SCIENCE!

July 19, 2012 6:33 PM

Friends of Science in Medicine (FSM) is a new advocacy group of senior medical practitioners and researchers seeking to drive "complementary and alternative medicines" from universities around Australia, and to make non-evidence based therapies ineligible for private health insurance. Naturally, this has caused a fair degree of outrage and pushback from the CAM sector.
posted by wilful (90 comments total)

How dare they demand evidence that treatments are beneficial to patients!
posted by Pope Guilty at 6:35 PM on July 19, 2012 [13 favorites]

Next up: Twelve step.
posted by docgonzo at 6:43 PM on July 19, 2012 [3 favorites]

Well to be fair, not all of standard western medicine has a strong evidence base. there was a statistic quoted on the radio yesterday (that inspired this post) suggesting how much mainstream medicine is based on "stuff we know works, but don't quite know why". Can't find the quote unfortunately, though in looking for it, this interview with a Monash academic in favour of CAM is interesting.
posted by wilful at 6:46 PM on July 19, 2012 [3 favorites]

Q: What do you call 'alternative medicine' that works?

A: MEDICINE.
posted by His thoughts were red thoughts at 6:48 PM on July 19, 2012 [28 favorites]

I think theres a big difference between "stuff we know works, but don't quite know why" and "stuff we don't know whether it works" or "stuff we know doesn't work" that should probably be reflected in insurance rates.
posted by motorcycles are jets at 6:49 PM on July 19, 2012 [18 favorites]

Someone should have told them that FSM is already taken.
posted by hippybear at 6:52 PM on July 19, 2012 [3 favorites]

Snark aside, I would have thought that insurance companies themselves would be motivated not to cover alternative medicine treatments that didn't actually work.
posted by His thoughts were red thoughts at 6:53 PM on July 19, 2012 [3 favorites]

Snark aside, I would have thought that insurance companies themselves would be motivated not to cover alternative medicine treatments that didn't actually work.

Insurance companies would way rather pay for homeopathic pills and accupuncture than chemotherapy.
posted by Pope Guilty at 6:55 PM on July 19, 2012 [3 favorites]

Insurance companies would way rather pay for homeopathic pills and accupuncture than chemotherapy.

Actually, chemo would be covered by Medicare and the Pharmaceutical Benefits Scheme.
posted by His thoughts were red thoughts at 7:02 PM on July 19, 2012

Here's a funny clip from That Mitchell and Webb Look on homeopathy in the emergency department of a hospital.
posted by wilful at 7:03 PM on July 19, 2012 [10 favorites]

Well, if we're into the videos, I'm partial to this awesome promo for the CSIRO that rags on pseudo-science.
posted by His thoughts were red thoughts at 7:07 PM on July 19, 2012

So... I can see the problems with homeopathy and iridology being taught, but what about things like reflexology, which is based on acupressure and acupuncture and which seems to have beneficial effects where the mechanism isn't entirely understood? Shouldn't those be taught and researched at the university level?
posted by hippybear at 7:11 PM on July 19, 2012 [1 favorite]

...not all of standard western medicine has a strong evidence base. there was a statistic quoted on the radio yesterday (that inspired this post) suggesting how much mainstream medicine is based on "stuff we know works, but don't quite know why".

Do you know what the word "evidence" even means? Pro-tip: It isn't a synonym of "explanation".
posted by DU at 7:12 PM on July 19, 2012 [9 favorites]

not all of standard western medicine has a strong evidence base

"Evidence-based medicine" is really about whether it works, not whether we know why it works. But even so, even within "western medicine", there are plenty of techniques that doctors favor that haven't been rigorously shown to help the patient. IIRC, Lewis Thomas argues that western medicine wasn't even a science until the mid-20th century.
posted by hattifattener at 7:20 PM on July 19, 2012 [3 favorites]

""stuff we know works, but don't quite know why""

That means they're is strong evidence that it works. If we give you a drug and you get better, at least better than the placebo patients, then we have good evidence the drug works.

Understanding how the drugs works, it's mechanism of action, is a different thing altogether but it doesn't undermine our evidence that the treatment works.
posted by PJLandis at 7:20 PM on July 19, 2012 [2 favorites]

Placebos work.
posted by Foosnark at 7:24 PM on July 19, 2012 [5 favorites]

"what about things like reflexology, which is based on acupressure and acupuncture and which seems to have beneficial effects"

These things are studied, and it's not at all clear that they have any benefits over that of placebo. For acupuncture in particular, sham needles or needling without any regard to the principles of acupuncture all still give the same or similar results.

At best I think you can say pricking people with needles may help with pain, but everything associated with it, meridians, qi, energy, or whatnot, don't seem to have relevance.
posted by PJLandis at 7:25 PM on July 19, 2012 [7 favorites]

Next up: Twelve step.

Yeah, it's about time we put a stop to AA bilking all those insurance companies
posted by charlesminus at 7:26 PM on July 19, 2012 [2 favorites]

I was living in Mexico and had a friend there who was a Mexican medical student. They have to do a kind of field internship, where they spend a year or whatever in a small village, helping out. She told me that they were instructed to work closely with the local brujos (medicine men) who, for example, will wave an egg over a sick person to capture the bad vibes, or whatever. She said they told her that the cure rates were better if you combined modern scientific medicine with the traditional techniques.

On a related note, I just a prescription for some pills that are supposed to cure my addiction to placebos, and they seem to be working!
posted by twoleftfeet at 7:38 PM on July 19, 2012 [1 favorite]

I am currently seeing a chiropractor for shoulder pain. As far as I can tell, once you take away "subluxation", chiropractic is really no different to specialised physiotherapy. It's a four year university course (though that doesn't entitle them to being called a doctor in my view).
posted by wilful at 7:41 PM on July 19, 2012

Placebos work.

Claiming they're not placebos but are in fact real medicine is despicable.
posted by Pope Guilty at 7:44 PM on July 19, 2012 [6 favorites]

At best I think you can say pricking people with needles may help with pain

I recall reading in "The Thirteenth Element" that people used to ingest Phosphorus when they weren't feeling well....after a few days they would report feeling better than ever! Phosphorus was touted as a "pick me up" drug.

