I’m a dog person. I always wanted a dog as a child, and while my extended family all had dogs, we never had one in our home. I finally got my wish just over a decade ago. My wife and I were referred to a breeder with an excellent reputation for raising healthy, family-friendly Labrador Retrievers. Within moments of meeting a tiny black lab, we immediately put a deposit down. When we took Casey home a few months later she was healthy – a ball of kinetic energy. The breeder offered us a health guarantee – free of hip and elbow dysplasia, supported by certifications from the dog’s parents and grandparents. The breeder recommended we use a specific brand of food (which we ignored), and other than vaccinating her and promising not to breed her, there were few conditions for the guarantee. We were excited “parents” and that first year was a lot of fun.
At about 12 months of age, Casey started limping. At first we thought it was a temporary consequence of boisterous play. It was initially subtle, but then became very obvious – she started walking differently, and it didn’t go away. The x-rays confirmed what we feared: elbow dysplasia. Our breeder was deeply apologetic – consistent with the guarantee, she offered to replace our dog. Giving up our pet was out of the question, so we started looking at treatment options. The veterinarian offered surgery, but even he wasn’t enthusiastic, citing the very real likelihood it would do nothing. Knowing the toxicity of anti-inflammatory drugs, I wasn’t optimistic that would be tolerable for the long run. Instead we went the supplement route. (more…)
Not Dr. Oz’s usual television audience
Dr. Mehmet Oz is one of the most well-known, and possibly the most influential medical doctor in America. The Dr. Oz Show is broadcast in 118 countries and reaches over 3 million viewers in the USA alone. When Oz profiles a product or supplement on his show, sales explode – it’s called “The Dr. Oz Effect”. Regrettably, Oz routinely and consistently gives questionable health advice, particularly when it comes to weight loss products, where Oz regularly uses hyperbolic terms like “miracle” for the products he profiles:
- (On green coffee extract) — “You may think magic is make-believe, but this little bean has scientists saying they found the magic weight-loss for every body type.”
- (On raspberry ketone) — “I’ve got the number one miracle in a bottle to burn your fat”
- (On Garcinia cambogia) — “It may be the simple solution you’ve been looking for to bust your body fat for good.”
Dr. Oz has profiled so many dubious health strategies that “The Dr. Oz Effect” more accurately refers to the wasted time, effort and finances of any consumer that actually follows his health advice and purchases the steady stream of “miracles” that Oz endorses on his television show. Not surprisingly, Science-Based Medicine is probably Oz’s most persistent and tenacious critic. It’s not just that he’s high profile – it’s that Dr. Oz is a bona fide physician who ought to know better, but chooses to ignore science in favour of hyperbole. It’s the antithesis of what a health professional should be doing. And this is the root of the Oz problem: Oz can give good advice, but he regularly combines it with questionable statements and pseudoscience in a way that the casual viewer can’t distinguish between the science and the fiction. So when Oz calls something a miracle – people listen. Even when miracles show up several times per year. (more…)
The Canadian Parliament, hypothetically protecting consumers since Confederation.
One of the most pervasive yet appealing health myths is the idea that natural equals safe. It’s a statement that’s repeated constantly by manufacturers of supplements and “natural” health products. It’s been the primary argument used, with considerable success, to give these products completely different regulatory structures than exist for drug products. Weaker regulation of supplements and natural health products has been a boon to manufacturers, but the same can’t be said for consumer protection. It’s effectively a buyer-beware marketplace in most parts of the world, with little accurate information available to consumers. But supplement manufacturers aren’t content with the minimal regulation that’s currently in place – they want health “freedom”. In this case, “freedom” means the right to sell any product, while being exempted from safety and regulatory requirements. New Canadian legislation is poised to raise safety standards for drugs and enhance the ability of regulators to recall dangerous products, yet consumers of natural health products are left behind. The legislation proposes to exempt anything considered a “natural health product”. This is not only bad public policy, but it has the potential to cause avoidable harm. After all, shouldn’t users of supplements and natural health products be entitled to the same safety and quality standards as those that use prescription drugs? If the supplement industry gets its way, the answer will be “no”. (There is an opportunity until June 10 for you to provide feedback on this legislation – see below.) (more…)
Imagine a retail pharmacy where some of the medicines on the shelves have been replaced with similar-looking packages that contain no active ingredients at all. There is no easy way to distinguish between the real and the fake.
