Can Alternative and Conventional Medicine Get Along? No.

If there’s one thing that I write that I don’t feel I repeat too much (although some might disagree), it’s that, unlike other centers and institutes at the National Institutes of Health (NIH), there is not, and never was, a compelling scientific justification for the National Center for Complementary and Alternative Medicine (NCCAM) to exist as a separate entity. There is nothing that NCCAM does that couldn’t be done just as well in other parts of the NIH, with the exception of research into modalities with such low prior plausibility and such fantastical proposed mechanisms of working that it’s a waste of money to study them. For example, “complementary and alternative medicine” (CAM) long ago co-opted nutrition and exercise, as well as natural products pharmacology (in the form of herbalism and supplements) as somehow being “alternative.” These could easily be studied in one of any number of other institutes or centers at the NIH, depending on the specific disease process being studied. In contrast, modalities like “energy medicine” (e.g., reiki, therapeutic touch, “bioenergy” and “biofield” medicine) rely on the claimed existence of “life energy” fields that no science has ever been able to detect, much less reliably measure.

The fact is that NCCAM was the creation of some prominent woo-friendly legislators, most prominently Senator Tom Harkin (D-IA), who introduced the original legislation to create the Office of Alternative Medicine, which later became NCCAM in 1998, thanks to legislation that he introduced, largely in response to efforts of then NIH Director Harold Varmus to bring NCCAM under more rigorous scientific control. (Elevating the Office of Alternative Medicine to the level of a Center removed it from the direct control of the NIH Director). Since then, NCCAM has grown into a $125 million a year boondoggle studying a range of treatment modalities that range from sheer quackery to science-based modalities that have been co-opted by CAM, often becoming “woo-ified” in the process. Unfortunately, given the structure of NCCAM, no matter how much the Director tries to impose scientific rigor, there is considerable pushback. I keep asking how NCCAM can continue to exist, but it’s a government agency with powerful political patrons, particularly Tom Harkin. No matter how much critics say say we should take off and nuke the entire center from orbit (it’s the only way to be sure), NCCAM endures. Maybe now that Harkin’s retiring there might be a chance in 2015, but I wouldn’t count on it. Senator Orrin Hatch (R-UT) or Senator Barbara Mikulski (D-MD) could easily pick up the slack.

Unfortunately, the current Director of NCCAM, Josephine Briggs, seems to “get it” less and less. As evidence of how Dr. Briggs doesn’t understand how she is serving the cause of infiltrating quackademic medicine into the most hallowed halls of medical academia, the NIH, I present to you a video web chat in which she participated yesterday, Live Chat: Can Alternative and Conventional Medicine Get Along? It featured Dr. Briggs, as well as an associate editor from Science Translational Medicine, Yevgeniya Nusinovich, M.D., Ph.D., who served as moderator, and a practitioner of “integrative medicine” at Kansas University, Dr. Jeanne Drisko, whose titles include Director, KU Integrative Medicine and the Riordan Endowed Professor of Orthomolecular Medicine. Of course, as I’ve discussed many times before, orthomolecular medicine, which basically posits that if some vitamins are good, more will be better, is pure quackery. In fact, I’ve discussed the infiltration of quackademic medicine at the University of Kansas before in general and Dr. Drisko in particular, less than a year ago, where I mentioned that KUMC offers its patients high dose vitamin C quackery for cancer.

Unfortunately, I couldn’t watch it live yesterday because I was in clinic when it was going on, but the video has been saved so that it was possible for me to take a look at it last night:

My first thought was: WTF? This was as one-sided a presentation as I’ve ever seen. Never was heard a skeptical word, as I had expected when I learned who the participants were going to be. We had the director of the single largest government agency promoting quackademic medicine (with the possible exception of the unfortunately named OCCAM) and the director of an integrative medicine program in which quackery like orthomolecular medicine is “integrated” with science-based medicine in an academic medical center. Add to that an associate editor of a journal that has recently shown a distressing tendency to publish a dubious placebo study by Ted Kaptchuk (blogged about a mere three weeks ago by yours truly). Given that, you know that the answer to the question being asked—Can Alternative and Conventional Medicine Get Along?—is going to be a resounding “yes,” and so it was. This was a discussion whose outcome was every bit as predetermined as that of a professional wrestling match but nowhere near as entertaining.