....turns out the phosphorus poisoning made the pain from the original illness so much worse that they felt much better once it had been processed out of their system.

Placebos work.

There's a big difference between "alternative treatments/placebos" "working" and people thinking/reporting they've worked. People on placebos may change their lifestyle, thinking they've been given a new lease on life because they think the placebo is a drug, and it's the lifestyle, not the placebo, that's directly responsible for the improvement.
posted by Lt. Bunny Wigglesworth at 7:44 PM on July 19, 2012

Placebos work.

Claiming they're not placebos but are in fact real medicine is despicable.

Placebos don't work when patients know they're placebos.
posted by Golden Eternity at 7:50 PM on July 19, 2012 [1 favorite]

I am currently seeing a chiropractor for shoulder pain. As far as I can tell, once you take away "subluxation", chiropractic is really no different to specialised physiotherapy. It's a four year university course (though that doesn't entitle them to being called a doctor in my view).

I don't think the problem with chiro is that it doesn't work. It does work - for back pain in certain circumstances.

What it doesn't do is cure cancer, or asthma, or diphtheria, or any of the other things that some chiros claim. A large part of the industry is infected with woo.
posted by His thoughts were red thoughts at 7:51 PM on July 19, 2012 [5 favorites]

Placebos don't work when patients know they're placebos.

Good call. Let's start training doctors in habitual lying and shut down the publication of Skeptical Inquirer.
posted by Pope Guilty at 7:55 PM on July 19, 2012

I wish people would see their quack, who in many cases is making serious bank with a minimal investment in training, as as juicy a target for litigation as their doc.
posted by biochemicle at 7:57 PM on July 19, 2012 [1 favorite]

Q: What do you call 'alternative medicine' that works?

A: MEDICINE.

Ample evidence suggests that physicians tend to underutilize even those non-pharmacological treatments that have been validated and recommended in clinical guidelines. See pulmonary rehabilitation in COPD, obesity counseling, exercise for diabetics, CBT for insomnia, and the list goes on. These modalities are already classified as "medicine." Non-drug therapies don't have a lot of traction for reasons that don't necessarily have to do with whether they work.
posted by Wordwoman at 7:59 PM on July 19, 2012 [7 favorites]

Placebos don't work when patients know they're placebos.

Yes they do!
posted by markr at 8:03 PM on July 19, 2012 [7 favorites]

Placebos don't work when patients know they're placebos.

Are you sure about that? (SCIENCE!)
posted by Wordwoman at 8:03 PM on July 19, 2012 [4 favorites]

(jinx)
posted by Wordwoman at 8:04 PM on July 19, 2012

Placebos don't work when patients know they're placebos.

Are you sure about that? (SCIENCE!)

My bad. They really should have had 3 groups: marked placebo, unmarked placebo, and no treatment.
posted by Golden Eternity at 8:08 PM on July 19, 2012

Placebos don't work when patients know they're placebos.

Actually, that's not true. Here's a cite to a Guardian article on this. The article contains further citations. Short story is that placebos can have an effect even if the patient knows. My understanding is that the jury is till out on the whole placebo question.
posted by charlesminus at 8:09 PM on July 19, 2012

Just a wee bit of context for our non-Australian audience regarding private health insurance. The government does not spend taxpayers money directly on CAM, via the PBS.

Due to a comprehensive universal healthcare system (Medicare), private health insurance in Australia is quite optional, and retained largely by the wealthier part of society. Competition is fierce, so product offerings are dictated by consumer preference. Hence the quite common offer in yuppie packages of things including acupuncture etc.

However, private health insurance is also subsidised by the federal government and there are price controls and other strong regulation. Very much not a free market in that sense. So the FSM group are arguing that if people are going to take taxpayers money, well it damn well better not be spent on things with no evidence base. Also, universities are all government supported, so again their angle of attack is based on public subsidy.
posted by wilful at 8:12 PM on July 19, 2012 [3 favorites]

At best I think you can say pricking people with needles may help with pain, but everything associated with it, meridians, qi, energy, or whatnot, don't seem to have relevance.

they may not seem to have any relevance to most folks but they have everything to do with the underlying foundation of what acupuncture is based on, traditional chinese medicine.

What it doesn't do is cure cancer, or asthma, or diphtheria, or any of the other things that some chiros claim. A large part of the industry is infected with woo.

and for those chiropractors who do claim such things, they are being irresponsible to their practice and patients. extraordinary claims require extraordinary evidence.

---
acupuncture is having a hard time transitioning into western society for many reasons, and i think part of that has to do with the way most people raised in western civilization think. see this paper for what i'm talking about.

performing good studies are hard (time, money, etc.) and so i'm not surprised that there aren't that many studies showing the benefits of acupuncture, especially since it's not geared towards producing pharmaceutical products. western medicine of course has these issues as well - many landmark cancer studies can't be reproduced.
posted by kuroikenshi at 8:23 PM on July 19, 2012 [1 favorite]

they may not seem to have any relevance to most folks but they have everything to do with the underlying foundation of what acupuncture is based on, traditional chinese medicine.

And? If sticking needles in somebody reliably produces a desired effect, that has nothing to do with the alleged interaction of agents never observed in the entire history of real physics, medicine, biology, chemistry, etc.
posted by Inspector.Gadget at 8:32 PM on July 19, 2012 [2 favorites]

So, is this FSM group comprised of Pastafarians?
posted by pompomtom at 8:35 PM on July 19, 2012

Demand the Government subsidise pasta-based treatments now!
posted by kithrater at 8:36 PM on July 19, 2012

As far as I'm concerned, if insurance companies are paying for homeopathy (mine actually would, if I had extras), they should dip a $100 bill in some water and pay with the water.
posted by Jimbob at 8:38 PM on July 19, 2012 [5 favorites]

It would be more fiscally responsible to dip a $10 and dilute 10X.
posted by sebastienbailard at 9:10 PM on July 19, 2012 [4 favorites]

You actually have to start with the opposite of what you want your end product to be. So you'd dip the bill in water, shake it (that's also key -- you have to get the water to remember what was in it), dilute 10x, shake again, repeat that thirty times, and then give your homeopath a drop of the result.

