Complementary and alternative medicine: A double standard

While I’m on the topic of alternative medicine and NCCAM again, I’ve said on many occasions that I reject the distinction between evidence-based medicine and “alternative medicine” as a false dichotomy. To me, the only dichotomy that matters is between medicine that has high quality scientific evidence showing that it works and medicine that does not, a category that includes plausible treatments that might work but have not yet been shown to work and treatments, implausible treatments with little or no evidence of efficacy (a category that includes the vast majority of what is lumped together as “alternative medicine”), and treatments for which the preponderance of evidence shows that they do not work. The very concept of “alternative medicine” represents a double standard under which certain types of therapies labeled “alternative” are apparently either exempt from the normal standards of medical and scientific evidence or subject to a much looser standard that that evil “conventional” or “allopathic” medicine of whose medical-industrial complex I seem to be considered a tool.

It turns out that Steve Novella agrees with me and has made a compelling, almost Orac-length case (sadly, minus the usual Orac-style snark, but that’s OK) for the existence of this double standard. It’s well worth your reading in full. Particularly damning is Steve’s description of how “health care freedom” laws do nothing more than codify substandard care as acceptable as long as it covered under the rubric of “alternative” medicine. He also points out how physicians abandon treatments that don’t work. I often make the same point, but I also usually point out that this weeding out of ineffective treatments may take longer than we like. It does happen, however. In alternative medicine, as far as I can tell, there has never been a treatment that has been abandoned because it was found to be ineffective or unsafe.

Although this case has been used to attack the FDA and our drug approval system, the recent case of Avandia, the diabetes drug that has been linked to an increased risk of myocardial infarction and cardiac death. Whatever the flaws in our drug approval system this case may have revealed, the reactions of practitioners “in the trenches” that I’ve seen so far are quite instructive. They range from practitioners who plan on taking all their diabetic patients off of Avandia, to those who, seeing that a closer examination of the study does reveal problems but is not quite as dramatic as the press is painting it, plan on taking just their patients with heart disease off of it, to those who are taking more of a “wait and see” attitude while seriously considering cutting back or ceasing their use of Avandia for diabetic patients. In other words, when faced with evidence that a previously favored drug may not be safe, at least in some patients, most practitioners seem to be either abandoning it now or thinking very seriously about abandoning it in the near future. (Look for sales figures of Avandia to plummet, if the drug isn’t pulled by the FDA first.) Contrast this to the alleged anticancer drug Laetrile, which failed to show any efficacy in multiple trials 25 years ago but which is still pushed by alternative medical practitioners. Contrast this to chelation therapy, for which multiple trials have failed to show efficacy against cardiovascular disease, yet which is still used by thousands upon thousands of “alternative” practitioners for heart disease with the promise that patients can “avoid angioplasty or bypass surgery.” My guess is that, 100 years from now, even if no evidence of efficacy is ever found for these therapies (as is likely), alternative practitioners will still be using chelation therapy, Laetrile, qi gong, Reiki, and homeopathy. Now speculate about how many of today’s “conventional” medical treatments will still be in wide use 100 years for now or look back and determine what “conventional” medical therapies from 100 years ago that are still in use today, and the difference is clear. Alternative medicine simply does not stop using therapies that are shown not to work. Although the external trappings may change, at its heart it is stagnant and unchanging.

Whatever the faults of “conventional” medicine, it does change in response to new evidence. It does ultimately discard therapies that are shown not to work or shown to have an unfavorable risk-benefit profile in favor of therapies for which better evidence is found. It may take longer than we like and be a messier process than we like, but it does happen. A more stark contrast with alternative medicine I can’t imagine.