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The NCCAM Strategic Plan 2011-2015: The Good, The Bad, and The Ugly

As hard as it is to believe, it’s been nearly a year since Steve Novella, Kimball Atwood, and I were invited to meet with the director of the National Center for Complementary and Alternative Medicine (NCCAM), Dr. Josephine Briggs. Depending upon the day, sometimes it seems like just yesterday; sometimes it seems like ancient history. For more details, read Steve’s account of our visit, but the CliffsNotes version is that we had a pleasant conversation in which we discussed our objections to how NCCAM funds dubious science and advocacy of complementary and alternative medicine (CAM). When we left the NIH campus, our impression was that Dr. Briggs is well-meaning and dedicated to increasing the scientific rigor of NCCAM studies but doesn’t understand the depths of pseudoscience that constitute much of what passes for CAM. We were also somewhat optimistic that we had at least managed to communicate some of our most pressing practical concerns, chief among which is the anti-vaccine bent of so much of CAM and how we hoped that NCCAM would at least combat some of that on its website.

Looking at the NCCAM website, I see no evidence that there has been any move to combat the anti-vaccine tendencies of CAM by posting pro-vaccination pieces or articles refuting common anti-vaccine misinformation. Of all the topics we discussed, it was clearest that everyone, including Dr. Briggs, agreed that the NCCAM can’t be perceived as supporting anti-vaccine viewpoints, and although it doesn’t explicitly do so, neither does it do much to combat the anti-vaccine viewpoints so ingrained in CAM. As far as I’m concerned, I’m with Kimball in asserting that NCCAM’s silence on the matter is in effect tacit approval of anti-vaccine viewpoints. Be that as it may, not long afterward, Dr. Briggs revealed that she had met with homeopaths around the same time she had met with us, suggesting that we were simply brought in so that she could say she had met with “both sides.” Later, she gave a talk to the 25th Anniversary Convention of the American Association of Naturopathic Physicians (AANP), which is truly a bastion of pseudoscience.

In other words, I couldn’t help but get the sinking feeling that we had been played. Not that we weren’t mildly suspicious when we traveled to Bethesda, but from our perspective we really didn’t have a choice: if we were serious about our mission to promote science-based medicine, Dr. Briggs’ was truly an offer we could not refuse. We had to go. Period. I can’t speak for Steve or Kimball, but I was excited to go as well. Never in my wildest dreams had it occurred to me that the director of NCCAM would even notice what we were writing, much less take it seriously enough to invite us out for a visit. I bring all this up because last week NCCAM did something that might provide an indication of whether it’s changed, whether Dr. Briggs has truly embraced the idea that rigorous science should infuse NCCAM and all that it does, let the chips fall where they may. Last week, NCCAM released its five year strategic plan for 2011 to 2015.

Truly, it’s a case of The Good, The Bad, and The Ugly.

The Good (more accurately: The Least Bad)

Let’s start by listing the goals of the NCCAM Strategic Plan 2011-2015:

  • GOAL 1: Advance the science and practice of symptom management.
  • GOAL 2: Develop effective, practical, personalized strategies for promoting health and well-being.
  • GOAL 3: Enable better evidence-based decision making regarding CAM use and its integration into health care and health promotion.

To accomplish these goals, NCCAM proposes five Strategic Objectives:

As much as I detest NCCAM as a political tool foisted upon the NIH by quackery-friendly legislators, in particular Senator Tom Harkin (D-IA), even I have to admit that there is some good in NCCAM’s strategic plan, specifically Objective 4: Improve the Capacity of the Field To Carry Out Rigorous Research. If you’re a scientist, arguing against improving the capacity to do rigorous science is akin to arguing against mom and apple pie; no serious scientist would do it. Of course, implicit in this NCCAM objective is an admission that the CAM research NCCAM has tended to fund in the past has not been very good, and, worse, it is very telling that NCCAM should even find it necessary to make improving the quality of its funded research a strategic objective. After all, improving the the capacity of a field to carry out rigorous research should be part of the mission of every NIH institute and center, so much so that it should almost go without saying. Unfortunately, how NCCAM proposes to go about improving the scientific rigor of its work isn’t exactly the way it should go about improving the scientific rigor of its work. For example, one key method proposed by NCCAM is to “support a variety of high-quality research training and career development opportunities to increase the number, quality, and diversity of CAM researchers”:

A successful and robust CAM research enterprise must draw from two sources of well-trained, skilled, and experienced talent: CAM practitioners expert in their respective disciplines and biomedical/behavioral scientists expert in cutting-edge scientific methods. CAM practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines. NCCAM has always recognized the need for research training and career development efforts targeted specifically toward this diverse community. Over the years the Center has developed a number of programs aimed at enhancing CAM practitioners’ abilities to critically evaluate biomedical literature, participate in clinical research, and, in some cases, seek advanced training and career development opportunities for careers in the field of CAM and integrative medicine research.

All of this sounds very nice, but where the rubber meets the road, what this means is listening to reiki practitioners, acupuncturists, therapeutic touch practitioners, and homeopaths (in other words, believers in unsupported modalities based on magical thinking) when setting priorities, in addition to listening to less unreality-based CAM practitioners, such as herbalists or even chiropractors who stick with musculoskeletal disorders and don’t claim that chiropractic can cure asthma or other unrelated diseases. Using such practitioners to set research priorities and to collaborate with real scientists is what Harriet Hall would call Tooth Fairy science. It’s putting the cart before the horse. Implicit in this strategy is the assumption that there is an actual phenomenon to be studied in modalities like reiki, which, let’s face it, is nothing more than faith healing stripped of its Christian religious background and replaced with Eastern mysticism. If I knew that NCCAM was in actuality trying to determine whether these phenomena exist, rather than “how” they work, perhaps I’d be less critical. Another part of me can’t help but note that trying to suck real scientists into the study of pseudoscience, NCCAM is blatantly trying to cloak various modalities in the mantle of scientific respectability before they deserve to wear it.

Whether I’m being cynical or realistic I leave to the reader to judge. Certainly, given that Objective 3 (Increase Understanding of “Real-World” Patterns and Outcomes of CAM Use and Its Integration Into Health Care and Health Promotion) seems custom-designed to develop a case for “integrating” CAM into science-based medicine, rather that determining which modalities actually have some utility supported by science and therefore should cease being “alternative” and become just “medicine.”