At which point they would become a billionaire.
posted by Scientist at 9:19 PM on July 19, 2012 [6 favorites]

I always get annoyed with these discussions when it is (not always, I'll grant, but often) assumed that herbal or naturopathic medicine or whatever you want to call it, universally has no evidence backing it up. I also get annoyed when it is taken that homeopathy = naturopathy.

When I go through one of my bouts of insomnia I can go to my naturopath and get a herbal mixture that is far more effective than anything I've ever been prescribed, partly because it has fewer side effects.

The reasons those herbs work are understood by science, they are backed up by evidence. That doesn't mean I can get the same product or something as effective from my GP, I can't.
posted by deadwax at 9:24 PM on July 19, 2012 [2 favorites]

The reasons those herbs work are understood by science, they are backed up by evidence.

Yup. Contains molecules that do stuff. I take a tincture made from nettles for my allergies.

But when you have a "School of Naturopathic Medicine, and it teaches iridology, that's a major problem. Because that's been disproved. And when it teaches homeopathy, that's a problem, because it basically conflicts with the belief that matter is made out of atoms.

But they're teaching this stuff in schools!?!

This stuff needs to be taught from the perspective of the hard sciences. And each prospective subject needs to be evaluated in terms of how it agrees or conflicts with our scientific understanding, and what the evidence for it is. Because otherwise you're abusing your students by teaching them garbage. And hurting people.

I always get annoyed with these discussions when it is (not always, I'll grant, but often) assumed that herbal or naturopathic medicine or whatever you want to call it, universally has no evidence backing it up.

Huh.

Teaching Naturopathy to students means children are more likely to be born with deafness, eye abnormalities, and heart deformations. Because those students, when they're Naturopaths, tend to be anti-vax.
posted by sebastienbailard at 10:34 PM on July 19, 2012

Legal implications of the placebo effect
posted by figurant at 10:44 PM on July 19, 2012 [1 favorite]

Where do you draw the line between unproven and proven-false? Physical therapy has failed proof far more than otherwise. Some things are extraordinarily difficult to pin down in proof, when treating humans. Some things work, but not for the reasons we may think. Some things work by virtue of the caring taking place, the treatment being unimportant.
posted by Goofyy at 10:47 PM on July 19, 2012

Legal implications of the placebo effect

This article is hilarious.

Although this 'cure' had (unsurprisingly) proven ineffective, HerpBGone's council had cited Waber et al. 2008 (ref. 1) — which clearly showed that a placebo's efficacy increased with price — arguing that the treatment could have worked if Dexter had only paid more for it. As he had refused to do so (the same product was sold under a different name at $4,000), responsibility devolved to the plaintiff. The case had been dismissed.
posted by Golden Eternity at 10:56 PM on July 19, 2012

Placebos and woo work well on diseases that are mostly perceptual. HIV and cancer, not so much.
posted by benzenedream at 11:00 PM on July 19, 2012

The worst thing about woo is that it is so fun to say.

Wooo! WOOOOOO! WOOOOOOOOOOOOOO!

Such a harmful phenomenon should have a guttural, unpleasant sounding name. 'Gronk', say. Or 'schmattery'.
posted by His thoughts were red thoughts at 11:03 PM on July 19, 2012 [2 favorites]

Legal implications of the placebo effect

Uh, it's worth noting that this is basically a speculative short story, rather than an actual event. That it was the first time that Peter Watts got published in Nature, despite years as an actual marine biologist, appears to have been nevertheless quite satisfying for him.
posted by figurant at 11:17 PM on July 19, 2012

and to make non-evidence based therapies ineligible for private health insurance

Where does that put things like Neurontin, Lexapro, Vioxx and Avandia?

Covered or not covered?
posted by rough ashlar at 11:21 PM on July 19, 2012

Well, Vioxx is no longer on the market, so I'm pretty sure it's not covered.
posted by hippybear at 11:34 PM on July 19, 2012

If you seriously believe in the cause of science against misinformation, I urge you to donate a small amount to the kinds of fundraisers that help real scientists with their legal defence against the larger funded woo-woo practitioners, like this in the UK. I'm sure there'll be one in your country. People's lives are being ruined because they're pointing out that the emperor has no clothes.

Follow people like @bengoldacre or @lecanardnoir on Twitter where you'll see stuff like this
"German Homeopathy company pays 'journalist' 43,000Euros to smear UK Academic' (quotes around the word journalist are mine as the claim lacks evidence)

The villification of Professor Edzard Ernst is truly appalling.

If we stand by and let the bullys get away with harrassment like this, fewer and fewer academics will speak out. By and large most of the academics trying to illustrate the facts and the science aren't well-paid and their blogs aren't exactly raking in the money. They have families who are suffering along with them, let's give a hypothetical friend example, shall we?

A surgeon 'friend' of mine is working on collecting data on X (where X is something costing 8 million a year) This has attracted the ire of the companies producing the more expensive Ys (costing 40 million) and it's been an eye-opener how many subtle ways the companies can exert pressure to make his life a misery.

If you value science over woo-woo also see the BBC/BMJ work on overselling powerdrinks, expensive runners, overhydration of marathon runners causing 16 deaths last year, or in the UK watch the BBC Panorama programme on iPlayer (July 19th). A truly wonderful debunking of the whole energy drinks, protein shakes etc., my favorite part was watching the South African equivalent of Special Forces running with 60kg packs for 50km in extremely high temps and their scientists showing that letting them drink water when they were thirsty was all the body needed (obviously with food when they were hungry).

Don't just get educated, get behind those who are doing the heavy lifting on this.

rant over
posted by Wilder at 1:01 AM on July 20, 2012 [4 favorites]

The reasons those herbs work are understood by science, they are backed up by evidence. That doesn't mean I can get the same product or something as effective from my GP, I can't.

