Choosing Wisely about homeopathy, supplements, and "detoxification" quackery

One of the major differences between science-based medicine (SBM) and alternative medicine—or, as they call it these days, “complementary and alternative medicine” (CAM) or “integrative medicine”—is that SBM is always questioning itself, always reevaluating its practices. Related to this difference is that SBM does change its practice, discarding treatments that don’t work and incorporating those that do work (or at least work better than older practices). As I’ve said many times before, the process by which this happens is messy and slower than we might like, and that provides ammunition to CAM practitioners to cast doubt on the scientific basis of medicine. However, when push comes to shove, SBM does evolve in response to science and evidence. In contrast, alternative medicine practices, regardless of whether they stand alone or are “integrated” with SBM (or, as I prefer to call it, they contaminate SBM), remain fixed in a prescientific mindset in which magical energy fields and life forces are manipulated and evil humors cause disease more than microbes. Sure, old concepts are gussied up with “science-y” sounding terms, but the basic concepts remain rooted in long abandoned humoral theory and vitalism.

One example of science-based medicine trying to improve itself is an initiative called Choosing Wisely. Basically, it’s the result of a challenge by the ABIM Foundation to professional organizations:

An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.

To spark these conversations, leading specialty societies have created lists of “Things Physicians and Patients Should Question” — evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation.

Consumer Reports is developing and disseminating materials for patients through large consumer groups to help patients engage their physicians in these conversations and ask questions about what tests and procedures are right for them.

It’s also an initiative that I fully support, so much so that I am involved with a statewide initiative to discourage practices related to breast cancer in Choosing Wisely lists. I’ve written about before, pointing out some of its prominent recommendations and also noting a couple of areas where it falls short (for instance, routine breast MRI before breast-conserving surgery in the absence of high breast density does not decrease reexcision rates or decrease the mastectomy rate). I’ve also used it (and a prominent study) to illustrate the key difference between SBM and CAM I alluded to at the beginning of this post.

Now I see that there are new recommendations, and they are of interest to those of us who keep track of CAM practices, in particular practices favored by naturopaths and other quacks who claim that everyone suffers from “heavy metal toxicity” or some variant thereof and recommend various treatments designed to eliminate that “toxicity,” such as replacement of amalgam fillings and chelation therapy. It’s a rather interesting interface between CAM and conventional medicine. In one way, I see these recommendations as a bit of a cop-out, but on the other hand they can also be viewed as a much-needed calling out of bad actors who profit from quackery and are used by quacks. I’m referring to the recently released Choosing Wisely list from the American College of Medical Toxicology and The American Academy of Clinical Toxicology. Let’s take a look at them, shall we?

Here’s #1:

1. Don’t use homeopathic medications, non-vitamin dietary supplements or herbal supplements as treatments for disease or preventive health measures.

Alternative therapies are often assumed safe and effective just because they are “natural.” There is a lack of stringent quality control of the ingredients present in many herbal and dietary supplements. Reliable evidence that these products are effective is often lacking, but substantial evidence exists that they may produce harm. Indirect health risks also occur when these products delay or replace more effective forms of treatment or when they compromise the efficacy of conventional medicines.

There really isn’t much to add to this one. The ACMT and AACT are absolutely right, but they didn’t go far enough. They really should have mentioned that homeopathic remedies are so diluted that, most commonly except in the case of the very “weakest” (i.e., least diluted) homeopathic remedies, there is a vanishingly small chance that there is even a single molecule of the original substance left.

The one that’s going to leave a mark is #2:

2. Don’t administer a chelating agent prior to testing urine for metals, a practice referred to as “provoked” urine testing.

Metals are ubiquitous in the environment and all individuals are exposed to and store some quantity of metals in the body. These do not necessarily result in illness. Scientific studies demonstrate that administration of a chelating agent leads to increased excretion of various metals into the urine, even in healthy individuals without metal-related disease. These “provoked” or “challenge” tests of urine are not reliable means to diagnose metal poisoning and have been associated with harm.

This is an issue I’ve written about since near the very beginning of this blog, and it’s great to see a mainstream organization to which many of the doctors running the labs that run these medically useless tests belong to. One of these laboratories is particularly notorious for this practice, commonly called the “provoked urine test” for heavy metals. Indeed, this very laboratory is engaging in a bit of legal thuggery, Stephen Barrett of Quackwatch for actually writing about its scientifically unsupported practice. (Personally, I hope that this new Choosing Wisely list provides Dr. Barrett with ammunition for his defense against this frivolous lawsuit.) It’s also a favorite test of the mercury militia looking for elevated mercury levels due to exposure to thimerosal in vaccines and elsewhere. (Never mind that thimerosal has been removed from childhood vaccines other than certain flu vaccines, and there are now only trace amounts of thimerosal in some vaccines.) In essence, the chelating agent given before this test elevates the levels of mercury and other heavy metals in the urine, sometimes far beyond normal. The urine is then collected for several hours after the chelator has been administered. That is the “provoked” nature of the urine test. This method is in contrast to the standard manner of measuring these metals in the urine, which involves collecting a 24 hour urine sample, no provocation. Here’s the problem. A provoked urine test, by its very nature, is designed to increase the secretion of heavy metals and thus increase their concentration in the urine. The problem is that there are no standard values for provoked urine tests, although there are reference values for standard, unprovoked, 24 hour urine specimens. Guess what values antivaccine quacks and naturopaths (but I repeat myself) use?