Less irritating is Strategic Objective 2: Advance Research on CAM Natural Products. Actually, it’s not so much “good” as least objectionable and even somewhat scientifically defensible. Here are the strategies proposed by NCCAM:

Strategy 2.1: Harness state-of-the-art “omics” and other high-throughput technologies and systems biology approaches of the sciences of pharmacology and pharmacognosy to:

  • Elucidate biological effects, mechanisms of action, and safety profiles of CAM natural products
  • Study interactions of components with each other and with host biology
  • Build a solid biological foundation for translational research needed to carry out clinical studies.

Strategy 2.2: Support translational research to build a solid biological foundation for research on CAM natural products to:

  • Develop and validate sensitive and reliable translational tools to detect and measure mechanistically relevant signatures of biological effect and to measure efficacy and other outcomes
  • Conduct preliminary/early phase studies of safety, toxicity, dosing, adherence, control validation, effect/sample sizes, ADME (absorption, distribution, metabolism, and excretion), and pharmacokinetics
  • Build upon established and proven product integrity policies and processes.

Strategy 2.3: Support targeted large-scale clinical evaluation and intervention studies of carefully selected CAM natural products.

Of course, the reason that I label this as being part of “the good” is because, of all the aspects of CAM, natural products represent the area with the most scientific plausibility. On the other hand, it’s hard not to point out that there is nothing here that natural products pharmacologists haven’t been doing for decades. Nothing. What NCCAM is in essence describing is nothing more than pharmacogonosy, the study of natural products pharmacology. It’s the sort of thing that our very own David Kroll does. It’s the sort of thing that thousands of pharmacologists do every day. Heck, it’s even the sort of thing that a lot of pharmaceutical companies do when they try to isolate drugs from natural products. There are many examples of drugs that have come from natural products, including taxol (Pacific Yew tree); vinca alkaloids (periwinkle plant); related drugs like campothecin, irinotecan, and topotecan (Camptotheca acuminata, a.k.a. Happy tree); and, of course, aspirin. The list is extensive, arguably longer than the list of synthetic drugs.

In fact, what NCCAM is doing here, whether Dr. Briggs realizes it or not, is the classic “bait and switch” that I discussed when kvetching about Dr. Oz’s promotion of various Ayruvedic medicines and “detox” diets. In essence, NCCAM has claimed for itself all of natural products pharmacology as being “CAM.” The difference is that there is a layer of belief slathered on it, specifically the CAM belief that somehow the natural plant is superior to purified components or molecules found to have medicinal value. The assumption is that the mixture of unpurified compounds somehow allows the components in the plant or natural product to be “synergistic.” While this sort of synergy is possible, it is actually pretty implausible, with precious few examples known. Worse, it’s very hard to demonstrate true synergy between only two or three components, much less the hundreds — or even thousands — of components in many plants used in CAM. In reality, for all practical purposes and even when a plant does have an active compound (or active compounds) in it that function as a drug, using whole plant extracts, as most CAM practitioners do, substitutes adulterated active ingredients whose purity and potency can vary wildly for well-characterized, predictable, purified active drug.

Actually, I don’t mind this sort of research so much, as long as it’s testing hypotheses that are supported by sound basic science and preclinical data. Certainly, that’s what NCCAM appears to be trying to do, and if NCCAM can’t be dismantled (as I would prefer), its components absorbed into the appropriate institutes and centers of the NIH, then I suppose this is the sort of research that is least likely to cause harm and might actually produce useful results, far more so than much of the rest of the research that NCCAM funds. However, I continue to question why such research should now be considered “CAM” when natural products research has long been a major area of “conventional research.” After all, the study of natural products and herbs with useful pharmacological activity has been an active area of research in pharmacology since time immemorial. There’s no scientific rationale why such studies should be segregated away as “alternative”; they could and should be evaluated just like any other scientific study. Worse, trying to segregate natural product pharmacology at NCCAM devalues pharmacognosy, and by association with the other woo (see below) also being funded under the rubric of “CAM” makes it look like woo too.

In fact, the entire set of goals set forth by Dr. Briggs in the introduction are a “bait and switch.” Notice how two out of the three of these have nothing to do with CAM. Seriously. Why is it that symptom management is CAM? Take the example of oncology. Considerable research and effort go into trying to develop strategies to minimize the effects of therapy. A whole branch of anesthesiology is devoted to the management of chronic pain. If that’s not “symptom management,” I don’t know what is. So what does CAM bring to the science and practice of symptom management? Very little, I would argue, that can’t be studied outside the context of CAM. Unfortunately, what CAM really does bring to symptom management is pseudoscience and prescientific ideas of how the body works. It brings qi. It brings human energy fields. It brings vitalism. Do we really need to “integrate” nonsense with science in symptom management? Perhaps NCCAM can help us understand placebo effects better, for example, but that is research that can and should be the bailiwick of other NIH institutes and centers.

And don’t get me started on Goal 2, which, similarly, is a province of science-based medicine. One might argue that medicine hasn’t done as good a job of developing personalized strategies to promote health and well-being, but the solution to that problem is to emphasize such strategies more in science-based medicine, not to bring in pseudoscience.

The Bad and The Ugly

Let’s take a look at all the strategic objectives. I only discussed Strategic Objective 2 above, but that’s just because I wanted to discuss the least objectionable objective. Actually, in and of itself, Strategic Objective 2 is not objectionable. After all, natural products pharmacology is something I consider fascinating. So here are the five Strategic Objectives in the NCCAM Strategic Plan 2011-2015. Neither would Objective 4 be objectionable if the science were truly rigorous and subject to analyses of Bayesian prior probability before highly improbable modalities like homeopathy or reiki are tested in human beings.