Honest question here - how come nobody has turned these herbs into a form that is easier to use, calculate doses for, store and market? Is it that the active ingredient can't be reliably or economically processed or do equivalent medicines have negative side effects?
posted by Dr Dracator at 1:30 AM on July 20, 2012

I always get annoyed with these discussions when it is (not always, I'll grant, but often) assumed that herbal or naturopathic medicine or whatever you want to call it, universally has no evidence backing it up. I also get annoyed when it is taken that homeopathy = naturopathy.

Thing is, if it has evidence backing up its effects, it's by definition not part of the "non-evidence based therapies" that these people are fighting against. All that is, is packaging, in that some people find it more comforting to get a "natural" remedy than a "chemical pill" even if the active ingredients are largely the same in both.

It's like prefering something made from willow bark over aspirin.
posted by MartinWisse at 2:06 AM on July 20, 2012

Honest question here - how come nobody has turned these herbs into a form that is easier to use, calculate doses for, store and market? Is it that the active ingredient can't be reliably or economically processed or do equivalent medicines have negative side effects?

I'm not going to say that there is no modern pharmaceutical equivalent, I don't know that for a fact. My statement though, was that I can't get one from my GP. That's an issue that is wider than the efficacy of any of the substances we are talking about, it probably has things to do with overworked doctors prescribing in a hurry vs expensive naturopaths that have the time to work with you and work out what you need.

The point I was making was that a naturopath, has for me, given excellent treatment with herbal mixtures that are backed by evidence and actually work. The same woman believes homeopathy is bunk and refers me back to pharmaceutical medicine when that would work better. I don't like the implication that people like that are no different to homeopaths.
posted by deadwax at 2:09 AM on July 20, 2012

Honest question here - how come nobody has turned these herbs into a form that is easier to use, calculate doses for, store and market? Is it that the active ingredient can't be reliably or economically processed or do equivalent medicines have negative side effects?

The ones that work often are, e.g. Aspirin is a packaged form of the salicylates in willow bark.
posted by polyglot at 2:27 AM on July 20, 2012 [2 favorites]

performing good studies are hard (time, money, etc.) and so i'm not surprised that there aren't that many studies showing the benefits of acupuncture, especially since it's not geared towards producing pharmaceutical products.

Alternative medicine is big business, there's plenty of money behind it when it comes to marketing, lobbying and legal wrangling. I don't see any good reason for any treatment not to be backed up with high quality randomised controlled trials.

This isn't about 'western' versus other medicines, it's about evidence versus superstition and anecdote. A few comments here note that some conventional medicines are perhaps lacking in evidence too. That's actually not an argument for giving alternative treatments free reign. In fact, it's a symptom of the same problem -- that the financial interests in health and medicine are often given priority over the results. Still, as imperfect as the system is, big pharma and their dubiously effective drugs are still held to a higher standard than the homoeopaths and the like.
posted by londonmark at 4:07 AM on July 20, 2012

Natural medicine enjoys 3 powerful streams of evidence:

1. The peer reviewed scientific evidence that strongly supports areas of natural medicine, which is why so many Universities are teaching this evidence based medicine
2. The thousands of years of use of natural medicine throughout the world
3. The ever expanding and growing popularity of natural medicine throughout Australia today

In some ways I think this right here is the core of the dispute. Most scientists would dispute the claim that either #2 or #3 count as evidence at all. The implied argument is that people wouldn't believe that a remedy works unless it actually does. But this flies in the face of a huge body of psychological research: we find it too easy to detect illusory correlations for either #2 or #3 to count as strong evidence. Once you throw placebo effects and wishful thinking into the mix, it's really not safe to treat the long history of usage of traditional medicines as strong evidence of effectiveness.

The fact that intuitive judgments cannot be completely trusted in this context seems to be a very hard lesson to learn. Fortunately, scientists have statisticians (e.g.) to keep us honest. Annoying as they are, we couldn't get by without them.
posted by mixing at 4:32 AM on July 20, 2012 [1 favorite]

Thanks for posting this, wilful, I hadn't heard of this group even though it's of interest to me. It seems that they're running a quite focused campaign on insurance and universities, which seems like a good long-term strategy.
posted by harriet vane at 5:18 AM on July 20, 2012

"performing good studies are hard (time, money, etc.) and so i'm not surprised that there aren't that many studies showing the benefits of acupuncture, especially since it's not geared towards producing pharmaceutical products."

This is incorrect. There are LOTS of trials of accupuncture! I'm a medical student (at a science-based uni!) and we're always having to do literature searches for things. One of the questions in our foundations of clinical practice exam, which we were warned about in advance (it was a learning objective of the section of the course we were doing) asked us to name and discuss several alternative (non-pharmacological) treatments for back pain.

To prepare for this we had to do a literature search, which uncovered not just individual studies but also systematic reviews and reviews of reviews, which reviewed the evidence of hundreds of trials, looking not just at the outcome but also the quality of the studies.

Accupuncture has been examined in large scale, double blinded trails, using sham needles which may, or may not, actually penetrate the skin in a way which cannot be determined by either the patient or the acupuncturist, sham techniques (i.e. someone pretending to use proper acupuncture in the right spots vs someone who is trained in acupuncture and targeting the "correct" spots) etc.

What do all of these studies show?

1 It doesn't seem to matter if the needle actually deeply penetrates the skin to the recommended depth, or just superficially irritates the skin in a way which the patient feels the pinprick but it doesn't actually go in.
2 It doesn't seem to matter if the person giving the treatment actually targets the "correct" acupuncture spots or just sticks them in at random spots and pretends it's correct.
3 It doesn't seem to matter if the person is following the recommended acupuncture guidelines for diagnosis of the illness, i.e. hitting the spots supposedly appropriate for the condition, or if the person just uses spots appropriate for some other condition. Hitting spots which are claimed to be appropriate for the liver works just as well at curing a headache as hitting the headache spots!
4 Acupuncture works no better than a similarly administered placebo at any condition for which it has been properly tested!

The most annoying myth about CAM, in my opinion, is the myth that CAM techniques simply haven't been tested enough for there to be evidence either way.

