MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

critical thinking

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As so often in the realm of so-called alternative medicine (SCAM), the Australians are setting an example. The Australian Health Practitioner Regulation Agency (Ahpra) is the national organisation responsible for implementing the National Registration and Accreditation Scheme (the National Scheme) across Australia. Yesterday, the Ahpra have issued an important press-release. Here is an excerpt:

… While the vast majority of health practitioners are responding professionally to the COVID-19 emergency and focusing on providing safe care, Ahpra and National Boards are seeing some examples of false and misleading advertising on COVID-19.

During these challenging times, it is vital that health practitioners only provide information about COVID-19 that is scientifically accurate and from authoritative sources, such as a state, territory or Commonwealth health department or the World Health Organization (WHO). According to these authoritative sources, there is currently no cure or evidence-based treatment or therapy which prevents infection by COVID-19 and work is currently underway on a vaccine.

Other than sharing health information from authoritative sources, registered health practitioners should not make advertising claims on preventing or protecting patients and health consumers from contracting COVID-19 or accelerating recovery from COVID-19. To do so involves risk to public safety and may be unlawful advertising. For example, we are seeing some advertising claims that spinal adjustment/manipulation, acupuncture and some products confer or boost immunity or enhance recovery from COVID-19 when there is no acceptable evidence in support.

Advertisers must be able to provide acceptable evidence of any claims made about treatments that benefit patients/health consumers. We will consider taking action against anyone found to be making false or misleading claims about COVID-19 in advertising. If the advertiser is a registered health practitioner, breaching advertising obligations is also a professional conduct matter which may result in disciplinary action, especially where advertising is clearly false, misleading or exploitative. There are also significant penalties for false and misleading advertising claims about therapeutic products under the Therapeutic Goods Act 1989.

Patients and health consumers should treat any advertising claims about COVID-19 cautiously and check authoritative sources for health information about COVID-19, such as state, territory and Commonwealth health departments.

As always, patients and health consumers should ask their practitioner for information to support any advertising claims before making decisions about treatment. Patients and health consumers should receive accurate and truthful messages so they can make the right choices about their health.

Many of my posts during the last weeks have dealt with this problem. The sad truth is that charlatans of all types are trying to exploit the fear of consumers during the current crisis for making a fast buck. This is despicable, unethical, unprofessional and possibly criminal.I do hope that the authorities of other countries follow the Australian example.

Many hundreds of plants worldwide have a place in folk medicine as treatments for microbial infections and antimicrobial activity of extracts in vitro may be readily assessed in microbiology laboratories. Many so tested are reported to show inhibitory effects against a range of organisms. For less than responsible entrepreneurs, this is often enough reason to promote them as therapeutic options.

But laboratory testing can at best be only a very crude, though relatively inexpensive and rapid screen, while in vivo testing is very costly and time consuming. On this background, we conducted a review in 2003 to examine the range of plants or herbs that have been tested for antiviral properties in laboratories, animals and humans. Here is its abstract:

Background and aims: Many antiviral compounds presently in clinical use have a narrow spectrum of activity, limited therapeutic usefulness and variable toxicity. There is also an emerging problem of resistant viral strains. This study was undertaken to examine the published literature on herbs and plants with antiviral activity, their laboratory evaluation in vitro and in vivo, and evidence of human clinical efficacy.

Methods: Independent literature searches were performed on MEDLINE, EMBASE, CISCOM, AMED and Cochrane Library for information on plants and herbs with antiviral activity. There was no restriction on the language of publication. Data from clinical trials of single herb preparations used to treat uncomplicated viral infections were extracted in a standardized, predefined manner.

Results: Many hundreds of herbal preparations with antiviral activity were identified and the results of one search presented as an example. Yet extracts from only 11 species met the inclusion criteria of this review and have been tested in clinical trials. They have been used in a total of 33 randomised, and a further eight non-randomised, clinical trials. Fourteen of these trials described the use of Phyllanthus spp. for treatment of hepatitis B, seven reporting positive and seven reporting negative results. The other 10 herbal medicines had each been tested in between one and nine clinical trials. Only four of these 26 trials reported no benefit from the herbal product.

Conclusions: Though most of the clinical trials located reported some benefits from use of antiviral herbal medicines, negative trials may not be published at all. There remains a need for larger, stringently designed, randomised clinical trials to provide conclusive evidence of their efficacy.

