In order for medication to work, getting a prescription filled isn’t enough. You have to actually take the medication. And that’s where you (the patient) come in. Estimates vary based on the population and the medication, but a reasonable assumption is that 50% of people given a prescription don’t take their medication as prescribed. In pharmacy terminology we usually call this medication compliance, but because that sounds a bit paternalistic, the term medication adherence is also used. People forget doses, deliberately skip doses, and sometimes even take more than directed. Often, the prescription isn’t finished completely. Perhaps not surprisingly, people are less likely to adhere to their prescribed medication schedule when the condition they are treating has no symptoms. All things being equal, you’re more likely to take your pain control medicine than your hypertensive medications: Pain medications have side effects, but should help you feel better right now. Hypertension medications can only make you feel worse. Statins (as a group of medications) are another good example. We treat high cholesterol to lower the risk of heart disease: heart attacks, strokes, and death. It has no obvious benefit now, nor will we ever be able to point to the benefit we received. We’re taking the medication to reduce the risk of something happening in the future. If the drug isn’t taken regularly (or at all) then you’re not going to get the expected benefits of statin therapy. The “value” that treatment delivers is reduced (or eliminated). And if you stop a medication periodically, then restart it, you might get more side effects than you would have if you just took it regularly. (more…)
The biggest challenge we face promoting high standards of science in medicine is not making our case to the community. Our case is rock solid, in my opinion, and backed by evidence and logic. There is no question, for example, that homeopathy is 100% bogus and should not be part of modern medicine.
Our challenge is that there are literally billions of dollars to be made selling fake medicine and dubious treatments. This means that unscientific practitioners have an immediate financial incentive to promote themselves and their treatments, and they will tirelessly do so, on any front they can find. Further, the stars of unscientific medicine have the resources to do so – to intimidate critics, cozy up to politicians, open centers in respected hospitals, and market their brand.
We simply don’t have the manpower to confront them on every front, and the mainstream scientific and medical communities are frankly just not paying enough attention. They are largely unaware that pseudoscience is infiltrating their profession right under their noses, or they have been lulled into thinking this is a small and benign phenomenon.
These many fronts in which science confronts pseudoscience include the media, hospitals, continuing education, journals, the marketplace, politics and regulation, and research funding.
The complete sequencing of the human genome by the Human Genome Project was a remarkable accomplishment and a cause for celebration. Several companies including 23andMe, Navigenics, and deCODE have capitalized on that scientific achievement by offering genomic testing directly to the public. They promise more than they can deliver, and consumers don’t understand the limitations of the test results. The subject has been covered in several SBM articles.
One of the expected benefits of genomic testing is that if people knew they were at high risk of a disease, they would take preventive steps to reduce their risk. That seems plausible; but a recent study, a systematic review in the BMJ (formerly the British Medical Journal) calls that assumption into question. It found that communicating DNA-based disease risk estimates did not increase risk-reducing health behaviors or motivation to engage in such behaviors.
Stem cells are magical. Stem cells are all-powerful. Stem cells cure everything. Stroke? No problem! Paralysis? Stem cells’ll fix it. Autism? Yes, even autism.
That’s the narrative one frequently hears about stem cells in the press and courtesy of offshore stem cell clinics and direct-to-consumer marketing of stem cells in the US. Of course, stem cells aren’t mystical and magical, although they are very promising as a treatment for some degenerative conditions. As promising as they are, though, they don’t cure everything. In fact, we don’t even know for sure that they cure anything because for the vast majority of conditions for which stem cells are used in these clinics, they are still at best experimental and at worst completely unproven. In fact, at their worst, they can do great harm.
I learned about the unrelentingly positive spin the media tend to place on stem cell treatments when I first started blogging about Gordie Howe’s stroke and Dr. Maynard Howe (CEO) and Dave McGuigan (VP) of Stemedica Cell Technologies reached out to the Howe family to see if it could help him with its products. When Howe and McGuigan discovered that Howe was not eligible for any of their US clinical trials, they facilitated Howe’s receiving an unproven stem cell therapy through one of its partners in Mexico, Novastem, which uses Stemedica stem cell products to treat patients in its clinic, Clínica Santa Clarita. In the ultimate bit of privilege for a sports hero (or, as I saw it at the time and as it ultimately turned out, an excellent investment for marketing and advertising of Stemedica products) Gordie Howe even received the treatment for free, even though Clínica Santa Clarita charges everyone else around $30,000. Let’s just say that I didn’t find the explanations for waiving this rather massive fee in Gordie Howe’s case to be persuasive, and I was rather disturbed at the entitlement expressed by Howe’s son over it, who didn’t see the ethical problem at all. Nor did I find the excuses given by Stemedica and Novastem for why their clinical trial protocol in Mexico was so substandard.
It turns out that this new, poorly regulated industry operates a lot like the many quack cancer clinics that I’ve blogged about over the years and like a lot of other dubious businesses, such as multilevel marketing scams. This comes in the form of a recent paper in Stem Cells Translational Research by Paul Knoepfler, who describes attending a marketing seminar.