Many CAMs, particularly the more popular ones, have been tested extensively in large studies, often paid for by the US government's own NCCAM at huge, and largely wasted, taxpayer expense.

It is reasonable to conclude with most CAMs, including acupuncture, that we now have enough scientific evidence for a reasonable person to conclude that they don't work. It is not reasonable to say that there is insufficient evidence. You can, quite reasonably, say that acupuncture has been proven to not work for a large number of conditions, any more effectively than a placebo. I am aware of no conditions for which reasonably large and well carried out studies have shown it to actually outperform placebos.

One of the features of the CAM literature is that all the positive studies showing efficacy have significant problems with the way they were performed including lack of blinding and randomisation, small sample sizes, lack of placebo controls, clear conflicts of interest and poor data quality and record keeping.

The studies that lack these problems are the ones which show it doesn't work!
posted by Mokusatsu at 5:18 AM on July 20, 2012 [15 favorites]

Honest question here - how come nobody has turned these herbs into a form that is easier to use, calculate doses for, store and market? Is it that the active ingredient can't be reliably or economically processed or do equivalent medicines have negative side effects?

You can't patent a herb.
posted by pompomtom at 5:21 AM on July 20, 2012

You can't patent a herb.

You can patent an active ingredient, particularly if you tweak it.

Many drugs which are in common use, including some of the largest and most profitable ones, are based on natural products.

The pharmaceutical company takes the herb, breaks it down to figure out what the active ingredient is and what receptors it activates. Then they test variations on it, adding or subtracting chemical groups to see if they activate the receptor more effectively and specifically.

If the variant is better, they patent it and may make a tonne of money.

(To understand this talk of "receptors" requires basic pharmacology knowledge. Essentially, nearly all drugs work by activating, or blocking, receptors on cells.

Side effects of drugs are primarily the result of those drugs activating receptors on other types of cells. The same drug which does something desirable to the heart may do something bad to the lungs if this drug binds to receptors on each. A good drug will only bind receptors on the cells we want, and not the cells we don't want.

It is therefore a major part of pharmacology to find variant molecules that will bind very specifically to only the things we want them to bind to. The result will be fewer side effects.

And yes, absolutely, you can patent that!)
posted by Mokusatsu at 5:32 AM on July 20, 2012 [3 favorites]

Dr Dracator: "Honest question here - how come nobody has turned these herbs into a form that is easier to use, calculate doses for, store and market? Is it that the active ingredient can't be reliably or economically processed or do equivalent medicines have negative side effects?"

In addition to the intellectual properly issues that underly all of these discussions, efficacious treatments don't always have a single active ingredient that can be purified, stably stored, consistently applied, or efficiently tested in a reductive way. The canabinoids in marijuana are a decent example of how some of these kinds of problems interact with our pharmaceutical industry in a way that doesn't really work.

(–)-trans-Δ9-tetrahydrocannabinol is the primary isomer of the primary cannabinoid in marijuana, but other isomers and many different canabinoids are found in differing amounts in different strains with unique pharmacodynamic and psychoactive effects. Thus it makes theoretical sense that the efficacy that marijuana has been experimentally demonstrated to have for a long laundry list of diseases, particularly with palliative care, is absolutely strain, patient, and context dependent.

Marinol is an attempt to market (–)-trans-Δ9-tetrahydrocannabinol alone as a consumable, dose regulated, and double blind verified drug. However, as a treatment strategy, it is markedly inferior to physician supervised experimentation with more traditional strategies, as most patients who experiment with the various other available strains and dosing methods find another strategy that alleviates their symptoms more effectively. I suppose it would be possible to generate different cocktails of (–)-trans-Δ9-tetrahydrocannabinol with other isomers and other canabinoids, but it wouldn't make any damn sense to synthetically generate each possible cocktail and then demonstrate safety and efficacy for each of them, especially when we have such an easy and safe alternative. With the safety data we already have, the traditional double blind three stage drug development pathway is simply not an appropriate use of resources in deciding whether and how to treat patients with weed. Other methods for addressing experimenter and patient bias while generating the kinds of significant results needed to create a standard of care make more sense in this context, such as regularly published case reports and at least loosely coordinated multi-site non-blind trials.

These sorts of treatment models that can be clearly demonstrated to work but don't fit into the standard model are really what alternative medicine should have been for. However, as a microbiologist doing basic research with a treatment model that would ideally work a lot like this, I can tell you that my discipline simply cannot trust the alternative medicine community to take our research and not fuck it up. There are many self-aware, honest, and well informed naturopaths practicing alternative medicine and using treatments with levels of evidence appropriate to their context, but they are surrounded by way too many homeopaths, chiropractors who honestly think they manipulate 'energy', anti-vaxxers, and masters of Laser Reiki for us to even consider it. Despite the real potential that I see alternative medicine as having, I'm still pretty solidly in these guys' camp. If alternative disciplines are going to work they will need to demonstrate an ability to effectively self regulate irresponsible quacks out of their practices. Yet, despite many excessively sympathetic state governments willing to follow the consensus of alternative medicine communities, horrifyingly quackish hucksters are still everywhere.
posted by Blasdelb at 5:35 AM on July 20, 2012 [4 favorites]

You can patent an active ingredient, particularly if you tweak it.

Absolutely, and sometimes the 'these herbs' are (cf: bark to aspirin, or whatever). I don't claim to know the particular treatment deadwax was referring to, but the fact that some things have been deconstructed and 'tweaked' to enable them to fall under the rubric of IP law doesn't mean that other things, other useful and efficacious things, have not.
posted by pompomtom at 5:40 AM on July 20, 2012

(actually, on reflection, I'm not sure that you can patent an active ingredient without 'tweaking' it)
posted by pompomtom at 5:41 AM on July 20, 2012

When I go through one of my bouts of insomnia I can go to my naturopath and get a herbal mixture that is far more effective than anything I've ever been prescribed, partly because it has fewer side effects.

The reasons those herbs work are understood by science, they are backed up by evidence.