One thing I found particularly galling depends upon some inside knowledge that few people watching the video chat. Nearly four years ago (and it’s really hard to believe that it’s already been that long), I actually met Dr. Briggs and some of her staff. She had invited Kimball Atwood, Steve Novella, and me to meet with her as critics of NCCAM. Of course, not long after that, she wrote a truly misguided editorial entitled Listening to Differing Voices in which she stated that she had met with “both sides,” namely homeopaths and us, and dumped a classic bit of false equivalence between “skeptics” and CAM advocates in which “advocates would like to see more research dollars supporting various CAM approaches while the skeptics see our research investment as giving undue credibility to unfeasible CAM modalities and want less research funding,” as though the two held equal positions. Apparently she had met with an “international homeopathy team” sometime soon before or after she met with us. In any case, one thing we observed at that meeting was that Dr. Briggs tried as hard as possible to distance herself from the Trial to Assess Chelation Therapy, a massively unethical and pointless clinical trial to test a treatment for heart disease with close to zero prior plausibility and clinical evidence demonstrating that it is unlikely to work. She very pointedly reminded us that TACT started before her tenure as NCCAM director began and that it had been turned over from NCCAM to the National Heart, Lung and Blood Institute (NHLBI). Her eagerness to dissociate herself from TACT was palpable, and she declined to comment on it because it was, according to her, not part of NCCAM.

How her tune has changed in less than four years!

In this video chat, Dr. Briggs and Dr. Drisko gushed over TACT. Dr. Briggs even showed a figure from the study. Why? It’s because she seemed to think that she could spin TACT as a positive trial by focusing on the subgroup analysis that suggested a benefit for chelation therapy in diabetics. I’ve discussed this issue before when I analyzed the results of TACT reported about a year ago. The first problem I noted was that the outcome measure was an composite endpoint consisting of death, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. There was no significant difference in any of these individual outcome measures between control groups and test groups. Nada. Zero. Zip. In fact, there wasn’t a difference between the composite adverse cardiovascular event outcome in the overall population, either. The only way the investigators salvaged a seemingly positive result was through subgroup analysis of diabetics, which purported to show a difference, although even in diabetics there was no statistically significant difference in any of the individual cardiovascular endpoints.

This subgroup analysis was tarted up a bit a few months ago in a separate paper (thus reinforcing the concept of the MPU, or “minimal publishable unit”). Nothing new was presented, and the TACT investigators even published a graph virtually identical to the “diabetics vs. non-diabetics” graph in the original JAMA article about TACT. If you don’t believe me, just compare Figure 4 in the original JAMA article to Figure 2 in the new article. The only significant difference is that the new figure is in color and much more appealing to the eye.

Both Dr. Briggs and Drisko keep saying that there is “enough there to say that there’s something helpful.” No, really, there isn’t. It’s just a composite endpoint, and there are no statistically significant differences between any individual endpoints. Moreover, as I described before, there could be other reasons for the apparent difference in composite cardiovascular events. Or it could be a fluke due to how poorly the study was run, the problems with the study having been amply documented by Kimball C. Atwood, Elizabeth Woeckner, Robert Baratz, and Wally Sampson four years before the results of TACT were reported.

Once having done everything she could in private to dissociate herself from TACT, Dr. Briggs now exults over these results, while Dr. Drisko proclaims that it’s time to look for the “mechanism” by which chelation therapy “works” and/or do a larger trial to nail this result down. Really? TACT cost taxpayers $30 million. Does she really think that this probably spurious result is worth spending more than $30 million to chase down in these days of highly constrained NIH funding? I can think of a lot more important things that the NIH should be spending money on than confirming or disconfirming the results of a clinical trial that the government never should have spent $30 million on in the first place. Moreover, I can’t help but point out that Dr. Briggs and Dr. Drisko don’t say the obvious thing that needs to be said about TACT, even if we assume for the sake of discussion that the result seen in the subgroup analysis of diabetics, namely that the result of TACT strongly supports the conclusion that chelation therapy should not be used in non-diabetics with cardiovascular disease because TACT showed that in these patients it clearly doesn’t work. I’ve yet to hear a single CAM proponent say this about TACT, but they do say the same sorts of things that Dr. Drisko and Dr. Briggs say about “intriguing” results in diabetics. It’s pure poppycock.