Another section of the store offers a number of remedies with fantastic claims, such as “boosting” the immune system, “detoxifying” the body, or “cleansing” you of microscopic Candida. They look sciencey, unless you realize that they treat imaginary medical conditions.
A corner of the store offers unpurified drugs supplied as tinctures and teas. The active ingredients aren’t known, and the batch-to-batch consistency of the product is unclear. The store will suggest products for you based on your symptoms.
Walk past the enormous wall of vitamins and other supplements and you’ll find a nutritionist who will tell you what products you should be taking. You’ll also find a weight loss section. From a science-based perspective, this shouldn’t even exist, given no product has been shown to offer any meaningful benefit. But there are dozens of products for sale.
At the back of the store you’ll finally find the pharmacist. A sign on the counter offers blood- and saliva-based tests for food “intolerance” and adrenal “fatigue”, claiming to test for medical conditions that actually don’t exist or lack an evidence base. The pharmacy also offers a large compounding practice, advertising what it calls “personalized” approaches to hormone replacement with “bioidentical” hormones.
Welcome to the “integrative” pharmacy.
You may not see all these features in your local drug store, but they’re coming: claims of a new “integrative” way to provide health care that is changing the face of retail pharmacy. Unfortunately, it’s harkening back to the era of patent medicines and snake oil. It’s not good for the pharmacists and the profession of pharmacy, and it’s even worse for patients. (more…)
Do you take a vitamin or dietary supplement? It’s increasingly likely that you do, as over half of all American adults took some sort of supplement over the past 30 days. Now there’s evidence to suggest that about one-third of all Americans are taking supplements and prescription drug at the same time, which is renewing questions about risks and benefits. The same study reveals that combining supplements and prescription drugs is more common among those with certain medical conditions, compared to those without.
Many of us supplement in the absence of evidence of benefit, or even medical need. For example, there is little persuasive evidence to suggest that routine supplementation with products like multivitamins is necessary. There are exceptions of course: Those potentially becoming pregnant, those on dietary restrictions (e.g., vegans), and those with demonstrable medical need are among the cases where there is a clear benefit to vitamin supplementation, for example. The majority of us take supplements, like multivitamins, for “insurance” rather than because we have a deficiency or medical need. The evidence for non-vitamin supplements, like herbal products, is just as questionable as it is for vitamins, with few products showing meaningful health benefits. Ultimately decisions about supplements come down to evaluations of risk and benefits. Since I started working as a pharmacist, I’ve always cautioned consumers about the quality concerns and efficacy with herbal products and supplements, and the resultant risks that make me very hesitant to suggest their routine use – especially when they’re combined with prescription drugs. Yet the evidence suggests that it’s occurring – with increasing frequency. (more…)
We saw it coming. The re-emergence of vaccine-preventable disease should surprise no-one that’s been following the anti-vaccine movement.
