Sunday, May 13, 2007

Can complementary and alternative medicine be subjected to scientific scrutiny?

It’s often said that the debates over alternative medicine are pointless because there is really no alternative medicine; there’s only medicine that has been proven to work and medicine that hasn’t. At first glance the notion seems sound. Simply subject an alternative claim to scientific investigation. If it proves out it becomes mainstream, otherwise it is rejected. If only it were so simple! The reality is that little has been settled despite many years and hundreds of millions of dollars devoted to alternative medicine research. I offer examples here of why this is so.

Promoters of unscientific claims often reject ordinary scientific standards for experimental design and evidence
The American Medical Student Association, the largest and most influential organization of medical students, promotes many unproven methods. In their web pages on integrative, complementary and alternative medicine they suggest that currently accepted scientific methods may not be optimal to study alternative medicine. Moreover, they imply that complementary and alternative medicine should be adopted now, without waiting for definitive evidence, with this statement: “For most CAM therapies, the final word is not yet in on their effectiveness. But the medical community cannot wait for the final word; they need to know what patients are using now and if it is effective. Many primary care doctors are opening clinics with CAM practitioners. These integrated medical centers provide one of the best learning tools for current physicians and may be the most efficient and effective way to blend conventional and unconventional medicine.”

Even government funded CAM research is troubled with serious methodologic flaws
Perhaps the best example of such flawed design is the National Center for Complementary and Alternative Medicine’s ongoing Trial to Assess Chelation Therapy as a treatment for atherosclerosis. As I pointed out in this post, many of the study sites appear to be tainted by a lack of objectivity and dubious scientific qualifications. That lack of objectivity is especially concerning because the investigators are not securely blinded.

Research on complementary and alternative methods is conducted without regard to biologic plausibility
Numerous subjects of CAM “research” are so implausible they would require rewriting the chemistry and physics books. These include claims that a mystical force remains in water after solute is diluted out (homeopathy), imaginary claims of “energy fields” which can’t be measured or detected (various energy healing modalities) and purported energy channels that have no basis in anatomy (the meridians of acupuncture and related methods). It’s as if the NCCAM is willing to “study” any claim, no matter how preposterous, if there’s consumer interest and available funding.

Why is this problematic? Because the test of plausibility is an important safeguard, without which baseless health claims can be subject to clinical studies, occasionally passing the test of statistical significance and yielding “positive” results by chance variation. That might not be a major problem were it not for positive publication bias in quackery promoting journals which receive favorable consideration for Medline indexing, thus inflating dubious claims subjected to meta-analyses, which rely heavily on Medline searching. (See below). In consequence, woo based claims get the trappings of evidence based medicine. My principle for plausibility testing is crude but vivid: “evidence based” woo is still woo!

The proponents and funders of alternative medicine research do not accept negative results
Despite, for example, negative results in the National Center for Complementary and Alternative Medicine supported trail on echinacea the NCCAM apparently didn’t believe the results and wants to do it over again. Worse yet, last year the director and deputy director of the Office of Clinical and Regulatory Affairs of NCCAM published this editorial suggesting that multiple negative results from NCCAM supported studies should not be accepted. More recently, NCCAM has decided to seek funding for the performance of “omics analysis” on previous negative studies of CAM modalities.

Government oversight is biased in favor of complementary and alternative medicine
Dr. Wallace Sampson, Emeritus Clinical Professor of Medicine at Stanford University, has extensively researched the procedures of journal selection by the National Library of Medicine for indexing in Medline and uncovered enormous bias in favor of CAM oriented journals which are largely promotional, uncritical and agenda driven. The whole process, it seems, is corrupted by conflicts of interest. Moreover, the FDA has a lax double standard which is favorable to the development of herbal remedies.

Evidence based medicine (EBM) has failed to remedy the many problems in CAM research. It cannot adequately address the massive agenda which drives much of the research and pays too little regard to biologic plausibility. This is due to misappropriation and misunderstanding of EBM more than any inherent failings of EBM.


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Anonymous said...

Thanks for this piece. I feel like I am talking to a wall when I see things like the CAM/integrative pages on the AMSA site, and the little PDF booklet they have.

It sucks that you got spammed by ad-bots. I just love the alternative etiquette these CAM ad-bots display.