One of the herbal remedies that seemed to show some promise specifically for upper respiratory infections was Andrographis paniculata. This evidence prompted us in 2004 to conduct a systematic review focused on this herb specifically. Here is its abstract:

Acute respiratory infections represent a significant cause of over-prescription of antibiotics and are one of the major reasons for absence from work. The leaves of Andrographis paniculata (Burm. f.) Wall ex Nees (Acanthaceae) are used as a medicinal herb in the treatment of infectious diseases. Systematic literature searches were conducted in six computerised databases and the reference lists of all papers located were checked for further relevant publications. Information was also requested from manufacturers, the spontaneous reporting schemes of the World Health Organisation and national drug safety bodies. No language restrictions were imposed. Seven double-blind, controlled trials (n = 896) met the inclusion criteria for evaluation of efficacy. All trials scored at least three, out of a maximum of five, for methodological quality on the Jadad scale. Collectively, the data suggest that A. paniculata is superior to placebo in alleviating the subjective symptoms of uncomplicated upper respiratory tract infection. There is also preliminary evidence of a preventative effect. Adverse events reported following administration of A. paniculata were generally mild and infrequent. There were few spontaneous reports of adverse events. A. paniculata may be a safe and efficacious treatment for the relief of symptoms of uncomplicated upper respiratory tract infection; more research is warranted.

Before you now rush to buy a dietary supplement of A. paniculata, let me stress this in no uncertain terms: the collective evidence is at best suggestive, but it is not compelling. Importantly, there is, to the best of my knowledge, no sound evidence that any herbal remedy is effective in preventing or treating Covid-19 infections.

I truly wished to be able to report more encouraging news, but the truth is the truth, even (I would argue, particularly) in desperate times.

The objective of this trial, just published in the BMJ, was to assess the efficacy of manual acupuncture as prophylactic treatment for acupuncture naive patients with episodic migraine without aura. The study was designed as a multi-centre, randomised, controlled clinical trial with blinded participants, outcome assessment, and statistician. It was conducted in 7 hospitals in China with 150 acupuncture naive patients with episodic migraine without aura.

They were given the following treatments:

  • 20 sessions of manual acupuncture at true acupuncture points plus usual care,
  • 20 sessions of non-penetrating sham acupuncture at heterosegmental non-acupuncture points plus usual care,
  • usual care alone over 8 weeks.

The main outcome measures  were change in migraine days and migraine attacks per 4 weeks during weeks 1-20 after randomisation compared with baseline (4 weeks before randomisation).

A total of 147 were included in the final analyses. Compared with sham acupuncture, manual acupuncture resulted in a significantly greater reduction in migraine days at weeks 13 to 20 and a significantly greater reduction in migraine attacks at weeks 17 to 20. The reduction in mean number of migraine days was 3.5 (SD 2.5) for manual versus 2.4 (3.4) for sham at weeks 13 to 16 and 3.9 (3.0) for manual versus 2.2 (3.2) for sham at weeks 17 to 20. At weeks 17 to 20, the reduction in mean number of attacks was 2.3 (1.7) for manual versus 1.6 (2.5) for sham. No severe adverse events were reported. No significant difference was seen in the proportion of patients perceiving needle penetration between manual acupuncture and sham acupuncture (79% v 75%).

The authors concluded that twenty sessions of manual acupuncture was superior to sham acupuncture and usual care for the prophylaxis of episodic migraine without aura. These results support the use of manual acupuncture in patients who are reluctant to use prophylactic drugs or when prophylactic drugs are ineffective, and it should be considered in future guidelines.

Considering the many flaws in most acupuncture studies discussed ad nauseam on this blog, this is a relatively rigorous trial. Yet, before we accept the conclusions, we ought to evaluate it critically.

The first thing that struck me was the very last sentence of its abstract. I do not think that a single trial can ever be a sufficient reason for changing existing guidelines. The current Cochrance review concludes that the available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. Thus, one could perhaps argue that, together with the existing data, this new study might strengthen its conclusion.

In the methods section, the authors state that at the end of the study, we determined the maintenance of blinding of patients by asking them whether they thought the needles had penetrated the skin. And in the results section, they report that they found no significant difference between the manual acupuncture and sham acupuncture groups for patients’ ability to correctly guess their allocation status.

