me that if you have no quality information on the efficacy and/or safety of an intervention, you generally don’t use or recommend it in clinical practice, and thus the decision is simple and made in the certainty that the safety and efficacy are unknown and therefore cannot be relied upon.

    Absence of adequate, reliable information is not a problem in regards to advice about those practices. Advising people about practices not proven to be both safe and effective is simple: avoid them.

  5. cervantes says:

    The question of whether “CAM” use is increasing is of course dependent on the same problems that confront any epidemiological question. How do we operationalize the end point? I.e., what is “CAM,” how do we detect that someone has used it, and can we apply that test to a representative sample of the entire population? The “epidemic” of autism, for example, is almost certainly entirely an artifact of increased ascertainment, not an actual change in the prevalence of children with specific characteristics. They were always there, they just didn’t get labeled as autistic.

    In the case of “CAM” utilization we don’t even agree on what it is, let alone have any decent historical information to tell what’s happened over time. The ridiculous DelBanco/Eisenberg surveys are about the only thing I’m aware of. Are massage and yoga “CAM”? Only if somebody is making exaggerated claims for them. But just asking in a survey whether people have used them isn’t establishing that they use “CAM,” although perhaps in some cases they might be.

    But comparing time 1 to time 2 is problematic anyway because however you define CAM, what is inside the perimeter in one year is different from what’s inside it in another. There was a period during which rheumatologists were recommending glucosamine and chondroitin because there seemed to be some evidence it worked for osteoarthritis and they didn’t have much else to offer. So was it really CAM? Now it pretty much is, because better evidence doesn’t find that it works. I think the only meaningful questions to ask are more specific ones. How many people believe X, Y or Z, or use a particular modality expecting a particular result? Whether “CAM” use in general is increasing is imponderable, because it’s too ill defined.

  6. Harriet Hall says:

    The question of whether CAM use is increasing is really beside the point. The point is that it is being used at all, in the absence of evidence.

  7. Jann Bellamy says:

    @ Harriett Hall

    “The question of whether CAM use is increasing is really beside the point. The point is that it is being used at all, in the absence of evidence.”

    I was just about to say the same thing. The reference to “CAM” use is meant to point out how proponents are claiming widespread or increased use, which means it’s “popular,” therefore “conventional” medicine should study it, use it, etc., etc. It also was a bit of snark, as in “oh no, here they go again . . . “

  8. @Harriet Hall, Actually, I agree that whether CAM use is increasing or not is beside the point. A physician has to deal with the possiblity that a patient is using CAM “treatment” similar to how they have to deal with the possiblity that a patient may be using street drugs. Whether the number of those patients is increasing, decreasing or steady seems, well, interesting, but not particularily relavent to how the physician handles it (I would guess).

    Which is why I don’t understand why pointing out the increasing assumption is the first point in the article? It seems to me that nitpicking your opponent and letting your proponents slide is not a good way to build a reputation for being non-bias.

    Which may be the reason that I get the impression that JB’s criticism of the paper is based more on CAM proponent status of the authors of the paper than the actual content of the paper.

    Ultimately, I am baffled by the suggestion that a physician shouldn’t really be responsible for getting an accurate health history and asking their patient about their use of supplements, herbs (or street drugs, alcohol or depression for that matter). That only seems like the kind of conclusion one could draw from search vigilantly for flaws in your opponent.

    But, what do I know? This article was clearly written to appeal to the science based medicine doctor, not parents of children who need medical care.

  9. micheleinmichigan,

    To me it’s a bit of a question of a bridge too far. Yes a physicians should get an accurate health history including any medications the patient may be on, but CAM has a double standard here. They have the force of law that says that supplements are essentially food additives. In the specific example given, it seems reasonable to ask if the person was taking any other drugs or supplements, but not everyone will know what is meant by supplements. What about energy drinks, is it the physician’s responsibility to ask about those? “Supplements” can come from a variety of sources, not just bottles that look like medicine bottles.