So let’s look at Strategic Objective 5 (Develop and Disseminate Objective, Evidence-Based Information on CAM Interventions). These sound rather benign, don’t they? I mean, who could argue with disseminating “objective, evidence-based information on CAM interventions,” for example? Certainly not me. And I actually do hope that NCCAM does do that, that it really is serious about it. If so, it would tell people that homeopathy is nothing but water, that there is no evidence that reiki practitioners can manipulate a “universal energy field” to heal, and that there’s no scientifically convincing evidence that practitioners of therapeutic touch practitioners can detect or manipulate human energy fields. Let’s look at the key points NCCAM emphasizes about reiki:

  • People use Reiki to promote overall health and well-being. Reiki is also used by people who are seeking relief from disease-related symptoms and the side effects of conventional medical treatments.
  • Reiki has historically been practiced as a form of self-care. Increasingly, it is also provided by health care professionals in a variety of clinical settings.
  • People do not need a special background to learn how to perform Reiki. Currently, training and certification for Reiki practitioners are not formally regulated.
  • Scientific research is under way to learn more about how Reiki may work, its possible effects on health, and diseases and conditions for which it may be helpful.
  • Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Pointing out:

Reiki is based on the idea that there is a universal (or source) energy that supports the body’s innate healing abilities. Practitioners seek to access this energy, allowing it to flow to the body and facilitate healing.

Although generally practiced as a form of self-care, Reiki can be received from someone else and may be offered in a variety of health care settings, including medical offices, hospitals, and clinics. It can be practiced on its own or along with other CAM therapies or conventional medical treatments.

I could provide other examples, such as the entry on NCCAM for Ayruvedic medicine. However, perhaps the most instructive example is the entry for homeopathy. A truly science-based assessment of homeopathy would point out that the principles of homeopathy violate multiple well-established laws of physics and chemistry and that, for homeopathy to work, these well-established laws would have to be found not to be just wrong, but spectacularly wrong. It would also point out that, for that to happen, the amount of evidence in support of homeopathy would have to start to approach the level of evidence that tells us that homeopathy can’t work. While NCCAM does concede that homeopathy is “controversial” and that its tenets violate known laws of physics, it does so in a weaselly, wishy-washy way:

Homeopathy is a controversial area of CAM because a number of its key concepts are not consistent with established laws of science (particularly chemistry and physics). Critics think it is implausible that a remedy containing a miniscule amount of an active ingredient (sometimes not a single molecule of the original compound) can have any biological effect—beneficial or otherwise. For these reasons, critics argue that continuing the scientific study of homeopathy is not worthwhile. Others point to observational and anecdotal evidence that homeopathy does work and argue that it should not be rejected just because science has not been able to explain it.

Three of its “key points” about homeopathy are:

  • The principle of similars (or “like cures like”) is a central homeopathic principle. The principle states that a disease can be cured by a substance that produces similar symptoms in healthy people.
  • Most analyses have concluded that there is little evidence to support homeopathy as an effective treatment for any specific condition; although, some studies have reported positive findings.
  • There are challenges in studying homeopathy and controversies regarding the field. This is largely because a number of its key concepts are not consistent with the current understanding of science, particularly chemistry and physics.

Yes, NCCAM presents a classic “tell both sides” false equivalence argument. On the one hand, established laws of science tell us homeopathy can’t work. On the other hand, anecdotal evidence tells us it does work and therefore we should study it. Never mind that the two principles upon which homeopathy is based (“like cures like” and the law of infinitesimals) have no real basis in science, particularly the law of infinitesimals, which states that diluting and succussing a remedy to the point where not a single molecule is likely to remain somehow makes it stronger.

This brings us to the meanest, ugliest, nastiest one, the meanest Strategic Objective of them all, Strategic Objective 1 (Advance Research on Mind and Body Interventions, Practices, and Disciplines). Personally, I find it telling that this is Objective 1 on the list, and NCCAM even lists examples of CAM mind-body interventions:

  • Acupuncture
  • Breath practices
  • Meditation
  • Guided imagery
  • Progressive relaxation
  • Tai chi
  • Yoga
  • Spinal manipulation
  • Massage therapy
  • Feldenkreis method
  • Alexander technique
  • Pilates
  • Hypnosis
  • Trager psychophysical integration
  • Reiki
  • Healing touch
  • Qi gong
  • Craniosacral therapy
  • Reflexology

Here’s the “bait and switch” again. If NCCAM had restricted itself to modalities that, right or wrong, fall under “mind-body” interventions, such as meditation, guided imagery, breathing practices, hypnosis, and the like, I would have had little problem with proposing to study them as a major strategic initiative of NCCAM. Unfortunately, that’s not what NCCAM did. Notice how NCCAM also throws in there all manner of pure quackery, such as reiki, healing touch, craniosacral therapy, and even reflexology. Seriously, reflexology! You know, the idea that every organ and part of the body “maps” to parts of the foot or hand, an idea that is not supported — and, in fact, is contradicted — by what we know about human anatomy and physiology. Placing these forms of quackery next to forms of interventions such as guided imagery that could well turn out to be science-based and useful implies, either wittingly or unwittingly, that “mind-body” interventions already known to be quackery are somehow worthy of study. Also note how NCCAM includes modalities like Tai Chi, yoga, and Pilates in the mix as well. These are, in essence, forms of relatively gentle exercise, at least for most people. (Yes, I realize that some yoga workouts can become quite intense.) What makes them more “mind-body” than other forms of low impact exercise? Finally, I’m really puzzled about the inclusion of massage therapy on this list. No doubt about it, massages feel good, and they are probably even useful for some musculoskeletal disorders, but what makes massage therapy a “mind-body” interaction? It’s a body-body interaction!

In fact, this very list looks to me like a blurring of the line between things that might be true mind-body interventions (meditation, progressive relaxation, guided imagery, etc.) and so-called “energy medicine” (reiki, healing touch or therapeutic touch, acupuncture, and qi gong). In fact, this is intentional, as there is a notice after the list that states, “As used in this plan, mind and body encompasses interventions from the three domains of mind/body medicine, manipulative and body-based practices, and energy medicine.” The problem here is that certain forms of what is called “mind-body” medicine might actually have value, whereas “energy healing” is pure religion or pseudoscience. Yet they are lumped together.

Truly, Strategic Objective 1 is The Bad and The Ugly.

It’s also evidence that neither Dr. Briggs nor the NCCAM leadership understand the problem that is at the heart of CAM. For example, look at this statement from Dr. Briggs in her introduction:

My experience as a physician who has cared for patients struggling with chronic, painful, and debilitating symptoms greatly informs my perspective on our work. When I began medical school, one of my teachers taught that “the secret of care of the patient is in caring for the patient.”* I took these words to heart. Symptoms matter, and few would dispute the fact that modern medicine does not always succeed in alleviating them. Few would also dispute the need for better approaches for encouraging healthy lifestyle choices. These are places in which I believe CAM-inclusive approaches offer promise, and I look forward to exploring the possibilities in the years ahead.