I find this puzzling, since the authors also state that they tried to elicit acupuncture de-qi sensation by the manual manipulation of needles. They fail to report data on this but this attempt is usually successful in the majority of patients. In the control group, where non-penetrating needles were used, no de-qi could be generated. This means that the two groups must have been at least partly de-blinded. Yet, we learn from the paper that patients were not able to guess to which group they were randomised. Which statement is correct?

This may sound like a trivial matter, but I fear it is not.

Like this new study, acupuncture trials frequently originate from China. We and others have shown that Chinese trials of acupuncture hardly ever produce a negative finding. If that is so, one does not need to read the paper, one already knows that it is positive before one has even seen it. Neither do the researchers need to conduct the study, one already knows the result before the trial has started.

You don’t believe the findings of my research nor those of others?

Excellent! It’s always good to be sceptical!

But in this case, do you believe Chinese researchers?

In this systematic review, all RCTs of acupuncture published in Chinese journals were identified by a team of Chinese scientists. An impressive total of 840 trials were found. Among them, 838 studies (99.8%) reported positive results from primary outcomes and two trials (0.2%) reported negative results. The authors concluded that publication bias might be major issue in RCTs on acupuncture published in Chinese journals reported, which is related to high risk of bias. We suggest that all trials should be prospectively registered in international trial registry in future.

So, at least three independent reviews have found that Chinese acupuncture trials report virtually nothing but positive findings. Is that enough evidence to distrust Chinese TCM studies?

Perhaps not!

But there are  even more compelling reasons for taking evidence from China with a pinch of salt:

A survey of clinical trials in China has revealed fraudulent practice on a massive scale. China’s food and drug regulator carried out a one-year review of clinical trials. They concluded that more than 80 percent of clinical data is “fabricated“. The review evaluated data from 1,622 clinical trial programs of new pharmaceutical drugs awaiting regulator approval for mass production. According to the report, much of the data gathered in clinical trials are incomplete, failed to meet analysis requirements or were untraceable. Some companies were suspected of deliberately hiding or deleting records of adverse effects, and tampering with data that did not meet expectations. “Clinical data fabrication was an open secret even before the inspection,” the paper quoted an unnamed hospital chief as saying. Chinese research organisations seem have become “accomplices in data fabrication due to cutthroat competition and economic motivation.”

So, am I claiming the new acupuncture study just published in the BMJ is a fake?

No!

Am I saying that it would be wise to be sceptical?

Yes.

Sadly, my scepticism is not shared by the BMJ’s editorial writer who concludes that the new study helps to move acupuncture from having an unproven status in complementary medicine to an acceptable evidence based treatment.

Call me a sceptic, but that statement is, in my view, hard to justify!

 

The ‘Corona-Virus Quackery Club’ (CVQC) is getting positively crowded. You may remember, its members include:

Today we are admitting the herbalists. The reason is obvious: many of them have jumped on the corona band-wagon by trying to improve their cash-flow on the back of the pandemic-related anxiety of consumers. If you go on the Internet you will find many examples, I am sure. I have chosen this website for explaining the situation.

Herbs That Can Stop Coronavirus Reproduction

CoV multiplies fast in the lungs and the stomach and intestines. The more virus, the sicker you get. The herbs are in their scientific names and common names.

    1. Cibotium barometz – golden chicken fern or woolly fern grows in China and Southeast Asia.

      Cibotium Barometz

    2. Gentiana scabra – known as Korean gentian or Japanese gentian seen in the United States and Japan.

      Japanese Gentian

    3. Dioscorea batatas or Chinese Yam grows in China and East Asia

      Chinese Yam

    4. Cassia tora or Foetid cassia, The Sickle Senna, Wild Senna – grows in India and Central America

      Cassia Tora

    5. Taxillus Chinensis – Mulberry Mistletoe

Lectin Plants that Have Anti Coronavirus Properties

Plant Lectins with Antiviral activity Against Coronavirus

From the table above, all have anti coronavirus activity except for garlic. One plant that is effective but not listed is Stinging nettle.

Yes, very nice pictures – but sadly utterly unreliable messages. My advice is that, in case you have concerns about corona (or any other health problem for that matter), please do not ask a herbalist.

WELCOME TO THE CVQC, HERBALISTS!

