The director of NCCAM wants a "nuanced conversation" about "complementary and alternative medicine"

To say that I haven’t been much of a fan of the National Center for Complementary and Alternative Medicine (NCCAM) throughout the years is a gross understatement. If you want to see the depths of my—shall we say?—lack of enthusiasm for NCCAM, feel free to type “NCCAM” in the search box of this blog and in particular look for posts that have “NCCAM” somewhere in their titles. It won’t take you long to find posts by yours truly with titles as awesome as NCCAM: I say we take off and nuke the entire center from orbit. It’s the only way to be sure and NCCAM in the news: Why does it still exist? Trust me when I tell you that the articles are just as awesome as the titles.

As I have argued over the years, NCCAM is a misbegotten government agency whose activities have directly contributed to the rise of quackademic medicine over the last two decades in the U.S. Don’t get me wrong, it’s nowhere near all NCCAM behind the infiltration of so-called “complementary and alternative medicine” (CAM) quackery into medical schools and academic medical centers, but clearly NCCAM, wittingly and unwittingly, provides a patina of scientific plausibility to nonsense, not to mention the imprimatur of the federal government, much to the delight of quacks everywhere.

Amazingly, three years ago, criticisms by myself, Steve Novella, and Kimball Atwood led to an invitation to meet with Josephine Briggs, MD, PhD, the director of NCCAM. We found her to be earnest but also not understanding of what, exactly, the problem at the core of NCCAM as an entity. She is also a consummate politician who knows who her constituency is, because around the time she met with us she also met with an “international homeopathic team.” She then promptly produced a post on the NCCAM blog entitled Listening to Differing Voices in which she produced a false dichotomy between two groups of stakeholders, one of which consists of CAM advocates and the other of which consist of skeptics who reflexively dismiss CAM and want to eliminate it and then piously implied that NCCAM is the only reasonable position between them, proclaiming:

As I’ve stated before, our position is that science must remain neutral, and we should be strictly objective. There are compelling reasons to explore many CAM modalities, and the science should speak for itself.

The problem with NCCAM, of course, is that the science does speak for itself, saying that the vast majority of CAM is pure quackery, but NCCAM doesn’t listen any more than CAM advocates do. Modalities with little or no prior plausibility or convincing preclinical evidence, such as acupuncture, are studied as though they show great promise. Modalities that violate the laws of physics, such as “energy medicine” modalities like reiki and therapeutic touch, are studied as if they had plausibility. Sadly, Dr. Briggs is still at it, over three years later. Only this time somehow she’s gotten her views published in a top medical journal, JAMA, as viewpoint article co-authored with her deputy director Jack Killen entitled Perspectives on Complementary and Alternative Medicine Research. Accompanying this article is a press release on the NCCAM website, a new blog post by Dr. Briggs on the NCCAM blog entitled A New Conversation, and a video blog also entitled Perspectives on Complementary and Alternative Medicine Research:

In this blog, Dr. Briggs calls for a “a fresh, more nuanced and balanced conversation about research into complementary and alternative practices.” I don’t know what she’s talking about from our perspective as critics of CAM as unscientific, but we’ve always been “nuanced” when appropriate, particularly when discussing specific studies. We try very hard (and certainly I do too) to examine the evidence. The thing that disturbs Dr. Briggs about us is that we don’t find the evidence convincing and criticize NCCAM for being a massive waste of money that could be better used elsewhere in the NIH. In this, there is nothing in Dr. Briggs vlog, blog post, or opinion piece in JAMA that isn’t anything more than her 2010 message on steroids, wrapped up in a plea to reset and reboot the conversation. For example, in her NCCAM blog, Dr. Briggs writes:

Before I took on the role of Director of NCCAM, I worked as a kidney physician and researcher and regularly saw patients who were struggling with very difficult-to-treat symptoms. Now at NCCAM, I often have the opportunity to travel and meet people: consumers, health care providers, and researchers. These interactions have allowed me to hear a wide variety of insights, and I’m often struck at how strongly people react regarding the topic of complementary and alternative medicine. There are those who embrace these “all-natural” approaches and avoid conventional medicine completely. And there are those who completely dismiss anything labeled “complementary” as quackery.

I feel very strongly that this all-or-nothing debate does a disservice to patient care. The field of complementary and alternative medicine encompasses a very wide array of products and practices, with the only unifying factor being that we’re still exploring their safety and value. By embracing anything that is deemed “natural,” patients may put themselves at risk, falsely believing that natural equals safe. They may also forgo proven therapies that can help their condition. Likewise, by completely dismissing complementary approaches, we miss an opportunity to uncover and take advantage of promising therapies that can address very practical problems.