    Also, If something has not been adequately tested and confirmed to be safe and effective, should physicians be expected to know about possible interactions? Part of the problem is there is nearly zero regulation for supplements and thus almost anything could be in use.

    Considering the near zero amount of quality scientific testing supplements get, where is a physician supposed to go for reliable information on a possible interaction? What source of information was Jenny’s doctor supposed to go to, the plethora of phase III and IV studies on St. John’s wort or any so called supplement (unregulated drug)?

  10. …a bridge too far in regard to what a physician should be responsible for.

  11. GLaDOS says:

    Thanks Jann.

    I’m surprised the pediatricians can’t see Mr. Cohen’s argument for what it is: an effort to shift the burden of proof.

    Anyway, the bad people in my small corner of the world have moved on from their Lupron clinic franchise plan. Now they’re pimping impressively sciencey looking hyperbaric oxygen chambers.

    Here’s one site with an long list of “research” articles supporting HBOT for all sorts of problems:

    http://www.californiahyperbarics.com/research-reference.html

    In spite of all their listed evidence, California Hyperbarics still feels the need for a quack Miranda warning (complete with the usual and customary random capitalizations) at the bottom of their web pages:

    The content and information provided within this site is for informational and educational purposes only. Consult a doctor before pursuing any form of therapy, including Hyperbaric Oxygen Therapy. The Information provided within this site is not to be considered Medical Advice. In Full Support of the F.D.A., Hyperbaric Oxygen Therapy is considered Investigational, Experimental, or Off Label.”

  12. @Karl Withakay, Oh, I wasn’t familiar with that expression, but having looked it up…a too ambitious goal. Okay.

    From my reading of JB’s statement “They are mad at her HIV specialist because, according to the authors, although supplement — drug “interaction data are still scant, particularly from pediatric populations” the specialist who treats Jenny “should make special efforts to explore CAM use with patients during history-taking.”

    The parents are mad at the doctor for not exploring CAM use with patient during history-taking. Seeing as how I have filled out a few zillion health history forms that ask me to list the medications and supplements my children take regularly, I’m figuring it is standard procedure to ask about supplements. Of course, a patient may not think to list energy drinks on a form like this, but we are talking about a teen-ager here. If an energy drink is possibly going to cause a problem with a patient’s therapy, should the doctor try to clarify?

    Doesn’t it seem like a doctor who is prescribing azt therapy should think to take some time to explain that some supplements, OTC, herbs or energy drinks that contain supplement or herbs may possibly adversely effect the drug efficiency or increase side effects? One certainly can’t expect the doctor to know about drug-herb interactions that haven’t been researched, but can’t one expect the doctor to educate the patient when taking any un-researched supplement may interfere with their therapy?

    I am certainly not a proponent of CAM, I have no interest in moving the CAM agenda forward, but as a parent, if one of my pediatric specialist told me that my child’s therapy had been adversely effected by a supplement AND that specialist had never brought up the use of supplements, asked for a list of supplements taken or informed me that some supplement might cause a problem, I would be very upset with that doctor. And no, my first thoughts would not be Sen Hatch, or the supplement industry.

  13. GLaDOS says:

    If it’s got a quack Miranda on it, don’t take it, because we’re never going to know what’s actually in it until a few people die and the FDA is forced to take a look.

    If it doesn’t have a quack Miranda, it’s an OTC drug and it should be mentioned to the doctor like any other drug.

    Note that things like calcium supplements can be unregulated God-knows-what, or OTC FDA regulated stuff. Look for that quack Miranda to figure out which is which.

  14. GLaDOS “Note that things like calcium supplements can be unregulated God-knows-what, or OTC FDA regulated stuff. Look for that quack Miranda to figure out which is which.”

    Is that so? I did not know that. Can I get a kid’s some sort of evidence based kids or adult multivitamin by looking out for that?