You are deliberately eliding the distinction between "some compounds found in herbs have pharmacological effects" and "naturopathy is evidence-based." The former is indisputable; the latter is horseshit. You also confuse "science" and a rather laxer standard of "evidence" to the same effect.
posted by Inspector.Gadget at 6:01 AM on July 20, 2012

Well to be fair, not all of standard western medicine has a strong evidence base. there was a statistic quoted on the radio yesterday (that inspired this post) suggesting how much mainstream medicine is based on "stuff we know works, but don't quite know why". Can't find the quote unfortunately, though in looking for it, this interview with a Monash academic in favour of CAM is interesting.

That's not some smoking gun. Plenty of pharmacological profiles include phrasing like:

"Although the exact mechanism of ____ effect is not known, it is likely ____"

In evidence-based medicine the effect is the important part. In non-evidence based medicine the mechanism is the important part, the effect is almost irrelevant.
posted by odinsdream at 6:02 AM on July 20, 2012

Take, for example, acetaminophen (Tylenol in the US). The exact mechanism of action is not currently known. It's still being researched. That doesn't stop it from being routinely and widely used as an analgesic and antipyretic, however, because the effect, regardless of how it works, is understood very well.
posted by odinsdream at 6:06 AM on July 20, 2012

I suppose it would be possible to generate different cocktails of (–)-trans-Δ9-tetrahydrocannabinol with other isomers and other canabinoids, but it wouldn't make any damn sense to synthetically generate each possible cocktail and then demonstrate safety and efficacy for each of them, especially when we have such an easy and safe alternative.

Can you clarify this point a bit? It seems like you are saying we can't do a systematic test of all possible combinations, therefore individual doctors and patients should figure it out via trial and error using random strains. I can understand this as far as efficacy is concerned, but it seems the safety aspect only works because the risks are broadly understood to be minimal. In fact, it seems there is some asymmetry here: would the physician be allowed to experiment with an equally broad range of synthetic cannabinoids without being held to a much higher standard?
posted by Dr Dracator at 6:16 AM on July 20, 2012

Inspector.Gadget: "You are deliberately eliding the distinction between "some compounds found in herbs have pharmacological effects" and "naturopathy is evidence-based." The former is indisputable; the latter is horseshit. You also confuse "science" and a rather laxer standard of "evidence" to the same effect."

If you are trying to assert that deadwax did not experience the insomnia fighting effect they described, then that is an awfully extraordinary claim with extraordinary requirements. Without presuming to ask deadwax about their current medications, I can tell you that there are indeed herbal preparations on the market that have clear demonstrations of both safety and efficacy.

As many issues as I have with naturopathic colleges, the better ones do pump out physicians who are significantly better qualified to prescribe and manage herbs such as Valerian root (Valeriana officinalis) for complaints like insomnia than the average MD.
posted by Blasdelb at 6:31 AM on July 20, 2012 [1 favorite]

You can't patent a herb.

Check out the number of patents the US federal government has on cannabis products. Or is pot not a herb?
posted by PeterMcDermott at 8:40 AM on July 20, 2012

Rather than making non-evidence based therapies ineligible for health insurance, wouldn't it make more sense to make therapies that have evidence showing that they're ineffective or deleterious ineligible? That would take out the worse stuff, without needlessly (IMO) restricting the options people have to those that have institutional/corporate backing.
posted by cosmic.osmo at 12:53 PM on July 20, 2012 [1 favorite]

If you are trying to assert that deadwax did not experience the insomnia fighting effect they described, then that is an awfully extraordinary claim with extraordinary requirements. Without presuming to ask deadwax about their current medications, I can tell you that there are indeed herbal preparations on the market that have clear demonstrations of both safety and efficacy.

I understood Inspector.Gadget as saying, "Sure you experienced this effect I'm sure that particular treatment did work, but just because you classify it as naturopathic does not redeem the rest of naturopathic medicine." In that interpretation I agree.
posted by EsotericAlgorithm at 8:36 PM on July 20, 2012

"Rather than making non-evidence based therapies ineligible for health insurance, wouldn't it make more sense to make therapies that have evidence showing that they're ineffective or deleterious ineligible?"

The problem with this is that it is difficult to show that something has absolutely no effect. Even homeopaths can scrounge up a few studies that show some efficacy because with enough testing you will eventually get some outliers, even without fraud or self-deception. That's why the better standard is evidence of efficacy, not lack of evidence to prove a negative.

If you're expecting an insurance company to pay for a treatment, it's not asking a lot to say we need more than a few anecdotes. If your treatment truly helps people, it's not climbing a mountain to get someone, maybe an academic or non-profit, to perform a study; no one is demanding full Phase III trials, but you need some credible evidence that shows it has some effect before you should expect everyone in your insurance pool to pay for it.
posted by PJLandis at 10:07 PM on July 20, 2012

" I can tell you that there are indeed herbal preparations on the market that have clear demonstrations of both safety and efficacy"

Clear? I'm suspicious of that statement because most of the confirmatory studies of herbs or other supplements I've read at best show some possibility of an effect, and the larger, well-controlled studies often fail to find anything but placebo effects.

I'm interested to know which herbs/supplements people think have good evidence of efficacy?
posted by PJLandis at 10:18 PM on July 20, 2012

Check out the number of patents the US federal government has on cannabis products

Do you have some citation I could see? I can find this, but that seems to be just what we were discussing before: a patent covering a method of using particular products of the herb.
posted by pompomtom at 1:54 AM on July 21, 2012

I'm interested to know which herbs/supplements people think have good evidence of efficacy?

Valerian root for insomnia. I take it every night to help get to sleep - I have lifelong, chronic insomnia. I also take melatonin. Believe me, they work. It's not like Xanax or Ambien, but that's part of why I like them. The effect is not so severe, but it's not a placebo effect either. Valerian's effectiveness has been proven with studies, but the quality and number of studies warrant further research. However, I am happy continuing to use it, knowing how it works for me. The addition of cannabis/marijuana to Valerian and melatonin works very well treating insomnia for me, and sometimes it works OK by itself - really depends on how active my brain is at the time.