[Editor’s note: Mark Crislip is taking a well deserved vacation from blogging, and James Thomas has kindly agreed to provide another guest post to fill the gaping need left in all of your lives. Enjoy!]
According to the Orwellian-named National Center for Complementary and Integrative Health, roughly 33% of adults aged 18-44 and about 37% aged 45-64 use some form of CAM. More disturbing is that 12% of children aged 4-17 used some form of CAM in the last 12 months. If there is good news, it is that the NCCIH takes a broad view of “complementary health approaches” including acupuncture, Ayurveda, biofeedback, chelation therapy, chiropractic care, energy healing therapy, special diets (including vegetarian and vegan, macrobiotic, Atkins, Pritikin, and Ornish), folk medicine or traditional healers, guided imagery, homeopathic treatment, hypnosis, naturopathy, non-vitamin, non-mineral dietary supplements, massage, meditation, progressive relaxation, qi gong, tai chi, and yoga. In fact these approaches range from the wacky (energy healing therapy, homeopathy) to the mainstream (massage, yoga) with nothing alternative about them. With more than 60 million Americans using some form of CAM, it is fair to ask if we can build a case for truly integrating CAM into mainstream medical practice.
So who are these people using CAM and just what are they using it for? CAM users can be found in almost every demographic but the largest cohort is white, female, and fairly well educated. A good deal of CAM is used for common and often vague conditions with back pain being the most commonly cited. But it is also used by cancer patients, for cardiovascular disease, and even for Alzheimer’s disease. The problem is that none of the CAM approaches are useful for any of these conditions; strike that, none of the CAM approaches are useful for anything at all much beyond placebo.
I’m going to keep this essay down to a more reasonable length than my earlier offerings (pauses here for the applause to fade) so I’m not going to talk much about most CAM “modalities.” Reiki is deconstructed here and here, or for those who just want a Crislipian good time, here. Homeopathy is eviscerated here. For the deeper dive go here, or for the full monte, here. If after that you still have questions about homeopathy you should probably get a hobby.
But wait, there’s more!
Chiropractic, and acupuncture, and hypnosis, and chelation, and, and…go to the masthead and enter the CAM of your choice in the box with the little magnifying glass. If some charlatan has offered it as a medical treatment, this is your gateway to good information about it. But (and that ‘but’ was your spoiler alert), none of it has much impact on any measurable medical condition. CAM does not shrink tumors, CAM does not dilate bronchi, CAM does not strip pounds of icky toxins out of your colon. Those claims and most others are easily dismissed by anyone with basic reasoning skills and the URL for Pubmed (here it is: http://www.ncbi.nlm.nih.gov/pubmed).
There are however, two arguments in favor of CAM that deserve a bit more careful consideration: electro-acupuncture for pain relief through the mechanism of stimulating endorphin release, and the more general argument that many patients have needs unmet by the medical mainstream, often psycho-social needs that do not have an ICD-10 (a type of diagnostic code) and for which no treatment infrastructure exists within the mainstream health care delivery system. These are the cases I’ll try to build today. (more…)
In my career as a pharmacist I’ve answered a lot of questions about medication use in pregnancy. Pharmacists are among the most accessible health professionals, and we’re usually found near a wall of medicines and supplements. Many don’t trust Dr. Google, and for good reason: There are conflicting answers online. When it comes to medication use in pregnancy and effects on the fetus, we have no perfect data. Since no-one is randomizing women to drug treatment or placebo, we must rely on weaker, less definitive evidence. An appropriate response from a health professional will describe known risks and expected benefit, summarizing what we know, and how confident we are in that answer. One of the most popular drugs used in pregnancy is acetaminophen (sometimes called paracetamol or APAP), and commonly known by the brand name Tylenol. An emerging concern with acetaminophen is whether use during pregnancy raises the risk of attention deficit hyperactivity disorder (ADHD) and related behavioural problems. While I covered this question once, back in 2014, there’s a new paper that’s putting this issue back in the news. From Evie Stergiakouli and colleagues is the paper, “Association of Acetaminophen Use During Pregnancy With Behavioral Problems in Childhood: Evidence Against Confounding“, published this week in JAMA Pediatrics. (more…)
The definition of “propaganda,” like so many things, is a bit fuzzy. The dictionary definition is: “information, especially of a biased or misleading nature, used to promote or publicize a particular political cause or point of view.” There is no sharp demarcation line, however.
Speech occurs on a spectrum from obsessively objective, fair, balanced, and scholarly at one end, to deliberately deceptive and manipulative propaganda at the other. Most speech is somewhere in the middle. We are all coming from a certain narrative, one which we believe is valid and important, and often speech is meant to be persuasive.
