Margaret McCartney wrote about the placebo effect on this blog earlier in the week, in the context of the Commons Science committee recommending that the NHS should not pay for homeopathy.
Coincidentally The Lancet has a fascinating long review of placebos, looking at the clinical evidence and ethical considerations.
The authors, led by Damien Finniss of the University of Sydney, point out that placebo effects are “genuine psychobiological events” which can be produced in both laboratory and clinical settings.
A key conclusion is that there are many different placebo effects, depending on circumstances.
On February 22nd the UK government Science and Technology Committee published Evidence Check 2: Homeopathy and concluded that “the NHS should cease funding homeopathy”. Hurrah!
It also noted that ”the Medicines and Healthcare products Regulatory Agency (MHRA) should not allow homeopathic product labels to make medical claims without evidence of efficacy. As they are not medicines, homeopathic products should no longer be licensed by the MHRA.” Hurrah again.
But this is the really really interesting bit. “In the Committee’s view,
homeopathy is a placebo treatment and the government should have a policy on prescribing placebos.”. They go on to say that placebos involve deception, and are not consistent with informed consent.
To which I say: no, no, you miss the point.
I am the first to accept that modern medicine is not always good: lots of it is still unproven, or weakly proven, and in general use: and it has taken a very long time for doctors to realise that good intentions are not enough.
One has to have evidence of benefit and knowledge of harms: and to inform the patient of these and the uncertainties connected with treatment.
But – this only applies, it seems, if you are a regulated doctor. If you are dealing in unproven medicine, and your intentions are good, then it doesn’t really seem to matter whether your treatments work, or even if they give you cancer or renal failure.
This report on the judgement from the UK Old Bailey on a practitioner of Chinese medicine – Chinese herbal pills destroyed UK woman’s health – quotes the judge as saying “Although the MHRA did their best to try and make sure everybody knew about the dangers and about the regulations, it is not a foolproof system and I am certainly not blaming you for the fact you didn’t know about these regulations”.
This seems really rather a mystery of logic to me. If I set up a shop selling erratically behaving electrical goods which had a habit of giving the odd fatal electric shock, would I not be in some way responsible for my actions?
An interesting paper from the Annals of Asthma, Allergy and Immunology – Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients
People with bad asthma who took herbal remedies were more likely not to take their prescribed medication (not surprisingly) and have worse symptoms.
So is this just a case of people who don’t like conventional medication trying to find something alternative and as good, and failing to find it? That seems a reasonable explanation.
But could it be that the herbal medicines are in some way making asthma worse? It is worth considering, especially as many people will say that even if they don’t work “they won’t do any harm”. By making people think that herbal medicines work, they may end up not taking medicines which are of benefit.
Cannabis and the law have a clear relationship; to take the former is to break the latter. For years, pressure has been mounting on the government to change this position. And not just for recreational reasons, but medical ones too. It is often claimed, for example, that cannabis improves the lives of multiple sclerosis sufferers.
A recent systematic review of the evidence in BMC Neurology found that cannabis did help alleviate spasticity, the uncomfortable cramp that can become constant in MS, making affected limbs hard to use. But while patients reported an improvement following treatment, objective measurements did not show any significant change.
Spasticity may not be affected by cannabis; the drug may instead be treating muscle tension and discomfort. That doesn’t mean cannabis is not useful. Indeed, another review published last year in Pain Medicine found that “cannabis treatment is moderately efficacious for the treatment of chronic pain”. But it also noted that “beneficial effects may be partially (or completely) offset by potentially serious harms”.
Continue reading “Leaf that brings relief”
Miracles and medics are unlikely bedfellows, especially when the mattress is hard, unforgiving and demands a weight of evidence. Doctors witness unlikely things all the time in the normal swing of medical life, and it is usually difficult to seduce them into the opinion that unseen hands were at work.
The Roman Catholic Church itself imposes strict liturgical standards before it declares a miracle. Take, for example, the case of Jack Sullivan, a 71-year-old American deacon who had spinal surgery in 2001, in a bid to stop his vertebrae impinging on his spinal cord. His condition had been deteriorating towards paralysis, but at operation, his case was discovered to be hopeless. The fault in the spine was much worse than thought. Sullivan prayed to Cardinal John Henry Newman, a 19th century convert to Roman Catholicism – and recovered. Sullivan’s surgeon told him: “Jack, there’s no medical explanation for what happened to you: if you want an answer, ask God!”
Continue reading “Magical medicine”
Yes, because evidence is the only way medicine gets better. Yes, because people have sometimes died, or had risky procedures, or endured more suffering, because of the application of opinion-based, fashion-set meandering through all the medical interventions that imagination has to offer. Yes, because time, money and effort is wasted when people are given non evidence based treatments by healthcare practitioners.
Nevertheless, the careers section of the British Medical Journal website devotes some uncritical space to careers advice about osteopathy. The doctor describing his decision to pursue a qualification in the discipline – he now combines medicine with osteopathy – says that since the UK National Institute for Health and Clinical Excellence recommend it, it should be done.
But this isn’t, I don’t think, good enough: mainly because the evidence for treating back pain, which is the specific Nice recommendation he refers to, is complicated by the fact that the great bulk of back pain will get better no matter what doctors do or don’t do.
More importantly, a systematic review of systematic reviews of spinal manipulation a review of systematic suggests that ”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.”
There remains the concept that doing more in medicine is always better. In truth, doing can be far more evidence based.
Last Saturday, How To Spend It ran an interview with Professor Susan Greenfield, who is famous as a neuroscientist and a life peer. And she says that one of the “grooming staples I’m never without [is] Boots No 7 Protect and Perfect Intense Beauty Serum (£19.75) – it is, they tell us, clinically proven to reduce wrinkles. And I believe it.”
If Baroness Greenfield is having trouble sorting the science from the spin….oh dear. I wrote about this face cream earlier this year. Since the conclusions of the scientists studying this cream were that the improvement in appearances between the placebo cream and the No 7 cream were “not statistically significant”, I felt it wasn’t the breakthrough it was being touted as.
Links to previous interviews by Margaret McCartney:
Professor David Colquhoun, professor of molecular pharmacology and campaigning blogger
Dr Tom Jefferson and pandemic flu vaccines
Two things in particular made me want to talk to Richard Bandler, the American co-creator of “neuro-linguistic programming”. The first is that an email arrived from his PR agency in London, entitled “Richard Bandler: Shrinks are a waste of money”. It went on:
“His method is to teach the depressed, stressed or disillusioned to dispose of their poisonous memories, their fears and self-doubt, by exploring how we think, communicate and behave, changing negatives into positives by adopting more successful ways of using the mind. Richard, whose techniques have successfully helped millions of people, including billionaires, sports stars, celebrities and the mentally ill, says: ‘… They come to me in desperation – and often, I only need to see them a couple of times to re-program their thinking and give them a whole new outlook on life, success and happiness.’”