  15. rjcDO says:

    Jann,

    Are you planning to write a response to these articles in Pediatrics?
    You made me realize I did not get this Supplement with my November Pediatrics but you have me motivated to write a response once I finish reading it.
    On occasion when time allows I have shown this video clip to my patients and their parents:

    http://www.youtube.com/watch?v=ThdFqGLq4QU

  16. Quill says:

    I know a bit about HIV/AIDS meds and how they are prescribed by doctors who specialize in HIV medicine. While a regular family doc might not be up to speed on these things, it’s been well known for over a decade that St. Johns wort interferes with a number of HIV meds. There was even a series of posters made by the NIH about this. While its certainly possible a HIV specialist might have forgotten about it, it is not very plausible.

    It is also made very clear in most clinical situations I’ve been involved in that the patient bears the responsibility to disclose any and all medications and supplements being taken. In the case of an intake being done by an HIV specialist, I know that every patient is asked about supplements as it’s the standard of care. In this case, if the patient didn’t report because they didn’t consider it a medication but rather something “safe, natural and without side effects” then I can readily see whose “fault” such an attitude is and it’s not the specialist doctors.

  17. GLaDOS says:

    Example: Slow Mag by Purdue Products:

    Each two-tablet serving of Slow-Mag® Magnesium Supplement Tablets contains 143 mg of elemental magnesium and 238 mg of calcium.

    Has this quack Miranda on the bottle:

    This product is not intended to diagnose, treat, cure, or prevent any disease.

    Tums has about 500 mg of calcium per tab, but no quack Miranda.

  18. Scott says:

    Doesn’t it seem like a doctor who is prescribing azt therapy should think to take some time to explain that some supplements, OTC, herbs or energy drinks that contain supplement or herbs may possibly adversely effect the drug efficiency or increase side effects? One certainly can’t expect the doctor to know about drug-herb interactions that haven’t been researched, but can’t one expect the doctor to educate the patient when taking any un-researched supplement may interfere with their therapy?

    The implication of this would seem to be that doctors would have to provide this explanation every time they do anything. So we’re not talking a minor commitment here. How much money does it make sense to spend explaining, every time we turn around, that supplements are untested dangerous drugs?

    If anything, the observation that this would be necessary to marginally protect against some of the dangers demonstrates just how moronic it is that the supplement industry is so lightly regulated.

    Remember, we can’t limit this to cases where there’s a likely interaction since for the most part we have no clue what cases those are (some exceptions, as discussed above). Ergo, it has do be done for every prescription and every treatment.

    as a parent, if one of my pediatric specialist told me that my child’s therapy had been adversely effected by a supplement AND that specialist had never brought up the use of supplements, asked for a list of supplements taken or informed me that some supplement might cause a problem, I would be very upset with that doctor.

    The far more likely case would be that your child’s therapy was so affected, but nobody was able to identify that as the problem because the supplement manufacturer isn’t required to find out.

  19. CarolM says:

    Kinda sad because I’ve always thought as CAM as a sop to older people who are tired of regular medicine and feel they’re not getting enough attention. My mother took up with naturopaths and chiros in her old age, and would send one of them long letters, and got pretty good feedback. Any real situation, though, and she’d head off to a real doc.

  20. @Scott, The implication is that the doctor should get an accurate history so that they can give the best medical advise possible. If supplement use is common and is possibly detrimental to the patient then is should be (and is) included in the health forms.

    Also, since when are all supplements untested or dangerous. I’ve had pediatrician’s suggest poly-visol or a multiple-vitamin and temporary nutritional mixes (instant breakfast type). I wouldn’t think these would normally be dangerous, but, depending upon the drug or health problem, they might create a problem.

    Why is it that my pediatric specialists manage to request information about OTC medications, supplements, smoking in the home, pets, seat belts, allergies and health conditions that may effect the safety or well being of our child, but the SBM experts are portraying requesting information or educating the patient’s parent about the possibility of supplement/drug interactions as too much trouble. You appear to be lowering the bar.