See what I mean about the false dichotomy? In this passage, she makes it explicit, even more so than she did three years ago. You have the “all natural” types who don’t want to use anything other than “natural cures,” and you have reflexive skeptics who, apparently so blinded by ideology, reflexively dismiss CAM as quackery. In between, apparently, NCCAM places itself as the adult in the room, the reasonable people who neither believe completely in CAM over science-based medicine (SBM) nor reflexively dismiss all CAM, as those nasty skeptics are portrayed as doing. If there’s a better example of the fallacy of moderation or the fallacy of the golden mean, I haven’t seen one in a while.

The problem, of course, is the same problem that is encountered whenever science is juxtaposed with pseudoscience For some “debates” one position is clearly wrong based on science, such as when creationism is debated with evolution, anthropogenic global warming denialism is juxtaposed with climate science, HIV/AIDS denialism is debated with infectious disease science, or antivaccinationism is presented with vaccine science. In all these examples, there is a right answer and a wrong answer, and the right answer does not lie somewhere between the two “extremes.” Dr. Briggs’ argument is based on one massive logical fallacy, and that’s what we get in her JAMA article, even going so far as to reference an article by Paul Offit critical of NCCAM and declaring that “some criticisms betray a lack of understanding of scientific progress in this field and how it has shaped a compelling, sharply focused research agenda.”

As one of those critics standing with Paul Offit, I’d be lying if I didn’t say I wasn’t a bit insulted by such a characterization. I fully understand the scientific progress in this field. There hasn’t been any to speak of, all the smoke and mirrors laid down by NCCAM apologists and NCCAM itself notwithstanding. I’m also probably one of the few NCCAM critics who’s actually read the NCCAM strategic plan for 2011 to 2015 in its entirety, and I was not impressed. It amounts largely to a promise to do some real science for a change.

One statement by Dr. Briggs in her vlog stood out to me:

We also know a great deal more about the potential of complementary approaches to contribute to the management of chronic pain. Our current focus, on pain management, is driven by real world use data.

Our current research agenda reflects major evolution in research priorities. It recognizes that some of these practices are useful and can reasonably be integrated into care, some are not useful, some are dangerous and merit regulatory attention, and many are somewhere in between.

So it appears that NCCAM has found its niche, the one area where placebo effects confound SBM more than arguably any other area, chronic pain. It’s a savvy move. In what area are there probably the most seemingly “positive” acupuncture studies? Pain and especially chronic pain. The same is likely true for just about any CAM modality, be it “energy medicine” such as reiki or therapeutic touch, “mind-body” modalities, herbal medicine, or just about anything else CAM. It’s the one and only area of medicine where it’s really, really hard to differentiate true effects from placebo effects, other than perhaps psychiatry, particularly the treatment of depression.

As for the article itself, it begins with verbiage that is apparently mandatory for all articles of this type. (Heck, NCCAM even has an infographic for it!) It’s basically one massive appeal to popularity in which statistics are trotted out to show how many Americans use CAM. In this case, Briggs and Killen cite the 2007 National
Health Interview Survey, as all CAM apologists must, to come up with a figure of 40% of Americans using CAM. I swear, there must be a rule for these sorts of articles in which the author absolutely must cite this figure or the article is instantly rejected. The problem with this survey, as is the problem with many CAM use surveys, is that it lumps together modalities like massage (which is not really CAM) and prayer/spirituality, which is really not medicine of any kind but religion. If you look at the “hard core” CAM modalities, you’ll find that, for example, only 1.4% reported using acupuncture; 0.4% reported using naturopathy; 0.1% reported using Ayurveda; and 0.5% reported using reiki.

So what has NCCAM learned? Apparently, the most common use of CAM is for chronic pain, which is about as much a “Well, duh!” conclusion as I have ever seen. I could have saved them the money, time, and toil if they’d just asked me that question. Be that as it may, here are some of the major accomplishments of NCCAM as envisioned by Briggs and Killen:

For some mind-body approaches, however, there is mounting evidence of usefulness and safety, particularly in relieving chronic pain. A few examples include acupuncture for osteoarthritis pain; tai chi for fibromyalgia pain; and massage, spinal manipulation, and yoga for chronic back pain. Increasing comfort with this emerging evidence is reflected in practice guidelines from the American College of Physicians, the American Pain Society, and the Department of Defense.

Translational research is also elucidating effects of interventions like meditation and acupuncture on central mechanisms of pain perception and processing, regulation of emotion and attention, and placebo responses. Although not yet fully understood, these effects point toward scientifically plausible mechanisms—often unrelated to the traditional mechanistic explanations—by which these interventions might exert benefit.

No, acupuncture doesn’t work for arthritis. Tai chi is gentle exercise “rebranded” as mystical, “Eastern,” and mysterious. That it might decrease pain as repeated by patients with fibromyalgia is as unremarkable as it is disingenuous to lump Tai Chi in as a part of “CAM.” I’m pretty sure that over the years I’ve blogged about nearly all of these studies, both here and at my not-so-secret other blog, and I’ve been less than impressed.