Yesterday, it was announced that Prince Charles, a long-time advocate of so-called alternative medicine (SCAM), has been taken ill with the corona virus. Since then, I have been inundated with messages about this fact. Many thought that, because Charles and I have a bit of history (details here), I might now ‘have a cup of tea and a malicious smile on [my] face thinking about it’, as someone put it on Twitter. Others made sarcastic comments suggesting that he will be fine because of all the help of the homeopathic cult.

I cannot join these sentiments. On the contrary, I sincerely wish him well – not because he is royalty, but because I wish everyone well who has been infected with this virus.

And I honestly do not think that Charles will be popping homeopathic placebos to save his life. Whenever a member of his (usually pro-homeopathy) family had fallen seriously ill in the past, they very quickly sought the help of the very best evidence-based medicine could offer. Charles’ present illness will be no exception, I am sure. If his infection becomes serious, he will have the benefit of everything modern scientific healthcare has to offer.

When he recovers – and I do hope he does – he will have plenty of time to think. Chances are that he never before had been afflicted with a killer disease. This should make him see things from an entirely new perspective. He must realise that so-called alternative medicine (SCAM) is an option only as long as one is healthy. Once the battle for saving a life is on, real medicine must save the day.

I am a born optimist, and therefore I hope that Charles on his sick-bed might even think a little further. He might realise that a health crisis, like the current corona pandemic, regularly brings out the charlatans who are trying to flog their wares or services to the unsuspecting public. On my blog, I have discussed some of these irresponsible rogues:

With a bit of luck, Charles might even reflect that his past endorsement of these quacks has been less than helpful; in the present crisis, it might even cost lives. Charles, I hope, will thus reconsider his attitude towards medicine, heaven knows, he might even become an outspoken advocate fro EBM!

So yes, I am an incurable optimist. Yet, I realise, of course, that Charles might not have any of these insights. That would be regrettable, but it does not deter me from wishing him a speedy recovery:

GET WELL SOON, CHARLES!

[If you do not like black humour or sarcasm, please do NOT read this post!!!]

Donald Trump just announced that, at Easter, he wants to see churches packed, his way of saying the lock-down is over because it is damaging the economy. Many others have put forward similar arguments and have pointed out that caring for the vulnerable, sick, old, etc. creates an economic burden that might eventually kill more people than it saves (see for instance ‘Economic crash could cost more lives than coronavirus, study warns‘).

Many people have also argued that homeopathy is unjustly vilified because it is truly a wholesome and safe medicine that should be used routinely. The notion here is that, alright, the evidence is not brilliant, but 200 years of experience and millions of fans cannot be ignored.

I have been wondering whether these two lines of thinking could not be profitably combined. Here is my suggestion based on the following two axioms.

  1. The economy is important for all our well-being.
  2. Homeopaths have a point in that the value of experience must not be ignored.

What follows is surprisingly simple: in view of the over-riding importance of the economy, let’s prioritise it over health. As it would look bad to deny those poor corona victims all forms of healthcare, let’s treat them homeopathically. This would make lots of people happy:

  • those who think the economy must take precedent,
  • those who fear the huge costs of saving corona patients (homeopathy is very cheap),
  • those who argued for decades that we never gave homeopathy a fighting chance to show its worth.

There is a downside, of course. There would be a most lamentable mortality rate. But, to paraphrase Dominic Cummings, if a few oldies have to snuff it, so be it!

Once we get used to this innovative approach – I suggest we call it integrative medicine – we might even consider adopting it for other critical situations. When we realise, for instance, that the pension pots are empty, we could officially declare that homeopathy is the ideal medicine for anybody over 60.

What do you think?

 

My ‘Corona-Virus Quackery Club’ (CVQC) is getting rather popular. The current members,

homeopaths,

colloidal silver crooks,

TCM practitioners,

orthomolecular quacks,

Unani-salesmen

and chiropractors,

are now thinking of admitting the essential oil salesmen. It seems that many of them find it impossible to resist the chance to make a fast buck on the fear many consumers currently have. Take this website for instance:

If you have a breathing aid or respiratory device, use it to reduce breathing difficulties. Alternatively, you can use a breathing ointment like Breathe and Focus Oil. Formulated with menthol, eucalyptus, rosemary and thyme essential oils, this phyto-aromatherapy ointment helps ease breathing difficulties commonly associated with cold, flu, cough, asthma and pneumonia. Gently massage a few drops of Breathe and Focus Oil to your chest and apply 1 to 2 drops to a tissue or handkerchief then inhale the aroma. Repeat as often as necessary.