Next up, our fearless moderator asks which alternative therapies are being “integrated” into the mainstream. I can’t help but notice that she didn’t ask, “Which alternative therapies work?” That’s a very different question, because, thanks to the march of quackademic medicine there are quite a few alternative therapies that are being “integrated” into the mainstream through the pseudospecialty of “integrative medicine” without any compelling evidence that they work. As I like to say, citing Mark Crislip, integrating cow pie with apple pie doesn’t make the apple pie taste better, or, as I like to say, “integrating” pseudoscience and quackery into mainstream medicine doesn’t make mainstream medicine stronger. It dilutes it with quackery. In any case, close to no evidence is discussed indicating that these modalities being “integrated” (such as acupuncture, “mind-body,” massage, and the like) work for the conditions indicated.

A lot of the rest of the video chat had to do with supplements and nutrition. Of course, this is nothing more than the classic “bait and switch” of CAM, or, as I like to call it, the “rebranding.” Basically, CAM advocates rebrand perfectly fine science-based modalities, such as nutrition and exercise, as somehow being “alternative” and thus part of CAM. Since these interventions have a scientific basis and can work for certain conditions, this little trick allows CAM advocates to claim that CAM works, while lumping all the magic, such as reiki, “energy healing,” acupuncture, and the like, in with the rebranded science-based modalities, implying that the magic must work too.

If you want perhaps the most blatant example of this “rebranding” at work, near the end of the video chat, Dr. Briggs cited hospice care as a model of medicine that came from outside the mainstream and is now an accepted part of medicine. At first I thought she was trying to imply that hospice is CAM; so I listened to it again. It turns out that she was just citing hospice as an example of a practice that came from “outside the mainstream” and is now accepted that she could use to imply that CAM practices would soon be mainstream. It was probably the latter, but either way it was totally off base. However, if you go to the National Hospice and Palliative Care Organization website and peruse its history of the hospice movement or a similar page on the National Hospice Foundation website, you’ll see that it’s quite the exaggeration to claim that hospice arose from outside of the mainstream in the same way that CAM arose outside of the mainstream.

After watching the entire video, one thing that I noticed was that both Dr. Drisko and Dr. Briggs admitted that the evidence base behind CAM is very thin indeed. Dr. Briggs couldn’t really come up with a CAM modality that NCCAM had shown to be definitely effective. To explain, Dr. Drisko likened CAM to the situation in medicine in the 1950s, where what we had, according to her, was little more than anecdotal observations and observational studies but were starting to challenge existing practices with more rigorous studies and randomized clinical trials. She thinks we’re at the stage where clinical research will change CAM practices. I disagree. It’s already been shown time and time again by the reaction of CAM practitioners to research showing that their modality doesn’t work that CAM practitioners do not appreciably change practice. Specifically, unlike the case in science-based medicine, it’s always hard to come up with a list of CAM practices that have been abandoned because research showed that they didn’t work. Seriously, homeopathy is still with us. The day I see CAM practitioners completely reject homeopathy as pseudoscience is the day that I might believe someone like Dr. Drisko chirpily predicting that we’re at the dawn of a great new scientific age in CAM. After all, she practices orthomolecular medicine, works with a naturopath, and administers IV vitamin C, even mentioning a study recently published in, yes, Science Translational Medicine, claiming that high dose vitamin C is active against ovarian cancer. (Yes, I do plan on looking into that one.)

Perhaps the most annoying thing is how at the end Dr. Briggs co-opts a favorite saying of skeptics that there is no such thing as “alternative” medicine and that when something “alternative” is shown to work it ceases to be “alternative” and becomes just “medicine.” I’ve said that time and time again myself. I’ve also used that belief to argue that NCCAM shouldn’t exist. After all, there should be no such thing as “alternative” or “complementary” medicine. There should be just medicine. Unfortunately, neither Dr. Drisko, Dr. Briggs, nor the organizers of this web chat seem to understand this.