No one, of course, is arguing that symptoms don’t matter, although I note with some amusement that some CAMsters might not be too happy with Dr. Briggs’ emphasis on symptoms given how they like to claim that “Western medicine” treats only the symptoms and CAM treats the “root cause” of disease. Be that as it may, upon reading this, I can’t help but ask: How can “CAM-inclusive” practices offer promise above and beyond science-based medicine in encouraging healthy lifestyle choices, particularly when so much of CAM bases its recommendations on a prescientific understanding of how the body works? You have to know what the body needs before you can encourage healthy choices, and to a large degree we already do know what most American bodies need: More exercise, more fruits and vegetables in their diets, and less fat and calories. To add to that knowledge, we don’t need CAM. We need science-based medicine. More importantly, I would wonder on what evidence, specifically, Dr. Briggs bases her assessment.

Inquiring minds want to know!

Posted in: Basic Science, Clinical Trials, Politics and Regulation

Leave a Comment (54) ↓

54 thoughts on “The NCCAM Strategic Plan 2011-2015: The Good, The Bad, and The Ugly

  1. Draal says:

    For me, this was a much anticipated update. Thank you.

    So now that you’ve illuminated the trail head, I think it’s time for a guide to takes as through the woods. In other words, what are we to do now? Do we write to our congressional leaders? Do we petition NIH? Our new congress is supposedly all about fiscal responsibility. Axing NCCAM would save how much over the next ten years?
    $1.3 BILLION based on NCCAM 2011 yearly budget!

  2. Draal says:

    Perhaps discussing how the “Director’s Overview” correlates with the 2011-2015 Strategic Plan would be useful for another blog posting.
    nccam.nih.gov/about/budget/congressional/#Dir

  3. rmgw says:

    What about staring the plane with them all doing a personal trial of breathariansim for, say a year?

  4. daedalus2u says:

    The political environment has changed a lot in a year. The tea partiers in the GOP want to zero-out as many budgets as they can.

    Zeroing out the NCCAM budget would improve health care research by reducing the noise and disinformation it generates and would reduce the deficit and would give the GOP something to crow about by defunding something that has “health” in its name. Win win win.

  5. JMB says:

    I would agree with daedalus. I would also argue that it violates the separation of church and state, since this is tax dollars spent researching religion based medicine.

    I do have to admit, NCCAM funding is government spending that creates jobs. The government could hire some out of work elementary school teachers to give seminars on research methods, statistics, basic chemistry, and physics to CAM practitioners, thereby improving the quality of their published work.

  6. daijiyobu says:

    “These are the scatologisms of the Medship Enterpoop (NCC-AM-hrroid), whose five-year mission is to seek out new life-force, new chi-livizations, and to boldly return to the knowledge detritus we excreted in the past.”

    Anyway, always good to read a schwack of naturopathy.

    -r.c.

  7. Angora Rabbit says:

    “Strategic Objective 4: Improve the Capacity of the Field To Carry Out Rigorous Research”

    As an NIH funded researcher and grants reviewer (full disclosure, but not from NCCAM) this statement is horrifying. Or more precisely, that NCCAM felt it necessary to spell this out. This objective ought to be intrinsic to each Institute’s mission and, in my own extensive experience, is central to every study section where research proposals are evaluated. As Dr. Gorski says, the mere fact that NCCAM has to explicitly state this, and as a Strategic Objective no less, points out* how scientifically bankrupt their research portfolio must be.

    *Actually, more like huge flashing neon lights.

    Regarding Strategic Goal 2.1, I take a more cynical view. My lab runs a fair number of “omic” screens to characterize toxicant responses. Any screen reviews a large number of “hits” that may or not be meaningful. Here’s where your statistician comes into play, as well as a very careful study design that eliminates the noise in your controls. My fear is that, because any -omic screen generates signal, the NCCAM folks will seize on the data as “meaningful” when their study designs are incapable of distinguishing true signal from false signal.

    I predict a flood of NCCAM funded papers claiming that because Substance X causes This List of gene/protein changes presented in Table 1, Substance X must be working! And now I think I understand the difference between Science-based and Evidence-Based medicine. :)

  8. JMB says:

    @daijiyobu

    NCCAM is like fecal hoarding. It refuses to eliminate the poop.

  9. S.C. former shruggie says:

    From the NCCAM five year mission statement:

    Public interest in CAM remains strong. Helping the public and health care providers to be better informed about the safety and usefulness (or lack thereof) of CAM interventions, practices, and disciplines is the overarching communication goal of NCCAM.

    Link Quackwatch and Science Based Medicine. Add a few James Randi clips. Erase everything else on your website. Mission accomplished.

    If they meant what they said above, NCCAM owes you guys a grant and some serious back pay. (Hint: they didn’t mean what they said.)

  10. ConspicuousCarl says:

    The NCCAM page on “Ayruvedic medicine” is typical quack comedy, which usually goes something like this…

    Q: “What exactly is _____?”
    A*: “It’s been around for [a very long time], it originated in [semi-exotic location], and its goal is to [vague generalization].”

    None of that actually answers the question. It is evasive salesman’s BS which you always have to read past before getting to the ugly truth (which is usually something insane like “_____ means trying to cure cancer by sticking coffee beans in your ass.”). It almost seems like they KNOW how insane their product is and are embarrassed to say it without the preceding fluff.

    (* I hate even to use the letter “A” in front of that sentence)

  11. ConspicuousCarl says:

    In the world of quack medicine, I used to hate the word “alternative” more than anything. It implies that there is, could be, or ought to be, an “alternative” to using science and evidence to find useful medical interventions. But, despite the stupidity of that inherent meaning, the word “alternative” is almost honest. These crackpots really do want to engage in non-rational medicine (perhaps “rumor-based medicine”).

    The word I now hate most is “complimentary” because I think it is dishonest accommodationism.

    I don’t believe that people like Josephine Briggs or Mehmet Oz really do want to “compliment” real medicine with their nonsense. I think they are more like the nominally “moderate” religious leaders who go on CNN and preach “getting along” and “teaching all theories”, but then go back to their churches and tell the congregation that everyone will ultimately either have to convert or burn in hell. The unconditional inclusion banner is just an excuse to get their backward-thinking proposals into the public square (or, in the case of NCCAM, the public wallet), with the ultimate intent of replacing logic with dogma.