Studies showed that eucalyptus essential oil contains cineole that helps reduce inflammation and infection in the lungs. Eucalyptus Radiata essential oil has antiviral effects against coronavirus SARS. Rosemary essential oil has been shown to be effective against Klebsiella pneumoniae, a bacteria which causes pneumonia in humans and animals. Thyme essential oil has been shown to have antiviral activities against Influenza A virus (H1N1), while menthol with its cooling-effect has also been shown to reduce breathing difficulties. These essential oils may help you dealing with Covid-19 disease.

Another website even has the promising title ‘What can you try to cure from coronavirus ….’ and it tells us that:

Black cumin can boost immunity, especially in patients with impaired immune systems. According to research, 1 gram Seed capsules, twice daily for four weeks can improve T-cell ratio between positive and negative up to 72%. Increased immunity plays an important role in the healing of colds, influenza, AIDS, and other diseases related to the immune system.

But there is more – so much more that I can here only present a very small selection of that is on offer.

Recommended antiviral essential oils for healthy adults:

  • Cinnamon bark
  • Clove bud
  • Eucalyptus globulus/radiata
  • Lemon
  • Lemon myrtle
  • Manuka
  • Melissa
  • Niaouli
  • Ravensara
  • Ravintsara
  • Rosemary
  • Saro
  • Tea tree
  • Thyme thymol & linalool

Yet another website includes the claim: “The most powerful anti-virus essential oils to provide defence (sic) against coronavirus include:

  • Basil
  • Bergamot
  • Cajuput
  • Cedarwood Virginian
  • Cinnamon
  • Clove Bud
  • Eucalyptus Globulus, Radiata and Smithii
  • Juniper Berry
  • Lavender Spike
  • Laurel leaf
  • Lemon
  • Manuka
  • Niaouli
  • Peppermint
  • Ravensara
  • Ravintsara
  • Rosemary
  • Sage
  • Tea Tree
  • Thyme Sweet Thyme White.”

I know, this is confusing! I do sympathise with the difficulty of choosing between all these recommendation; therefore, let me help you. Here is the full list of essential oils proven to prevent or treat a corona-virus infection:

Yes, that’s right: NO ESSENTIAL OIL HAS EVER BEEN FOUND TO BE EFFECTIVE AGAINST THIS OR ANY OTHER VIRUS INFECTION!

The FDA agree and have therefore sent out letters to seven US companies warning them to stop selling products that claim to cure or prevent COVID-19 infections, stating that such products are a threat to public health because they might prompt consumers to stop or delay appropriate medical treatment.

WELCOME TO THE CVQC, ESSENTIAL OIL SALESMEN!

Boris Johnson said we should take the coronavirus ‘on the chin’ and count on ‘herd-immunity’. This, he claimed, is what his scientific advisers recommended.

I find this very hard to believe and have many doubts and questions.

To start with, I doubt that this is what Johnson’s scientific advisers recommend – it is a solution that SOME of his scientific advisers recommend. And it is a solution that seems easy to follow. It is, however, by no means the only strategy for tacking the pandemic; it is just one of several options.

The fact that all other countries have opted for other solutions, suggests to me that it is an unusual path to go down to. The modellers who obviously like it had to make a number of assumptions; that’s what modellers always have to do and rarely tell us about. But what if not all of these assumptions are correct?

The herd-immunity strategy counts on the fact that, once a certain percentage of the population has taken the infection ‘on the chin’, it is immune and therefore the transmission of the virus within such a population will be dramatically reduced or even zero. The percentage of the population needed for that to happen depends on how contagious the virus is. For the measles virus, herd immunity requires 90% of the population to be immune. For the coronavirus, the figure is said to be 60 – 70%. Is that an assumption or a fact? If it is a current fact, would the figure change, if the virus mutates? Could it be that a mutated virus can re-infect formerly immune people?

But let’s postulate that the herd-immunity assumption is both correct and stable. Johnson’s herd-immunity strategy would thus require that about 40 million Brits get infected with the virus to generate the required herd-immunity. Assuming a mortality rate of 1 – 2%, this means that Johnson is cheerfully accepting 400 000 – 800 000 fatalities.

But, as I said, this scenario is based on wild assumptions. It applies only if the virus does not mutate. And it only applies, if we do not run out of intensive care (IC) beds. However, running out seems possible, perhaps even likely, considering that we have only about half of the French and just one third of the German IC capacity. Sod’s law has it that both might happen. In this case, we might easily have far in excess of 800 000 fatalities. How should we take that ‘on the chin’, Mr Johnson?