St. John's Wort has also been proven to work for treating depression. Saw palmetto has been widely used to treat enlarged prostate for some time. The Mayo Clinic has a short list of supplements here sourced from Natural Standard.
posted by krinklyfig at 1:59 AM on July 21, 2012

Do be careful with St John's Wort though - one of the established side effects is that it reduces the efficacy of some birth control pills. Which is why it's important not to assume that 'natural' or 'herbal' doesn't mean 'no side effects'. Anything that has a real effect on your body can have knock-on effects too.
posted by harriet vane at 3:07 AM on July 21, 2012

I understood Inspector.Gadget as saying, "Sure you experienced this effect I'm sure that particular treatment did work, but just because you classify it as naturopathic does not redeem the rest of naturopathic medicine." In that interpretation I agree.

Precisely my meaning.
posted by Inspector.Gadget at 5:46 AM on July 21, 2012

"Recently, controversy has been raised by two high-quality trials of St. John's wort for major depression that did not show any benefits. However, due to problems with the designs of these studies, they cannot be considered definitive."

I find it strange that the Monograph calls them "high-quality" studies and then notes problems with the design. What problems? Maybe they didn't find what they wanted.
posted by PJLandis at 8:25 AM on July 21, 2012

And I'm not doubting that they work for people, but do they work for reasons other than a placebo effect?

For melatonin, not even the Natural Standard monograph makes any claims other than noting what it does in the human body. Noting what a drug does inside your body, and what taking a pill of it will do to you are very different things.
posted by PJLandis at 8:28 AM on July 21, 2012

St John's Wort is indisputably a somewhat effective anti-depressant, there is little question in the medical community that it does that.

However, it's not a particularly good one, we have much better synthetics (see my post higher up about "tweaking") and St John's Wort is well known for its various drug interactions.

Drugs interact via various mechanisms, they can work on the same receptors or similar ones and create an exaggerated effect (or a greatly weakened one, if they work on the same receptors but have opposite effects). Or, they can interfere with the metabolism of each other because the two interfering drugs rely on the same enzymes in the liver and thus one can completely block the other from being turned into an active form, or from being eliminated from the body, or something else.

Pharmacologically speaking, St John's Wort is a so-so antidepressant which happens to be particularly good at interacting with other drugs, thus it is essential that you tell your doctor if you're on it, he/she may have to find some alternative drugs that won't interact with St John's Wort, or he/she may recommend you take something safer than St John's Wort.

"Herbal" does not imply "safe".
posted by Mokusatsu at 11:20 AM on July 21, 2012 [2 favorites]

For melatonin, not even the Natural Standard monograph makes any claims other than noting what it does in the human body. Noting what a drug does inside your body, and what taking a pill of it will do to you are very different things.

This is true. However, I have tried many different methods and medications for insomnia, and I am not a believer in homeopathy or "woo" in general. I use what works for me. In the case of melatonin, once I found the right dose it worked very well for me, and the effects were different than any other sleep aid or method I'd tried previously. For what it's worth, my psychiatrist recommended its use, but I had already been using it when I first saw her.

The effects of valerian are easily discernible, but it works best for people who have chronic issues with insomnia rather than people who only have problems sleeping occasionally.

I've worked with and known many doctors, and most aren't given to believing in "woo," but overall they are willing to acknowledge the effects of effective supplements and will recommend them to patients if appropriate.

And I'm not doubting that they work for people, but do they work for reasons other than a placebo effect?

You do understand that many of these supplements have active ingredients, correct? I'm not claiming all of them do, and many supplements are purely placebos, but some of them do work.

"Herbal" does not imply "safe".

Of course not. I'm not sure anyone here was implying it did, but if so I didn't catch it. But the effects of melatonin, valerian and cannabis are much less severe than prescription sleeping pills, which are mostly effective but also have unpleasant side effects.
posted by krinklyfig at 12:24 PM on July 21, 2012

Can you clarify this point a bit? It seems like you are saying we can't do a systematic test of all possible combinations, therefore individual doctors and patients should figure it out via trial and error using random strains. I can understand this as far as efficacy is concerned, but it seems the safety aspect only works because the risks are broadly understood to be minimal. In fact, it seems there is some asymmetry here: would the physician be allowed to experiment with an equally broad range of synthetic cannabinoids without being held to a much higher standard?

All I can say in response to this is finding the correct type and dose of medication for psychiatric issues is often a bit of trial and error as far as medication. This was very much the case for most people I know who are being treated for ADHD (including myself) and depression. The effects of the major cannabinoids by themselves and in combination are pretty well understood by the medical marijuana community, including many of the doctors who prescribe cannabis. I recently applied for a medical cannabis card here in CA, and my doctor went over all these effects and gave me a detailed handout which cross-referenced hybrid strains and pure indicas and sativas and how effective they were for certain symptoms or problems, and also contraindications and warnings. I had done most of the research myself, but it's not like people who have a medical need for cannabis are just messing around. Most of the dispensaries have cannabinoid percentages labeled on the product - a few do not but will at least be able to tell you if it's sativa or indica, which can mostly steer you in the right direction. Knowing what you're getting is a huge advantage (and in many cases necessity) if you're taking cannabis for specific reasons, which is is nearly impossible if you're not able to obtain it legally.
posted by krinklyfig at 12:40 PM on July 21, 2012

Blasdelb: "I suppose it would be possible to generate different cocktails of (–)-trans-Δ9-tetrahydrocannabinol with other isomers and other canabinoids, but it wouldn't make any damn sense to synthetically generate each possible cocktail and then demonstrate safety and efficacy for each of them, especially when we have such an easy and safe alternative."

Dr Dracator: "Can you clarify this point a bit? It seems like you are saying we can't do a systematic test of all possible combinations, therefore individual doctors and patients should figure it out via trial and error using random strains. I can understand this as far as efficacy is concerned, but it seems the safety aspect only works because the risks are broadly understood to be minimal. In fact, it seems there is some asymmetry here: would the physician be allowed to experiment with an equally broad range of synthetic cannabinoids without being held to a much higher standard?"