  12. Scott says:

    Well, they SHOULD want to “compliment” SBM. What they’re trying (and failing) to do is “complement” it.

  13. ConspicuousCarl says:

    Doh!

    Actually, they don’t want to compliment, either. They don’t call real medicine “EBM” or “SBM”, they call it “conventional” (implying an old or rigid lack of insight) or “western” (implying that science is just a cultural oddity). It is really all insult.

  14. windriven says:

    Now remind me again, what was the “Good” part?

    Oh yes: “Improve the Capacity of the Field To Carry Out Rigorous Research”

    This seems to me akin to improving the capacity of a 1963 Ford Galaxy for interstellar travel.

    Having a bunch of people dressed up for a Trekkie convention speaking weightily about di-lithium crystals and warp drive mechanics doesn’t move the Ford an inch closer to Alpha Centauri. And having a bunch of magical thinkers in lab coats doesn’t move quackery an inch closer to scientific rigor.

    It seems to me that this is just another case of science getting the rope-a-dope treatment from NCsCAM: They do not want to bring scientific rigor because it would let the gas out of the balloon, and with the gas goes the funding. But going through the motions bestows credibility to the incredible and paves the way for the next funding increase request.

    Doh!

  15. Jeff says:

    Regarding Strategic Objective 2: I applaud NCCAM’s goal of discovering how various constituents of natural products work together to affect health. This is quite different from pharmacology, which views natural products only as a source of drug discovery.

    New NIH centers to unlock botanical complexity and ‘inform consumer decisions’

  16. Paddy says:

    @ConspicuousCarl,

    Don’t forget “Allopathy”.

  17. Jeff,

    Can you explain the difference? If a constituent of something affects our health and is not a macronutrient, how is it not a drug?

  18. ConspicuousCarl says:

    Jeff on 07 Feb 2011 at 3:19 pm

    Regarding Strategic Objective 2: I applaud NCCAM’s goal of discovering how various constituents of natural products work together to affect health. This is quite different from pharmacology, which views natural products only as a source of drug discovery.

    That sounds pretty, but it is actually nonsense for two reasons:

    1. It sounds, in both their and your words, as though there is an assumption that “natural” products possess this characteristic over non-”natural” products, and they intend to do the research to prove how it works even in the absence of evidence that it ever/often actually does.

    2. It isn’t “quite different” in the sense of other forms of research being only for “drug discovery”. Whether a plant has one effective substance which works on its own, or has several which do multiple things in concert, the ultimate logical goal is to remove the substance(s) and provide them to patients in controlled dosages. That’s called a drug, and there is no point in doing any medical research if that is not your true goal.

    What is ironic, though I can’t list it as a refutation because I don’t know if either you or the NCCAM have expressed this, is that the pro-nature crowd typically complains when scientifically complex conditions result in the patient needing multiple drugs.

    Also ironic is that this supposed push into cutting-edge biological elegance and complexity is headed by an organization which displays pathetic knowledge of biology.

  19. Scott says:

    @ Jeff:

    Please also explain how your comment isn’t precisely addressed by:

    The difference is that there is a layer of belief slathered on it, specifically the CAM belief that somehow the natural plant is superior to purified components or molecules found to have medicinal value. The assumption is that the mixture of unpurified compounds somehow allows the components in the plant or natural product to be “synergistic.” While this sort of synergy is possible, it is actually pretty implausible, with precious few examples known. Worse, it’s very hard to demonstrate true synergy between only two or three components, much less the hundreds — or even thousands — of components in many plants used in CAM. In reality, for all practical purposes and even when a plant does have an active compound (or active compounds) in it that function as a drug, using whole plant extracts, as most CAM practitioners do, substitutes adulterated active ingredients whose purity and potency can vary wildly for well-characterized, predictable, purified active drug.

  20. Jeff says:

    @Alison Cummins: Drugs are lab-created, single-molecule substances, patentable by drug companies. For example research into the bioflavanoid quercetin produced the anti-histamine drug Cromolyn Sodium. Howeverquercetinis a bioactive compound with multiple effects on health.

    @Scott: With production methods becoming more sophisticated, botanicals are increasingly sold as standardized extracts. For example one typical green tea extract product lists this:

    Green Tea (Camellia sinensis): 725 mg.
    Decaffeinated Extract (leaf) [std. to 98% polyphenols by UV (710.5 mg), 45% EGCG by HPLC (326.25 mg)]

  21. Paddy says:

    @Jeff,

    Might I suggest you consider Mosby’s definition of the word drug as well?

    “1 also called medicine. any substance taken by mouth; injected into a muscle, the skin, a blood vessel, or a cavity of the body; or applied topically to treat or prevent a disease or condition.
    2 informal. any substance that can be abused for its stimulant, depressant, euphoric, or hallucinogenic effects.”

    If your beef is with single-molecule treatments, you might as well be explicit about it.

  22. ConspicuousCarl says:

    Jeff on 07 Feb 2011 at 6:08 pm
    Drugs are lab-created,

    So “drug” means “created under controlled and sanitary conditions”?

    single-molecule substances,

    So “night time” cold remedies cease to be drugs if they contain both diphenhydramine AND acetaminophen?

    patentable by drug companies.

    So drugs become non-drugs when they are transported into relaxed civil jurisdictions?

    None of this is very useful from a medical perspective.

  23. pmoran says:

    CAM practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines.

    Well, over 18 years and billions of dollars worth of research into CAM by the NCCAM and others has not delivered a single, notable, uniquely useful treatment for any condition.

    So, — what ? Have the “experts” been looking at the least likely methods thus far? Why would the next $100 million do any better?

    I am more tolerant of CAM use than many here, but we have surely reached the point where we should be trying to better understand the common ground between proper medicine and CAM, i.e. expectancy (placebo) and other non-specific effects of medical attentions.

    All else (in CAM) is proving to be illusion, even most use of herbals.

  24. As a former massage therapist, I had a good chuckle over the inclusion of massage in NCCAM’s list of “mind-body” interventions. Massage can certainly involve rich psychological and emotional experiences and by-products of the interaction between therapist and patient. Being manipulated intensely might change your literal sense of yourself, how it feels to be in your skin, and thus it has the potential to bump you out of some sensory rut or uncomfortable habit. People tend to hop of the massage table full of determination to treat their bodies better.