Sadly, this is not all; I have further doubts about our PM’s ideas.

The present strategy regarding diagnosis of coronavirus cases is to self-isolate once suspicious symptoms start. Even if someone is seriously ill (with high fever etc.), they are told to stay at home and sit it out. This means we will never know whether these patients had or had not suffered from a coronavirus infection. How then can we ever be sure that the 60% target of infection has been reached? And if we are uncertain about it, how can we be sure that herd-immunity will work in the way the modellers predicted?

Moreover, we now know that people who caught the virus are infective BEFORE they develop symptoms. If that is so, the strategy of self-isolation will be far less effective than predicted. And, given this fact, are we not much more likely to have a sharp peak of cases early on which would make us run out of IC capacity? When that happens, even the pessimistic death rates might turn out to be too optimistic.

It seems to me that Johnson’s herd-immunity strategy is risky to the point of being reckless. It also seems to me that there are very good reasons why other countries have not adopted it.

But what is the solution?

In my view, the solution cannot be to uncritically adopt the theories and assumptions of modellers. This is not a computer game; we are talking about human lives, many human lives!

I wish I new what the best solution is – but I don’t. I merely fear that ‘taking it on the chin’ is not a solution at all. In any case, a wise move for Johnson and his team might be to consider that foreigners might be at least as clever as they are. Subsequently they could carefully study the actions of those countries which managed to bring down their death-rates despite being attacked by the coronavirus.

This ‘Manifesto of the European Committee for Homeopathy (ECH) and the European Federation of Homeopathic Patients Associations (EFHPA)‘ has just been published. It is worth considering in more detail, I think. So, I will first reproduce the document in its entirety and subsequently provide some critical assessment of it.

Homeopathy: a solution for major healthcare problems in the EU

  • Helps to reduce the need of antibiotics in human and veterinary health care, thus reducing the problem of antimicrobial resistance [i],[ii]
  • Increases quality of life and reduces severity of complaints in patients with chronic disease, when integrated in health care [iii],[iv],[v],[vi],[vii],[viii]
  • Can reduce the use of long-term conventional prescription drugs, when integrated in health care [ix]

Homeopathy: safe and cost-effective with a high patient satisfaction

  • Can lead to lower health care costs, when integrated in health care, [x],[xi],[xii],
  • Is safe, with high patient satisfaction [xiii],[xiv],[xv],[xvi]
  • Patients using homeopathy have better outcomes than users of conventional treatment, with similar costs [xvii]
  • Quality, safety and correct labelling of homeopathic products is guaranteed by Directive 2001/83 EC

 EU consumers expect and demand homeopathy as part of their health care

  • Reported as the most used medical complementary medicine in Europe [xviii]
  • Three out of four European citizens know about homeopathy and out of them 29% use it for their day-to day health care [xix]

 Scientific evidence of the highest calibre confirms the clinical efficacy of homeopathic   medicine

There is convincing evidence for biological efficacy of homeopathic medicine

  • Irrefutable scientific evidence has been published on the positive effects of homeopathic products in laboratory settings [xxvii],[xxviii]

References

[i] Grimaldi-Bensouda L, Bégaud B, Rossignol M, et al. Management of upper respiratory tract infections by different medical practices, including homeopathy, and consumption of antibiotics in primary care: the EPI3 cohort study in France 2007-2008. PLoS One. 2014 Mar 19;9(3):e89990

[ii] Camerlink I, Ellinger L, Bakker EJ, Lantinga EA. Homeopathy as replacement to antibiotics in the case of Escherichia coli diarrhoea in neonatal piglets. Homeopathy. 2010 Jan;99(1):57-62

[iii] Witt CM, Lüdtke R, Baur R, Willich SN. Homeopathic medical practice: long-term results of a cohort study with 3981 patients. BMC Public Health 2005; 5:115

[iv]  Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005; 11:793–798

[v] Mathie RT, Robinson TW. Outcomes from homeopathic prescribing in medical practice: a prospective, research-targeted, pilot study. Homeopathy 2006; 95:199–205

[vi] Thompson EA, Mathie RT, Baitson ES, et al. Towards standard setting for patient-reported outcomes in the NHS homeopathic hospitals. Homeopathy 2008; 97:114–121