The other accomplishments touted by Briggs and Killen include a string of negative studies of various supplements, such as St. John’s Wort for depression, glucosamine and chondroitin for osteoarthritis, silymarin for chronic liver disease, saw palmetto for prostatic hypertrophy, vitamin E and selenium to prevent prostate cancer, and gingko for early cognitive decline. Of course, doing studies on all of these supplements is nothing more than rebranding the old and respected branch of pharmacology known as pharmacognosy (natural products pharmacology) as somehow being “alternative” or “CAM.” It’s not. Testing natural products and trying to isolate active ingredients in herbs, for instance, is pharmacognosy. There is no reason to categorize such studies as “CAM.” They easily fall within the purview of science-based medicine. Another point: All of these studies were negative, likely because the preliminary data were so weak and the prior plausibility wasn’t so hot either.

So, after enumerating a bunch of not-so-impressive accomplishments, where do Briggs and Killen think that NCCAM should go from here? Take a look:

First and foremost, the conversation should reflect current realities, including the evolution of research priorities and the shifts in funding to projects that address them, rather than areas that have less scientific promise or less amenability to scientific investigation.

Translation: Ignore all that quackery we used to study in the past, like homeopathy distance healing, reiki, and the like. We don’t do that (much) anymore.

Second, although discussions about complementary and alternative medicine often imply a clear demarcation distinguishing a monolithic alternative domain from conventional medicine, this distinction breaks down in the realities of the pluralistic US health care system. The boundaries also shift—in both directions—as evidence changes.

Gee, did the director and deputy director of NCCAM just channel Tim Minchin and Richard Dawkins and tell us that that the word for alternative medicine that has passed scientific muster is “medicine”? Now there’s some chutzpah! I’d be insulted if my irony meter hadn’t exploded in my face. I will give the credit, though, for another false equivalency, namely the claim that the boundaries between alternative medicine and conventional medicine shift such that alternative medicine become medicine and medicine becomes “alternative.” I’d really love to know examples of alternative medicine that’s ever been scientifically validated to become “medicine.” No doubt they’d try to tell me that acupuncture is an example of such a medicine. I’d sadly tell them that it is not. It’s still quackery. However, I’d love even more to know an example of a conventional medical treatment where the boundary shifted to make it “alternative.” Maybe Stanislaw Burzynski’s incompetent “personalized gene targeted cancer therapy,” which in reality consists of various chemotherapy drugs used off-label. No, that’s probably not the example they meant.

Third, the conversation should recognize the state of current evidence indicating that some of these practices are useful and can appropriately be integrated into care, some should not, some are dangerous and merit regulatory attention, and many are somewhere in between.

You know, at this point I’d really love to know a few things. Which modalities, in Briggs’ and Killen’s opinion, have sufficient evidence supporting them such that they can be “integrated” into science-based medicine, much the way Mark Crislip describes “integrating” cow pie with apple pie? Yeah, yeah, I know. Acupuncture. Sadly, no, acupuncture does not have convincing evidence that it is better than placebo. It is a “theatrical placebo.” More importantly, I’d love to hear what CAM modalities are dangerous, in Briggs and Killen’s opinion. Odd that they don’t mention even a single example in their article. Which CAM modalities merit regulatory attention. Again, they don’t say, and I can’t find any calls for regulation of, for example, supplements on the NCCAM website. Of course, Killen and Briggs would never do that. The National Advisory Council for Complementary and Alternative Medicine (in essence, Dr. Briggs’ bosses) would react very badly such statements were ever publicized. After all, there are acupuncturists, chiropractors, naturopaths, and homeopaths on the council.

Briggs and Killen conclude with a plea for a more “nuanced conversation” about CAM. I rather suspect that what they mean is something akin to, “You quacks, quit pressuring us to study obvious quackery like homeopathy and distance healing! It’s embarrassing and gives our opponents ammunition to use against us!” and “You skeptics, stop being so mean to us, accusing NCCAM of studying quackery, and demanding that NCCAM be defunded and absorbed back into the NIH. In a way, I rather feel for Dr. Briggs. She’s in a no-win situation. If she tries to make NCCAM too science-based, she risks alienating her constituency on the National Advisory Council for Complementary and Alternative Medicine. They’re likely not particularly happy with her to begin with, given that she’s tried to deemphasize the quackiest CAM modalities. Meanwhile, nipping at her heels are those of us who realize that applying rigorous science to quackery and rebranding modalities that should be part of SBM as somehow “alternative” are not good uses of taxpayer money. Yes, I feel for her, but not enough to give her the “nuanced conversation” that she wants to hide behind.