Rebutting anti-vaccine rhetoric feels like a Sisyphean struggle. Steven Novella likened it to a game of whack-a-mole, where the moles are the same old tropes that keep popping up, no matter how often they are refuted with facts. Vaccines are a remarkable success of modern medicine: They are health interventions that are both demonstrably effective and remarkably cost-effective. Vaccination has likely prevented more deaths in the past 50 years than any other health intervention. Smallpox was a ruthless killer that took 300 million lives, just in the 20th century alone. Today it’s gone – eliminated forever. And now there are now over two dozen diseases that are vaccine-preventable. They should be an easy sell, and to most people, they are. But the control of vaccine-preventable disease relies in part on herd immunity – sufficient immunization to stop the spread of infection (no vaccine offers 100% protection) and protect those that cannot be immunized. Even a modest number of unvaccinated individuals can lead to reemergence of disease. None of this matters to antivaccinationists, to whom vaccines are bad. Viewing anti-vaccine websites for only five to ten minutes can increase the perception of risk of vaccination, and decrease the perceived risk of omitting vaccines. It also lowers vaccination intentions. By changing perceptions of safety, the willingness to vaccinate decreases. Now imagine that someone you believe to be a health professional openly questioned the efficacy and safety of vaccines – would it reduce your willingness to vaccinate? The evidence says it does. And that’s why the modern practice of naturopathy or “naturopathic medicine” is so concerning. Naturopaths have opposed vaccinations since the invention of naturopathy – starting with smallpox: (more…)
Does Tamiflu have any meaningful effects on the prevention or treatment of influenza? Considering the drug’s been on the market for almost 15 years, and is widely used, you should expect this question has been answered after 15 flu seasons. Answering this question from a science-based perspective requires three steps: Consider prior probability, be systematic in the approach, and get all the data. It’s the third step that’s been (until now) impossible with Tamiflu: Some data was unpublished. In general, there’s good evidence to show that negative studies are less likely to be published than positive studies. Unless unpublished studies are included, systematic reviews are more likely to miss negative data, which means there’s the risk of bias in favor of an intervention.
The absence of a full data set on Tamiflu (oseltamivir) and the other neuraminidase inhibitor Relenza (zanamivir) became a rallying point for BMJ and the AllTrials campaign, which seeks to enhance the transparency and accessibility of clinical trials data by challenging trial investigators to make all evidence freely available. (Reforming and enhancing access to trial data was one of the most essential changes recommended by Ben Goldacre in his book, Bad Pharma.) In 2009, Tamiflu’s manufacturer, Hoffman-La Roche committed to making the Tamiflu data set available to investigators. Now after four years of back-and-forth between BMJ, investigators, and Roche, the full clinical trials data set has been made freely available. An updated systematic review was published today in BMJ (formerly The British Medical Journal), entitled “Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments.” This will be a short post covering the highlights. As the entire study and accompanying data are freely available, I’ll await continued discussion in the comments. (more…)
“Will Tylenol harm my baby?”
Pharmacists are among the most accessible of health professionals, and so we receive a lot of questions from the public. No appointment required, and the advice is free. Among the most frequent sources of questions are women seeking advice on drug use in pregnancy. This is an area where some health professionals are reluctant to tread. Some prefer to redirect all of these questions to physicians. But physicians are not always easily accessible, and few want to make an appointment just to ask what appears to be a simple question: Is it safe, or not? Admittedly, addressing questions about drug use in pregnancy can be challenging. There are no randomized controlled trials we can look to — there’s only messier, less definitive data. Our responses are filled with cautious hedging about risk and benefit, describing what we know (and don’t know) about fetal effects. In the pharmacy, one of the most common questions from pregnant women is about the use of acetaminophen (aka paracetamol aka APAP), more commonly known by the brand name Tylenol. Google “Tylenol and pregnancy” and you get 4.8 million results. Which source should you trust? (more…)
I glanced at my pharmacy license recently, and noticed I became a licensed pharmacist almost exactly twenty years ago. Two decades seems like a long time to do pretty much anything, yet I can still vividly recall some of the patients I encountered early in my career, working evenings in a retail pharmacy that drew heavily on the alternative medicine crowd. It was the first pharmacy I’d ever seen that sold products like homeopathy, detox kits, salt lamps, ear candles, and magnetic foot pads. And the customers were just as unorthodox. There were some that told me they manipulated their own pH, and others that insisted any prescription drug was designed to kill. And there was a huge clientele that relied on the pharmacy for their “bioidentical” hormones. It was an instructive learning experience, as it was as far from the science of pharmacy school as you could expect to find in a place that still called itself a pharmacy. One of the really interesting aspects of that pharmacy was the enormous supply of vitamins and supplements for sale. It stretched over multiple aisles and even back into where the drugs were kept, as there were some brands kept behind the counter. This wasn’t for any regulatory reason – it was because these were the “naturopathic” supply, the brands often recommended by naturopaths. In order for this pharmacy to sell them they had to keep the products behind the counter, presumably to grant these supplements a veneer of medical legitimacy. After all, they were “special”, and had the prices to prove it. (more…)