[vii] Witt CM, Lüdtke R, Mengler N, Willich SN. How healthy are chronically ill patients after eight years of homeopathic treatment?–Results from a long term observational study BMC Public Health 2008;8:413

[viii] Rossi E, Endrizzi C, Panozzo MA, Bianchi A, Da Frè M. Homeopathy in the public health system: a seven-year observational study at Lucca Hospital (Italy). Homeopathy 2009; 98:142–148

[ix] Grimaldi-Bensouda L, Abenhaim L, Massol J, et al. EPI3-LA-SER group. Homeopathic medical practice for anxiety and depression in primary care: the EPI3 cohort study. BMC Complement Altern Med. 2016 May 4; 16:125

[x] Kooreman P, Baars EW. Patients whose GP knows complementary medicine tend to have lower costs and live longer. Eur J Health Econ. 2012 Dec;13(6):769-76

[xi] Baars EW, Kooreman P. A 6-year comparative economic evaluation of healthcare costs and mortality rates of Dutch patients from conventional and CAM GPs. BMJ Open. 2014 Aug 27;4(8):e005332

[xii] Colas A, Danno K, Tabar C, Ehreth J, Duru G. Economic impact of homeopathic practice in general medicine in France. Health Econ Rev. 2015;5(1):55

[xiii] Van Wassenhoven M, Galen Y. An observational study of patients receiving homeopathic treatment. Homeopathy 2004 Jan;93(1):3-11

[xiv] Marian F, Joost K, Saini KD, von Ammon K, Thurneysen A, Busato A. Patient satisfaction and side effects in primary care: An observational study comparing homeopathy and conventional medicine. BMC Complement Altern Med. 2008 Sep 18; 8:52

[xv] Witt C, Keil T, Selim D, et al. Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders. Complement Ther Med. 2005;13(2):79-86

[xvi] Marian F, Joost K, Saini KD, von Ammon K, Thurneysen A, Busato A. Patient satisfaction and side effects in primary care: An observational study comparing homeopathy and conventional medicine. BMC Complement Altern Med. 2008 Sep 18; 8:52

[xvii] Bornhöft G, Wolf U, von Ammon K, Righetti M, Maxion-Bergemann S, Baumgartner S, Thurneysen AE, Matthiessen PF. Effectiveness, safety and cost-effectiveness of homeopathy in general practice – summarized health technology assessment.Forsch Komplementmed. 2006;13 Suppl 2:19-29. Epub 2006 Jun 26. Review

[xviii] Eardley S, Bishop FL, Prescott P, Cardini F, Brinkhaus B, Santos K Ͳ Rey, Vas J, von Ammon K, Hegyi G, Dragan S, Uehleke B, Fønnebø V, Lewith G. CAM use in Europe. The patients’ perspective.Part I: A systematic literature review of CAM prevalence in the EU. 2012. Online retrieved 19-11-2019. https://cam-europe.eu/wp-content/uploads/2018/09/CAMbrella-WP4-part_1final.pdf

[xix] Report of the European Commission, 1997. Online retrieved 15-12-2019 via https://www.hri-research.org/resources/essentialevidence/use-of-homeopathy-across-the-world/

[xx] Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas WB. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet. 1997 Sep 20;350(9081):834-4.

[xxi] Cucherat M, Haugh MC, Gooch M, Boissel JP.Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. HMRAG. Homeopathic Medicines Research Advisory Group. Eur J Clin Pharmacol. 2000 Apr;56(1):27-33

[xxii] Hahn RG. Homeopathy: meta-analyses of pooled clinical data. Forsch Komplementmed. 2013;20(5):376-81

[xxiii] Mathie RT, Van Wassenhoven M, Jacobs J et al. Model validity and risk of bias in randomised placebo-controlled trials of individualised homeopathic treatment. Complement Ther Med. 2016 Apr; 25:120-5

[xxiv] Mathie RT, Lloyd, SM, Legg, LA, Clausen J, Moss S, Davidson JR, Ford: Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Syst Rev 2014 Dec 6; 3:142

[xxv] Mathie RT, Clausen J. Veterinary homeopathy: systematic review of medical conditions studied by randomised placebo-controlled trials. Vet Rec. 2014 Oct 18;175(15):373-81.