Doing provoked urine testing is a cottage industry among various medical laboratories, and there are labs that should know better that do these tests on the side or wink at the values even though values as high as they get are rare if no chelation agent is administered beforehand.

The next two item on the list is very much related to #2:

3. Don’t order heavy metal screening tests to assess non-specific symptoms in the absence of excessive exposure to metals.

Individuals are constantly exposed to metals in the environment and often have detectable levels without being poisoned. Indiscriminant testing leads to needless concern when a test returns outside of a “normal” range. Diagnosis of any metal poisoning requires an appropriate exposure history and clinical findings consistent with poisoning by that metal. A patient should only undergo specific metal testing if there is concern for a specific poisoning based on history and physical examination findings.

4. Don’t recommend chelation except for documented metal intoxication which has been diagnosed using validated tests in appropriate biological samples.

Chelation does not improve objective outcomes in autism, cardiovascular disease or neurodegenerative conditions like Alzheimer’s disease. Edetate disodium is not FDA-approved for any condition. Even when used for appropriately diagnosed metal intoxication, chelating drugs may have significant side effects, including dehydration, hypocalcemia, kidney injury, liver enzyme elevations, hypotension, allergic reactions and essential mineral deficiencies. Inappropriate chelation, which may cost hundreds to thousands of dollars, risks these harms, as well as neurodevelopmental toxicity, teratogenicity and death.

As I’ve discussed many times, a catch-all diagnosis from quacks of many varieties, but in particular from naturopaths, is “heavy metal toxicity.” It’s billed as the cause of autism in children, and diseases in adults as varied as cardiovascular disease and cancer; in particular it is blamed as the cause of common complaints such as fatigue and feeling run down. In addition, chelation therapy is a favorite treatment for “detoxification” by naturopaths and many other varieties of quacks. It is a real treatment for real acute heavy metal poisoning, but real acute heavy metal poisoning is quite uncommon in industrialized nations these days. Unlike the alt-med version of heavy metal “toxicity,” real heavy metal poisoning requires a history of exposure plus actual symptoms of toxicity. Those symptoms and the symptoms for which chelation therapy is frequently given are often related to each other only by coincidence.

Worse, chelation therapy is potentially dangerous. The most egregious example of this was a real “clean kill,” an unfortunate autistic child named Abubakar Tariq Nadama who was unfortunate enough to be born to parents who brought him to a physician near Pittsburgh who killed him with chelation therapy.

Finally:

5. Don’t remove mercury-containing dental amalgams.

Mercury-containing dental amalgams release small amounts of mercury. Randomized clinical trials demonstrate that the mercury present in amalgams does not produce illness. Removal of such amalgams is unnecessary, expensive and subjects the individual to absorption of greater doses of mercury than if left in place.

This is what is sometimes called “toxic teeth” quackery. It’s so pervasive that Dr. Oz featured it on his show. Sadly, he did so completely credulously and approvingly, but that’s par for the course for Dr. Oz. The bottom line is that quacks frequently tell people to have their amalgam fillings removed and replaced as part of their “detoxification” regimen. Sometimes, when it’s part of cancer quackery, removing fillings and replacing them is just one more thing making the patient suffer before the end.

As I mentioned at the beginning of this article, I’m a bit conflicted about this list. The purpose of Choosing Wisely is to point out commonly performed medical practices and procedures that are either unnecessary, ineffective, or even harmful. This is a very good thing indeed. If I didn’t think so, I wouldn’t be involved in promoting the initiative with respect to breast cancer. However, the purpose of the Choosing Wisely initiative struck me as being to promote the questioning of conventional medical treatments that don’t have a good evidence base for them. This entire list is basically calling out quackery. Then it occurred to me. The ACMT states that its primary mission is to serve physicians who are medical toxicologists, defined as treating “drug overdose, acute drug abuse problems, chemical exposures, and envenomations.” The AACT describes its mission as uniting “into one group scientists and clinicians whose research, clinical, and academic experience focus on clinical toxicology.”

On the other hand, the Choosing Wisely challenge specifically was that “national organizations representing medical specialists have been asked to ‘choose wisely’ by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.” The choice of these five items by the AACT and ACMT implies that these five practices, which, let’s face it, are all sheer quackery, are commonly used in its field. If that’s true, it’s very sad, but it is very good that the AACT and ACMT are finally calling the quacks out.