Persuasive speech promoting a point of view or certain conclusion is fine – it does not necessarily deserve the label of propaganda. The fuzzy line gets crossed, however, the more logic and evidence are compromised for the sake of the narrative. (more…)
The publisher recently sent me a review copy of Quackery: The 20 Million Dollar Duck, by Tony Robertson. My first thought was “Do we really need another book on this subject? Don’t I know all this stuff already?” I was very pleasantly surprised. Robertson has ferreted out an impressive array of facts and details that I wasn’t aware of; and yes, we need as many good books on the subject as we can get. Each author has a somewhat different approach that may appeal to a different audience. Robertson’s book is a worthy addition to the canon. He is a retired gynecologist who practiced, taught, and still lives in Zimbabwe. He is a critical thinker who understands and promotes science-based medicine, and he brings a unique perspective, especially on subjects related to his specialty. The book is not just about charlatans, it’s about non-science-based practices wherever they are found, including in mainstream medicine and in Robertson’s own field of obstetrics and gynecology.
I expected to like the book after I read the Dedication “To those who appreciate the truth fairy rather than the toothed one” and the Acknowledgements: “To my teachers and mentors who encouraged me to think, always to question and only to accept where there is good evidence.” That could serve as a motto for all skeptics, scientists, and critical thinkers to live by: Think, question, and only accept where there is good evidence. (more…)
I’ve not infrequently written about various dubious and outright quack clinics in different parts of the word with—shall we say?—somewhat less rigorous laws and regulations than the US. Most commonly, given the proximity to the US, the clinics that have drawn my attention are located in Mexico, most commonly right across the border from San Diego in Tijuana for easy access by American patients. Sometimes, in the case of dubious stem cell clinics, they are located in countries like China, Argentina, or Kazakhstan. That’s not to say that there aren’t a lot of quack clinics right here in the US (particularly for stem cell treatments), but, by and large, the clinics doing the truly dangerous stuff tend to be less common in the US.
There is, however, another country where alternative medicine clinics, particularly for cancer, are common and thriving, specifically Germany. I first learned of these clinics when the story of Farrah Fawcett’s battle with anal cancer hit the news nine years ago. Ultimately, she died of her disease at age 62, but before she did she sought treatment at a clinic in Germany, which administered alternative treatments as well as radioactive seed implants, the latter of which, despite sounding nice and “conventional,” were not standard-of-care for recurrent anal cancer. What this led me to learn is that German alternative cancer clinics tend to use both alternative medicine and experimental “conventional” medicine that has not yet been shown to be safe and effective in clinical trials.
I thought of Farrah Fawcett when news about a German cancer clinic hit the news again beginning more than a week ago, when two patients from the Netherlands and one from Belgium died shortly after having undergone treatment at the Biological Cancer Centre, run by alternative practitioner Klaus Ross in the town of Brüggen, Germany. Two others were hospitalized with life-threatening conditions. I didn’t blog about them at the time because the only reports I could find were those sent to me by readers, and they were in German or Dutch. They also didn’t have a lot of detail. Both reported that on July 25, a 43-year-old Dutch woman went to the Biological Cancer Center in Brüggen-Bracht for treatment of breast cancer and that she unexpectedly died on July 30 of unknown causes. The Dutch report stated that the death occurred under mysterious circumstances and that there were two other deaths, that of a Belgian woman the week before, and a Dutch man.
Elsewhere, Irish newspaper TheJournal.ie reports:
Dutch police, who are supporting the inquiry, appealed for information from other patients, as newspapers reported the clinic had been using an experimental transfusion.
Concern was first raised when a 43-year-old Dutch woman with breast cancer complained of headaches and became confused after being treated at the clinic on 25 July.
She later lost the ability to speak, and died on July 30 although the “cause of her death remains unclear,” the German prosecutors said in a statement earlier this week.
Later, it was learned that the identities of the suspected victims were Joke Van der Kolk, age 43; Leentje Callens, age 55; and Peter van Ouwendorp, age 55.
Unfortunately, the early reports were fairly basic, without much detail, and only a couple with any names. Fortunately, now there is an article in Science that reports more. It turns out that the suspected cause of death is an experimental cancer drug known as 3-bromopyruvate (3-BP) that has not yet been approved for use in humans. So what happened?
In June, an article in the Boston Globe covered yet another incursion of pseudoscience into a major academic medical center, this time at the Dana-Farber Cancer Institute. Dana-Farber, located just a couple of miles from the library where I’m writing this post, has provided world-class care for children and adults with cancer since 1947. It’s kind of a big deal.
Sidney Farber, already known as the “father” of pediatric pathology, was the first person to induce remission in pediatric acute lymphoblastic leukemia, which had a 100% mortality rate up to that point. He then went on to earn the title of “father” of modern chemotherapy by also curing Wilm’s tumor, a rare pediatric cancer of the kidneys. Farber, who was featured in the phenomenal book The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, would almost certainly be opposed the double standard being employed to justify quackery in the facility bearing his name (or anywhere else).
To Farber, a scientific approach to treating pediatric cancer patients was paramount, even to the point where he at first refused to initiate the combination therapy that would open the age of modern chemotherapy because he wanted to protect children from a potentially haphazard rush to cure them. He wanted strict scientific protocols in place and assurances that the evidence would be followed regardless of the outcome, so that the intense desire to find a cure for children that otherwise faced only suffering and death would not add to that suffering. (more…)