[xxvi] Mathie RT, Clausen J. Veterinary homeopathy: meta-analysis of randomised placebo-controlled trials. Homeopathy. 2015 Jan;104(1):3-8.

[xxvii] Tournier A, Klein SD, Würtenberger S, Wolf U, Baumgartner S. Physicochemical Investigations of Homeopathic Preparations: A Systematic Review and Bibliometric Analysis-Part 2. J Altern Complement Med. 2019 Jul 10

[xxviii] Witt CM, Bluth M, Albrecht H, Weisshuhn TE, Baumgartner S, Willich SN. The in vitro evidence for an effect of high homeopathic potencies–a systematic review of the literature. Complement. Ther Med. 2007 Jun;15(2):128-38

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Did I state above that the manifesto is worth considering in more detail? I need to retract or modify this statement.

Here are the considerations that are relevant, in my view:

  • The statements in the manifesto are based on wishful thinking and do not reflect the reality based on the best evidence available today.
  • The manifesto is the result of a mixture of cherry-picking and/or misinterpreting the evidence.
  • Most of the cited studies have been discussed on this blog in previous posts which disclose their flaws and/or erroneous conclusions.

So, instead of discussing all the tedious details yet again, I will present here a corrected version of the manifesto:

Homeopathy: no solution for major healthcare problems in the EU

  • Does not help to reduce the need of antibiotics in human and veterinary health care, thus reducing the problem of antimicrobial resistance
  • does not increases quality of life and reduces severity of complaints in patients with chronic disease, when integrated in health care
  • Cannot reduce the use of long-term conventional prescription drugs, when integrated in health care

Homeopathy: neither safe nor cost-effective with a high patient satisfaction

  • Cannot lead to lower health care costs, when integrated in health care
  • Is unsafe
  • Patients using homeopathy have no better outcomes than users of conventional treatment, but cause higher costs
  • Quality and correct labelling of homeopathic products is guaranteed by Directive 2001/83 EC

 Some EU consumers expect and demand homeopathy as part of their health care

  • Reported as a much-used complementary medicine in Europe
  • Three out of four European citizens know about homeopathy and out of them many use it for their day-to day health care

 Scientific evidence of the highest calibre fails to confirm the clinical efficacy of homeopathic   medicine

  • Clinical effects of homeopathic medicines have been confirmed by systematic reviews and meta- analyses to be no better than placebo

There is no convincing evidence for biological efficacy of homeopathic medicine

  • No irrefutable scientific evidence has been published on the positive effects of homeopathic products in laboratory settings

The objective of this analysis was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. The researchers employed a retrospective cohort design for analysis of health claims data from three contiguous US states for the years 2012-2017.

They included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. Two cohorts of subjects were thus identified:

  1. patients who received both primary care and chiropractic care,
  2. Patients who received primary care but not chiropractic care.

The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients of chiropractic care filled an opioid prescription, as compared with recipients.

The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.

Similar findings have been reported before and we have discussed them on this blog (see here, here and here). As before, one has to ask: WHAT DO THEY ACTUALLY MEAN?

The short answer is NOTHING MUCH! And certainly not what many chiros make of them.

They do not suggest that chiropractic care is a substitute for opioids in the management of spinal pain.

Why?

There are several reasons. Perhaps the most important ones are that such analyses lack any clinical outcome data, and that comparing one mistake (opioid-overuse) whith what might be another (chiropractic care) is a wrong apporoach. Imagine a scenario where half to the patients had received, in addition to their usual care, the services of:

  • a paranormal healer,
  • a crystal therapist,
  • a shaman,
  • or a homeopath.

Nobody would be surprised to see a very similar result, particularly if all of these practitioners were in the habit of discouraging their patients from using conventional drugs. Or imagine a scenario where half of all patients suffering from spinal pain are entered into an environment where they receive no treatment at all. Who would not expect that this regimen does not dramatically reduce the risk of filling an opioid prescription? But would that indicate that zero treatment is a good solution for managing spinal pain?

The thing is this:

  • If you want to reduce opioid use, you need to prescribe less opioids (for instance, by re-educating doctors to do as they have been told in med school and curb over-prescribing).
  • If you discourage patients to use opioids (as many other healthcare professionals would), many will not use opioids.
  • If you want to know whether chiropractic is effective in managing spinal pain, you need to conduct a well-designed clinical trial.

Or, to put it simply:

CORRELATION IS NOT CAUSATION!

 

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