I suppose THC makes a poor example in that it is complicated by its status as a Schedule II intoxicant, as well as the largely but not entirely manufactured controversy with regard to its safety, however if we were to hypothetically set these aside,

At least in the US, regulation of drugs is actually a lot more flexible than most folk, particularly those in alternative medice, give it credit for. There are quite few different specially tailored pathways for approving drugs that are each made to be appropriate the drugs involved. For example vaccines, especially annual ones like the influenza vaccine, have a very abbreviated pathway to acceptance. It makes sense, we've been making flu vaccines since the '40s and have a very good idea of how to make them safely and effectively. We don't really need to demonstrate either safety or efficacy to the same standard every year that we might use for a totally new drug as the evidence supports doing so.

Thus, if we were really going to invest the kinds of effort into weed based therapeutics that we do into combating an infectious disease that has the capability of wiping out human civilization, then we could in theory develop a similar pathway for canabinoids if the evidence generated supported doing so. However, it shouldn't really be necessary to demonstrate adequate efficacy for individual canabinoids, or even individual strains, so long as one can demonstrate general safety with appropriate forms of delivery and that patients who go looking for what ends up being the right strain for them end up finding one with efficacy at an adequate rate. For obvious reasons this sort of strategy isn't really translatable into a formal regulatory format, but that doesn't mean that it isn't viable or worthwhile.

Different standards of evidence are often entirely appropriate for different kinds of therapeutics, and this is already built into our system in entirely appropriate ways.
posted by Blasdelb at 4:08 PM on July 21, 2012

EsotericAlgorithm: "I understood Inspector.Gadget as saying, "Sure you experienced this effect I'm sure that particular treatment did work, but just because you classify it as naturopathic does not redeem the rest of naturopathic medicine." In that interpretation I agree."

It still always kind of bugs me when folks who claim to be speaking for science do so by making claims like ALL OF THIS BROAD AND HETEROGENOUS CATEGORY OF THINGS IS HORSESHIT. Since the 70s, when naturopathy made its modern resurgence, modern medicine has made amazing progress towards addressing the horrific paternalism with misogynistic and racist overtones, the inattention to effective low tech methods, the blindness to non-western medical practices, and the unwillingness to listen to patients or recognize the value of subjective patient histories that did so much to popularize alternatives. The big systemic things that have always been fucked up about Naturopathy are indeed becoming a larger and larger part of it as modern medicine requires less and less in the way of alternatives. However, there should still be a place for physicians who are trained specifically to keep track of what strains of what herbs do what and how as well as have the disposition to communicate effectively with woo-minded people but the education to not hurt them.
posted by Blasdelb at 4:30 PM on July 21, 2012

"I've worked with and known many doctors, and most aren't given to believing in "woo," but overall they are willing to acknowledge the effects of effective supplements and will recommend them to patients if appropriate."

The idea of Evidence-based or Science-based medicine isn't wholly focused on traditional woo, the real genesis of the idea was to challenge accepted medical dogma that simply didn't have enough evidence to back up it's widespread use and acceptance.

And "active ingredients" is referring to a drug that has shown efficacy, that ingredient is the one which is believed to cause the effect. Saying it has some substance in it doesn't mean it isn't still only giving results in line with expectations, a placebo effect.
posted by PJLandis at 4:49 PM on July 21, 2012

"unwillingness to listen to patients or recognize the value of subjective patient histories that did so much to popularize alternatives."

This is problematic when the history of people being sure that something has cured them and changed their life, and then all evidence later pointing to that something being ineffective and doing anything, is long. If anything, declining to tell people that there is little or no good evidence that this or that herb has any effect, beyond completely unreliable anecdotes, is classic paternalism.
posted by PJLandis at 4:54 PM on July 21, 2012

And here's why this group's work is needed: Cult cures on Medicare.

Serge Benhayon, a former tennis coach from Maroubra, has up to 1000, mainly female, devotees to his movement, Universal Medicine, based in the hills outside Lismore on the north coast of NSW. Mr Benhayon told The Sun-Herald he had no medical qualifications but stood by the effectiveness of his treatments, including ''esoteric breast massage'' - administered only by women - and ''chakra-puncture''. His daughter, Natalie, 22, claims to be able to talk to women's ovaries - for $70 an hour.

posted by harriet vane at 10:03 PM on July 21, 2012

PJLandis: "This is problematic when the history of people being sure that something has cured them and changed their life, and then all evidence later pointing to that something being ineffective and doing anything, is long. If anything, declining to tell people that there is little or no good evidence that this or that herb has any effect, beyond completely unreliable anecdotes, is classic paternalism."

Valuing a patient's subjective history and their experience of their chief complaint is different from refusing to challenge it. The curent model for taking one in a standard exam fits within the SOAP note format and it is designed to help physicians focus on the complaint presented to them rather the the sack of meat in front of them. This is a very good thing and vast improvement on how medicine used to be done not so long ago.
posted by Blasdelb at 11:30 PM on July 21, 2012

PJLandis, I am aware of the history of evidence-based medicine as well as the meaning of active ingredient. However, just because valerian root, for example, has not been demonstrated to be effective through studies does not mean it's not effective. So far, many of the studies which have been done are problematic in methodology and/or haven't been attempted to reproduce under the same methodology. In that case, further research is needed. But if you've ever experienced chronic insomnia, and you've tried and tried different substances and methods, when you hit on something which works consistently for you, you stick with it.

It's somewhat out of desperation that I discovered what works for me, but the effects of valerian, melatonin and cannabis are so distinctive individually, and I've been using them long enough now that I have become very familiar with what they do to me separately and combined. I accept that there may be a placebo effect with valerian and melatonin, since the research has yet to prove conclusively otherwise, but to me they are as separate and predictable in their individual effects with my physiology that it may as well be clinically proven - they work in ways I understand as well and as predictably as any prescribed pharmaceutical or supplement I've ever taken which has undergone more rigorous studies. This is not the case with other supplements I've tried (and I've experimented a lot and done the research all the same). It works for me, and side effects are minimal, so I can hardly complain that they haven't been tested thoroughly enough.
posted by krinklyfig at 1:14 AM on July 22, 2012