    It’s inspiring, basically!

    But all this occurs more or less regardless of the specific manipulation; it’s just how humans respond to being compassionately manipulated and massaged. It’s as hopelessly vague and random and non-specific as treatment outcomes can possibly be, and the connections between these effects and physical health — although they probably exist — are tenuous and subtle at best. And while massage is clearly a distinctive experience, none of this is substantively different from any other kind of catharsis or therapeutic experience.

    You might as well just go ahead and call any interesting experience “mind-body medicine.” ;-)

  25. Draal says:

    @Jeff

    A couple things about ‘bioflavonoids’; 1) They are called flavonoids. Adding the ‘bio’ in front of them is a squishy way to sex up the name. Sure, a number of synthetically derived flavonoids exist but unless you’re a chemist or a researcher with an account to a chemical distributor like Sigma-Aldrich, good luck getting your hands on them. Also, there are only a handful of examples of enzymatically-derived unnatural flavonoids. I know this ’cause I one of the few that published the research myself and have written a number of review papers and book chapters on the subject.
    2) Flavonoids have very poor bioavailability. That means they are not absorbed by the body in any appreciable amounts, especially quercetin (www.ncbi.nlm.nih.gov/pubmed/21184087). This is the little dirty secret about flavonoids. They work great in test tubes but only a small fraction of flavonoids ever make it into the bloodstream at concentrations well below therapeutic value and the clearance rate is fast. In fact, the gut microflora have a field day in breaking down flavonoids.
    3) Any association with their ‘antioxidant’ properties is likely due to the body’s own defenses. Flavonoids are foreign molecules that the body actively tries getting rid of. In the process of doing so, the body jacks up it’s own natural antioxidant capabilities. Flavonoids marketed as antioxidants is only relevant if you live in a test tube.

  26. Draal says:

    “For example research into the bioflavanoid quercetin produced the anti-histamine drug Cromolyn Sodium.”
    Better check your facts as khellin is linked with the discovery of cromolyn, neither of which are derived by the flavonoid biosynthetic pathway. Sorry, you just forfeited your Google University diploma.

  27. Davdoodles says:

    Sorry, off-topic and maybe you’ve seen this before, but this interview by Sanjay Gupta with Bill Gates is pretty awesome. Gates rips in the the Pro-Polio-and-Cervical-Cancer Cult with cool precision:

    http://www.cnn.com/2011/HEALTH/02/03/gupta.gates.vaccines.world.health/index.html

    In a bizarre but hardly surprising lack of insight, the Pro-Iron-Lung-Industry Shills at ‘Age of Autism’ have posted the vid as an example of Why Children Must Die to Protect Big Ecinacia*:

    http://www.ageofautism.com/2011/02/bill-gates-on-cnn-they-kill-children-vaccine-safety-advocates.html#more

    *possibly paraphrased slightly. It’s hard to tell exactly what they want, other than tho keep American jobs in the American Funeral Industry and Leg-Caliper Manufacturing sector.
    .

  28. Davdoodles says:

    “CAM practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines.”

    Few here would doubt that “CAM practitioners” are fully cognizant of the reality of the abject nonsense they peddle.

    Their otherwise inexplicable avoidance of scientific confirmation handily implies the true shape of their ‘knowledge’. A liar is always betrayed by what he avoids saying. It leaves a …shadow.

    But it is refreshing to read an actual admission that it is not mere (albeit quite possibly willful) ignorance. Progress, of a sort.
    .

  29. Jeff says:

    @Draal: You’re right about quercetin’s poor bioavaliablility. Quercetin is usually sold as a quercetin/bromelain combination (bromelain is a digestive enzyme). If taken on an empty stomach, absorption goes up considerably.

  30. ConspicuousCarl says:

    Davdoodles on 07 Feb 2011 at 10:54 pm

    Sorry, off-topic and maybe you’ve seen this before, but this interview by Sanjay Gupta with Bill Gates is pretty awesome. Gates rips in the the Pro-Polio-and-Cervical-Cancer Cult with cool precision:

    http://www.cnn.com/2011/HEALTH/02/03/gupta.gates.vaccines.world.health/index.html

    Well done by the big guy. No soft BS there: it’s a lie and it killed children.

    Bill Gates has poured billions into these programs and spent a lot of time trying to make sure they actually work. I can’t imagine how PO’d he must be every time he hears some idiot tell people that vaccines are bad.

    Too bad he stopped short of deleting Wakefield’s serial number from the Windows Genuine Advantage database. After all, if Wakefield doesn’t like protection from viruses, he won’t miss those Windows updates.

  31. Draal says:

    @Jeff
    “If taken on an empty stomach, absorption goes up considerably.”

    I’ll bite. What makes you so sure about this? Can you produce a peer-review journal article to support your claim? A health food store website is not an acceptable source.

    On the likely chance you can’t, here’s one more thing to consider. Quercetin is only found in the plasma as a gluconate and/or sulfate conjugate since the liver processes it pretty quickly. That means all the in vitro studies that used quercetin are essentially meaningless since we are talking about comparing apples to oranges as quercetin gluconate/sulfate will most likely have a much different affinity to whatever it’s binding to compared to quercetin aglycone.
    For a review on quercetin bioavailability see http://www.ajcn.org/content/81/1/230S.abstract

    [BANG] That’s the sound of a sacred cow being shot. Who wants burgers?

  32. Scott says:

    @ Jeff:

    Sorry, but your response doesn’t address the point – at all. A precisely measured amount of something of unknown composition, containing all sorts of irrelevant components, and highly variable amounts of whatever the relevant component is (depending on how, where, and when the plant was grown) is still completely uncertain and grossly impure.

  33. Jeff’s definition of drugs: “Drugs are lab-created, single-molecule substances, patentable by drug companies.”

    Ok, so the following are NOT drugs:
    Hash.
    Heroin.
    Caffeine.
    Nicotine.
    Alcohol. 

    Correct? And any research into, say, cannabinoids has no bearing at all into the use of cannabis. Research into the properties of cannabis must be funded by NCCAM because current research on cannabinoids with any other source of funding, whether conducted in universities or by pharmaceutical companies, is completely irrelevant to anyone using cannabis.