    @Quill, yes I agree, if the patient (or patients parents) are asked about supplements and they give don’t an accurate answer, the doctor isn’t at fault, same for any of the other health form questions.

    I also agree with your implied suggestion that the examples in the Pediatric and CAM paper do not appear to represent the current standard of care in the pediatrics I’ve dealt with (the examples suck) In my mind the criticism for that point should be, “Look, doctors are already doing what they can to protect their patients from medication/supplement interactions.” Not suggest that doctor’s shouldn’t have to follow the current standard of care, because the need for that extra step is imposed upon them by poor regulation and poor supplement company behavior.

    As an aside, I’m not even sure that more/better regulation would enable doctors to discontinue that aspect of the health history. Even if you curtail supplement use, if you still have a reasonable portion of patients using some sort of supplement, doctors will still need to ask about supplement use.

  21. Scott says:

    The implication is that the doctor should get an accurate history so that they can give the best medical advise possible. If supplement use is common and is possibly detrimental to the patient then is should be (and is) included in the health forms.

    And it is. That’s not what you suggested. You suggested

    a doctor who is prescribing azt therapy should think to take some time to explain that some supplements, OTC, herbs or energy drinks that contain supplement or herbs may possibly adversely effect the drug efficiency or increase side effects?

    Which goes far, far, far beyond that asking the question in the history.

    Also, since when are all supplements untested or dangerous. I’ve had pediatrician’s suggest poly-visol or a multiple-vitamin and temporary nutritional mixes (instant breakfast type). I wouldn’t think these would normally be dangerous, but, depending upon the drug or health problem, they might create a problem.

    You’re right, it’s not all and I shouldn’t have been so general. Those aren’t the problem. The problem are the ones which are marketed as drugs, for purposes completely unrelated to nutritional requirements, without going through the scrutiny of drugs.

    Why is it that my pediatric specialists manage to request information about OTC medications, supplements, smoking in the home, pets, seat belts, allergies and health conditions that may effect the safety or well being of our child, but the SBM experts are portraying requesting information or educating the patient’s parent about the possibility of supplement/drug interactions as too much trouble. You appear to be lowering the bar.

    Nobody’s portraying requesting information as going too far, that I can see. The scenario discussed in the original post isn’t about requesting information, but about knowing that the particular supplement/drug interaction would take place. As I read Karl’s post, that’s what he is talking about as well.

    And while it’s hard to say education is a bad thing, I AM going to say it here. Because there’s no potential for real education, since the interactions are in general not known. The only possibility is a blanket general statement about the possibility. It’s hard to see how a scenario where the requirement is that a doctor say, with every prescription, “remember that any supplements you take might interact with this” is reasonable. There’s no actual education or content there, except that supplements are dangerous.

    So ultimately, this line of thought leads necessarily to the conclusion that what’s actually being asked is for doctors to continually tell people that supplements are dangerous. Doesn’t that REALLY say that the fundamental brokenness of the situation is elsewhere?

    As an aside, I’m not even sure that more/better regulation would enable doctors to discontinue that aspect of the health history. Even if you curtail supplement use, if you still have a reasonable portion of patients using some sort of supplement, doctors will still need to ask about supplement use.

    Commonsense regulation would ABOLISH supplements as a distinct category, except for the limited case of nutritional requirements which aren’t being met by diet. Which means that no, doctors WON’T need to ask about “supplement” use as currently defined.