    Am I understanding you correctly?

  34. Jeff says:

    @Alison Cummins: The point I was trying to make is this: Natural products, as plant extracts, should not be viewed merely as a collection of chemicals, all of which should be isolated, purified, and potentially turned into drugs. Natural products often have several components which work individually or together to affect human metabolism. This is the way NCCAM means to study them:

    1. Elucidate biological effects, mechanisms of action, and safety profiles of CAM natural products.

    2. Study interactions of components with each other and with host biology.

    3. Build a solid biological foundation for translational research needed to carry out clinical studies.

    Is this “woo” or just good science?

  35. Scott says:

    Natural products often have several components which work individually or together to affect human metabolism.

    Citation needed.

    Is this “woo” or just good science?

    Unless one can demonstrate some good reason that the plant is superior to identifying, purifying, and using the active ingredient, it’s pure woo and horrible science. Assertion, by the way, does not constitute “demonstrating a good reason.”

  36. Joe says:

    @Jeff on 08 Feb 2011 at 3:57 pm

    It seems you interpret vague statements to suit yourself. When NCCAM refers to natural products, do they mean the (potential) active ingredients or the ground-up shrubbery? I suspect you imagine the latter (pulverized weeds), as opposed to the rational search for medicinal compounds that is already part of mainstream pharmacology.

    Further, I imagine NCCAM contemplates the same- flora that can be used directly as drugs, rather than rational drug development. A short while ago Dr. Atwood quoted a problem Prof. Kroll had with NCCAM when Kroll submitted a rational grant proposal to NCCAM.

  37. Paddy says:

    @Jeff,

    The problems with direct herbal preparations are these:

    - The strength of any given pharmacologically active ingredients may show extensive variation between plants, soils, years, etc. There may also be other pharmacologically active compounds that will turn up based on what bacteria and fungi may have been commensal with different plants. So you’re never sure what dose of a given substance you’re actually providing when you give someone a herb containing it.

    - Compounding this, it’s hard to thoroughly standardise preparation of the substance thus made. So, you’re giving someone willow bark as a painkiller. What part of the willow do you harvest it from? How much do you give them? Do they chew it, ingest it as a ground powder, take it pickled in alcohol or as a tea? If a tea, how do you brew it? And so on, and so forth. Or, of course, you could just give them aspirin, and then you’d know exactly what they’d had, and how much of it.

    - We still struggle to unpick easily the full actions of any given molecule we throw at somebody – hence, for instance, that they’re still finding out new things that aspirin does. If you’re going to throw everything that’s in a given plant at somebody, then you’ll never know what all the pharmacologically active substances you’re giving them are, never mind what they’re actually doing.

    That’s the argument for medicine over herbalism in a nutshell, really. Take your pick.

  38. Well, one of the arguments for herbalism over medicine is that if you can make do with what you can grow or gather in most situations, you are less dependent.

    Sure, maybe sassafrass or willow is less pure or unpredictably potent. But if they grow in my back yard and I’m envisioning a future in which aspirin will be much more expensive and I will be much poorer, then I’ll be really happy to know how to use sassafrass and willow.

    There’s a DIY element to some of this stuff that is completely legitimate, which can (and should) be respectfully unpacked from unsupported assertions and wishful thinking. (I prefer homemade washable menstrual pads to purchased disposable ones, but it has nothing to do with imagining that cotton is more absorbent than polyacrylate gel or more stainproof than plastic and everything to do with DIY.) (My beloved shares neither my preference nor my reasoning.)

    There are good reasons for wanting to know how to use a whole plant. But there is no special life force in the plant that transmits anything besides the chemicals it contains and plants were not “designed” to meet human needs. If we have reason to think that something could provide a useful drug with little preparation, then we need to look for the active drug or drugs and then determine how best to gather and prepare the plant.

    This is pharmacognosy. The distinction between “drugs” and “natural products” is unhelpful.

    The idea that a plant could contain several chemical substances that work in concert in useful ways is not inherently implausible, assuming we share the plant’s agenda. For instance, plants have to worry a lot about rotting and they produce chemicals to prevent it, especially in their roots. We also worry about rotting so it makes sense that plant roots could be useful sources of antimicrobials and work better as a whole root (because the whole root is what is resisting rotting) than any particular chemical component alone. Goldenseal would be an ideal example of this.

    … except that it hasn’t been demonstrated. Berberine (found in goldenseal) has weak antimicrobial activity in vitro and there has never been any objective support for the idea of synergistic effects. Even though it would make sense for them to exist, and they have been looked for, when it comes down to it they seem purely theoretical.

    Asserting that a whole plant has special powers doesn’t make it so. You have to look to see if it does, then report the specific examples where this effect is found.

  39. Always Curious says:

    “With production methods becoming more sophisticated, botanicals are increasingly sold as standardized extracts”

    Just last night, I was puzzling over two bottles that claimed the ingredients that are nearly the same in my dictionary: “Distilled Rose Water” and “Rose Water Extract”. They smell and taste wildly different. Adding an additional line or two of science-speak on a label doesn’t make it effective or standard or medicine. If I wanted the entire plant’s life history & subsequent processing, I’d grow it & extract it myself (Or, stick to the company that makes the best tasting product).

    In the mean time, the FDA can kindly ensure that the resultant products being sold on the shelves are safe and not making inappropriate claims. And the NIH can kindly fund research that will actually lead to effective treatments.

  40. Always Curious says:

    On another note, it seems to me that predicting synergistic relationships in pharmacy and toxicology remains a puzzle to this day. We don’t have efficient methods for screening for these relationships (especially if you think 5 or 6 compounds are all interacting to create an effect) and we don’t have strong theories to help us reduce any systematic screening we might decide to do.

    However, NCCAM doesn’t seem to be truly dedicated to nor capable of actually analyzing mutiple interacting chemical components in any given plant, nor whether any existing synergies actually are useful. So why not give that chunk of their budget to another department within NIH/EPA/FDA dedicated to analyzing these kinds of problems? Or simply cut it completely and save some $$ altogether?

  41. Jeff says:

    Here’s one animal study which concludes that catechin-polyphenols and caffeine (both constituents of green tea extract) work synergistically to promote brown fat thermogenesis:

    http://www.nature.com/ijo/journal/v24/n2/full/0801101a.html

    Many human trials have shown green tea extract is quite safe – research should continue until we know exactly how green tea works. But we don’t need to wait 15 years for a pharmaceutical company to come out with a high-priced synthetic green tea analogue, which would be marketed as a weight-loss aid. We can simply buy standardized green tea extract now (as thousands do).