  22. Scott I”ll quote it again “Who are the parents of Jenny, our HIV-positive teen, mad at about her dietary supplement — drug interaction? The government for failing to adequately regulate supplements? No. Sen. Orrin Hatch? No. Perhaps a supplement manufacturer for making overly broad claims about St. Johns wort? No. How about the manufacturer for failure to warn about drug interactions? Wrong again. They are mad at her HIV specialist because, according to the authors, although supplement — drug “interaction data are still scant, particularly from pediatric populations” the specialist who treats Jenny “should make special efforts to explore CAM use with patients during history-taking.” (S156-S158)”

    The parent are not angry because the doctor didn’t explore CAM use during TREATMENT, they are angry that he didn’t explore CAM use during HISTORY taking.* That sounds like asking the patient about any CAM they use during the health history. This is what I have said repeatedly, now. JB thinks that the parent shouldn’t be angry that the doctor took an inadequate history (that is below current standards) They should be angry at the Sen Hatch, or the supplement industry.The portion you quoted from me was suggesting the doctor should explain based on the health history (implied, not clearly stated) NOT arbitrarily warning them about the danger of supplements every time they turn around. Unless you think that history taking is done every time a doctor turns around.

    Also abolishing “Supplements”, sounds like a semantics arguments. Whether the kid is taking St. Johns Wort, the supplement, St Johns Wort the street drug or St. Johns Wort the OTC or Prescription, the specialist still gives better quality care if they know and educate the patient about the risks.

    *Sorry for the all caps, I always seem to screw up tags.

  23. Scott says:

    That’s what it said, sure. But what it said is nonsensical, since exploring CAM use during history-taking would have had no effect whatsoever unless accompanied by knowledge that the interaction exists. Per Quill that is indeed known for SJW and HIV meds, but if we’re going to try to draw deeper lessons from this one must assume that it’s meant to be general.

    If taken strictly at face value, the lesson of the scenario is simply “doctors treating HIV should specifically ask about SJW,” which is already standard of care (again, per Quill). Accordingly, it’s unremarkable, undisputed, and has no applicability to the overall subject at hand. So one must presume that’s not what the authors had in mind.

    If one assumes that the example was meant to apply generally to supplement use, and the particular example was selected because the authors didn’t want to just make up a fictitious interaction, then it makes sense. But trying to put that general example into practice ends up being meaningless since there isn’t enough known about such interactions in the general case.

    Put another way, the cases where taking a good history allows the doctor to avert interactions are sufficiently few that they are effectively special cases which have no place in a general discussion of CAM.

    Unless you think that history taking is done every time a doctor turns around.

    Yes, I think that history taking is done every time a doctor turns around. Every single appointment I’ve had includes asking about history updates.

    Regardless you’ve made clear that you really mean when the history specifically indicates supplement use, but I don’t really think that’s any better. It’d cost less, but it also even more emphatically drives home just how stupid the situation is if we establish a policy that doctors should be warning patients about supplement interactions every time the patient says they’re using such a thing.

    To draw an analogy (and yes, an extreme one), we’re currently in a state where people can drive on whichever side of the road they feel like. You’re arguing for reminding people to watch out for people coming the other way. I’m arguing that the situation is fundamentally broken and we should have people drive only on the right. (Apologies to any readers accustomed to the opposite, but you don’t get to complain if you’ve established a situation where left is right and right is wrong.) I suppose the warning is better than nothing, but the need for such a ridiculous thing really demonstrates that there’s a MUCH deeper problem.

    Also abolishing “Supplements”, sounds like a semantics arguments. Whether the kid is taking St. Johns Wort, the supplement, St Johns Wort the street drug or St. Johns Wort the OTC or Prescription, the specialist still gives better quality care if they know and educate the patient about the risks.

    Not even vaguely semantic. If it’s OTC or prescription, as it should be, then it’s gone through the appropriate testing to know what the interactions are. Therefore appropriate, meaningful, relevant guidance may be given instead of a blanket warning.

  24. Scott says:

    Incidentally, just to be more explicit, I agree with you that such steps are better than nothing in the current regulatory environment. But it’s really the wrong answer in the long run, is all I’m saying.

  25. Scott,
    “That’s what it said, sure. But what it said is nonsensical, since exploring CAM use during history-taking would have had no effect whatsoever unless accompanied by knowledge that the interaction exists. Per Quill that is indeed known for SJW and HIV meds, but if we’re going to try to draw deeper lessons from this one must assume that it’s meant to be general.”

    Really, Scott? I’ll just tell ALL our doctors they are wasting my AND their time the next time I see that medication, supplement questionnaire then. It just seems a bit silly when you have to be dismissive of standard medical procedures, just so you can beat the evil supplement dead horse.

  26. oh, sorry, Scott, My previous post went out before you last comment was posted.

  27. Quill says:

    “If taken strictly at face value, the lesson of the scenario is simply “doctors treating HIV should specifically ask about SJW,” which is already standard of care (again, per Quill).”

    They do on initial intake and at anytime when starting ARVs/HAART. SJW demonstrably interferes with amprenavir, nelfinavir, ritonavir, and saquinavir by rendering them less effective. HIV specialists have tended to get very specific about any and all supplements their patients are taking, down to noting exact dosage and sources. None of this is, indeed, remarkable.

    However, in case of SJW, it’s also contraindicated with a wide range of medicines from everything to psych drugs like xanax to anticoagulants like warfarin. Most physicians should be aware of this particular interaction and indeed any pharmacist would be as it’s in all medical databases under contraindications and/or interactions.

    That being said, the problem to me is that CAM is sold as “safe, natural and effective without side effects” and somehow that remains pure and true until (gasp!) a CAM remedy encounters something made by Big Pharma (instead of Big Supplement.) Then the “natural” order is torn and of course it’s all the fault of the doctor and pharma folks. If CAM was marketed more along the lines of “this is powerful stuff! Can do lots of things in a big way! Tell your allopathic physician about all the pills, potions and tablets you swallow as it may mean a lot to them when they try to push a ‘bad’ pill on you!” then things might be different.

    But look at the products, how they’re packaged and sold. Got a new prescription from the pharmacy recently? Notice the Patient Information Sheet which lists all kinds of important things, or perhaps put on your specs and read a package insert that comes with a drug. Breathtaking amount of useful information, most of which is science-based and backed up by studies and observations that stand up to analysis.

    But a CAM product? It’s all a wonderland of goodness (with a tiny Quack Miranda Warning someplace) that rarely if at all ever mentions that it might just cause problems, sometimes lethal ones. Why? Because it’s legally sold as food and not a drug. This point has been repeatedly made on SBM but I think it bears repeating when we are confronted by sad stories of suffering children.

    fwiw, I don’t think supplements should be outlawed but I do think this stupid game of food instead of drug should be amended to include useful information so that a person taking SJW knows either to tell their physician about it or discontinue use when having to take another medication.

  28. weing says:

    What if the patient was not on SJW when HAART was initiated but a month or so later a sCAM artist told him to take SJW and he did? Shouldn’t the burden be on the sCAMster to know what meds the patient is taking and whether there are interactions? What if the sCAMster refuses to accept HAART as legitimate treatment?

  29. Quill says:

    @weing: I’ll take a stab at some answers.

    “What if the patient was not on SJW when HAART was initiated but a month or so later a sCAM artist told him to take SJW and he did?”

    Hopefully the MD would have already given the patient the info about SJW and how it interacts with HIV meds. Also, most HIV/AIDS practices have a good new patient process that provides them with a lot of information about these topics. However,

    “Shouldn’t the burden be on the sCAMster to know what meds the patient is taking and whether there are interactions?”

    I think the burden should be on anyone prescribing something to another person to know that person’s entire current drug profile. In the case of MDs they usually ask but many CAM folks seem not to want to know about anything else.

    “What if the sCAMster refuses to accept HAART as legitimate treatment?”

    They can review decades of data, visit Aidstruth.org, thebody.com, UCSF’s HivInsite or any number of sites that completely debunk the myths of AIDS denialism and its variants. They can also study the horrible history of the HIV epidemic in South Africa and what excluding pharmaceuticals did to kill thousands of people. Ultimately, of course, it’s up to the patient to decide on their course of treatment.

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