    @Paddy: Real progress is being made in the identification of plant constituents – Now comes DNA Barcoding. Google this article:
    DNA: A New Frontier in Botanical Identity Testing

  42. Bogeymama says:

    Davdoodles said: Sorry, off-topic and maybe you’ve seen this before, but this interview by Sanjay Gupta with Bill Gates is pretty awesome. Gates rips in the the Pro-Polio-and-Cervical-Cancer Cult with cool precision:

    THANK YOU for that! I had not seen that. I am a little bit in love with Mr. Gates now. That he had the cajones to call anti-vaxers “child-killers” shows that he isn’t trying to appeal to the masses. He gets it. He is also pretty untouchable in terms of his power, so he has nothing to lose, right? Unlike Dr. Oz, who continues his fall into woo with Northrupe on his show today, among others.

  43. Scott says:

    Congratulations, you found one example. Now please proceed to demonstrate that this happens “often” as you claimed.

    While you’re at it, also demonstrate why green tea is superior to a combination medication containing catechin-polyphenols and caffeine.

  44. “this interview by Sanjay Gupta with Bill Gates is pretty awesome. Gates rips in the the Pro-Polio-and-Cervical-Cancer Cult with cool precision:”

    Great interview, thanks for the link. Good to see that Bill Gates is using his powers for good rather than evil these days. :)

  45. Joe says:

    @Jeff on 07 Feb 2011 at 6:08 pm wrote “… @Scott: With production methods becoming more sophisticated, botanicals are increasingly sold as standardized extracts. For example one typical green tea extract product lists this:

    Green Tea (Camellia sinensis): 725 mg.
    Decaffeinated Extract (leaf) [std. to 98% polyphenols by UV (710.5 mg), 45% EGCG by HPLC (326.25 mg)]

    So, what does that mean in terms of health care? Are you claiming that these are the proper amounts to achieve some effect? I must admit that it does look impressively sciencey. (Except for the part where it is 98% of one thing and 45% of another- which is reminiscent of Reaganomics.)

  46. Joe says:

    @Alison Cummins on 08 Feb 2011 at 6:33 pm wrote “Well, one of the arguments for herbalism over medicine is that if you can make do with what you can grow or gather in most situations, you are less dependent.

    Sure, maybe sassafrass or willow is less pure or unpredictably potent. …

    Those of us who disdain acquiring cancer have not used sassafras for a while.

  47. Joe says:

    @Jeff on 08 Feb 2011 at 9:58 pm wrote “Many human trials have shown green tea extract is quite safe …

    But, effective for what, exactly (with citations)?

  48. David Gorski says:

    Here’s one animal study which concludes that catechin-polyphenols and caffeine (both constituents of green tea extract) work synergistically to promote brown fat thermogenesis:
    http://www.nature.com/ijo/journal/v24/n2/full/0801101a.html

    Of course, I didn’t say that there weren’t examples, only that they were not common and proving them was difficult.

  49. Jeff on the nifty advantages of “natural” and the nastiness of scientific trials: “Many human trials have shown green tea extract is quite safe – research should continue until we know exactly how green tea works. But we don’t need to wait 15 years for a pharmaceutical company to come out with a high-priced synthetic green tea analogue, which would be marketed as a weight-loss aid. We can simply buy standardized green tea extract now (as thousands do).”

    A standardized green-tea extract is the use of a plant as a drug-delivery vehicle.

    The only advantage you are citing for the use of standardized green-tea extract over synthetic (and purer) forms of the identical chemicals is that the burden of proof is lower. Until standardized green tea extract has been held to the same standard of proof as Vioxx, no, we do NOT know that it is “quite safe.”

    In that vein, see:
    http://www.medscape.com/viewarticle/720021

    You want research to elucidate how green tea works, but a brief glance at the literature does not convince me that there is serious clinical evidence that it does work.

    Is this how you think prescription drug companies should work? Come up with something that they hope might work maybe, make it available in a form that they think makes sense to them, distribute it and then try to figure out whether it works or not for anything, and if so — how? Oh, and of course consumers should let them know if it slightly increases the risk of heart attack or something.

    No? Then why do you think that by using a plant extract as a drug delivery system you should be able to get around the very reasonable requirements imposed on prescription drug requirements?

  50. pmoran says:

    Jeff,what knowledge concerning green tea stems from CAM, or from traditional use? I am not aware of any.

    The point to be made here is that the NCCAM is not likely to turn up any useful herbal products. The bones of traditional herbalism have already been fairly well picked over, and that is all that modern Western CAM has ever had to draw from.

    Useful herbal products will continue to turn up, but almost certainly through the application of modern screening technology within the well-funded research of drug companies.

  51. Joe says:

    pmoran on 09 Feb 2011 at 4:33 pm wrote “… The bones of traditional herbalism have already been fairly well picked over, and that is all that modern Western CAM has ever had to draw from.

    That is well-said. Moreover, I worry that actual effective uses of herb-derived drugs will be missed if one concentrates on “traditional” uses. Certainly taxol was not used by indigenous people for cervical cancer.

  52. Dr Benway says:

    NCCAM’s copywriter is trying to kill me with this overly vague marketing bullsh_t.

    But at least he or she does say “effective, practical…” rather than the more LRH idiomatic, “effective, workable…”

    Thank you, Charles Philip Arthur George, Penny George, William George, and the several billionaire friends among your New Age set, for helping so many of the feeble minded to find gainful employment within the medical institutions of our two great nation-states.

  53. Jeff says:

    Here’s a recently posted article which suggests that studying the synergistic effects of various constituents in a single botanical substance (in this case tumeric root) could be a friutful avenue of research:

    http://www.life-enhancement.com/article_template.asp?ID=2403

  54. Harriet Hall says:

    @ Jeff,

    “studying the synergistic effects of various constituents in a single botanical substance (in this case tumeric root) could be a friutful avenue of research”

    It could be, but historically it is difficult to find an example of true synergistic effects where the whole substance was found to work better than the isolated active ingredient. The other constituents are more likely to have no effect or to interfere than to enhance the effectiveness.

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