Complementary and Alternative Medicine Science, Pseudoscience, and Ethics

Complementary and Alternative Medicine Science, Pseudoscience, and Ethics

اسلاید 1: www.tabaye.ir

اسلاید 2: Complementary and Alternative Medicine: Science, Pseudoscience, and EthicsMartin Donohoe, MD, FACPKaren Adams, MD, FACOG

اسلاید 3: OutlineWhat is CAM?Philosophies of CAM and “Western medicine”Recognizing Quackery, Pseudoscience and Bogus DiscoveriesRisks and Benefits of Herbal RemediesWhy Herbs are Not RegulatedConclusions and Recommendations

اسلاید 4: What is CAM?Any health care intervention not offered by traditional “Western” physiciansE.g., chiropractic, massage, acupuncture, homeopathy, distance healing, therapeutic touch, Reiki therapy, aromatherapy, herbs/nutraceuticals

اسلاید 5: CAMSome are recommended by physicians for certain conditions or people:Chiropractic, massage, acupuncture, aromatherapyProven benefit – e.g., acupuncture for certain types of chronic pain, chemotherapy-induced nausea and vomiting; guided imagery to reduce stress of surgery in children and adults

اسلاید 6: No Such Thing as CAMGood medicineScientificEvidence-BasedQuality ControlPeer ReviewedHumanistic and Caring

اسلاید 7: No Such Thing as CAMBad MedicineNon-scientificPoor or No Quality ControlNon-Peer ReviewedImpersonal, Uncaring

اسلاید 8: CAM is Not Unique in Its Emphasis on:Humanistic health careEmpathy and CompassionEmphasis on healing the mind and body / recognizing the powerful links between the two

اسلاید 9: CAM is Not Unique in Its Emphasis on:Care involving family, friends, religious practitionersCare emphasizing the “whole patient” or the provider-patient relationship

اسلاید 10: CAM Versus Western MedicineThese attributes are the characteristics of quality medicine and public health, yet have been co-opted by the CAM movement

اسلاید 11: Don’t get sCAMmed by CAMSome CAM is without benefit, some harmfulTherefore, it is important to be able to recognize quackery, pseudoscience and bogus discoveries

اسلاید 12: How Quackery HarmsEconomic harm –individual costsDirect harmMedical – e.g., cyanide toxicity from laetrile, electrolyte imbalances from coffee enemas, quadriplegia from cervical spine manipulationsPsychological – e.g., unjustified guilt, distortion of perspective

اسلاید 13: How Quackery HarmsIndirect harm:E.g., delay in seeking careHarm to Society:Perpetuates pseudoscience, puts other contemporary and future patients at risk

اسلاید 14: Warning Signs of a Bogus Scientific DiscoveryThe discoverer pitches the claim directly to the mediaThe discoverer says that a powerful establishment is trying to suppress his/her workThe scientific effect involved is always at the very limit of detectionEvidence for a discovery is anecdotal

اسلاید 15: Warning Signs of a Bogus Scientific DiscoveryThe discoverer says a belief is credible because it has endured for centuriesThe discoverer has worked in isolationThe discoverer must propose new laws of nature to explain an observation

اسلاید 16: Characteristics of PseudoscienceIndifferent to factsLooks only for evidence supporting hypothesisIndifferent to criteria of valid evidenceRelies heavily on subjective validationDepends on arbitrary conventions of human culture, rather than on unchanging regularities of nature

اسلاید 17: Characteristics of PseudoscienceAvoids putting its claims to meaningful testsOften contradictoryDeliberately creates mystery where none exists, sometimes by omitting important detailsDoes not progressAttempts to persuade with rhetoric, propaganda and misrepresentation

اسلاید 18: Characteristics of PseudoscienceAppeals to false authority, emotion, sentiment, or distrust of established factsExtraordinary claims and fantastic theoriesOften described by an invented vocabulary of words with ambiguous meaningsRelies on anachronistic thinkingAppeals to vanity, fear, magical thinking or desperation

اسلاید 19: Characteristics of PseudoscienceRelies on anecdotes and testimonialsProducts often claim to be effective against a wide range of unrelated diseasesQuick, dramatic results promised for one-time therapies; frequent re-treatments/maintenance treatments required for ongoing therapies$

اسلاید 20: Characteristics of PseudoscienceDisclaimers couched in pseudo-medical jargonClaims that “Western Medicine” is dangerousPractitioners advise, “Don’t trust your doctor”

اسلاید 21: Characteristics of PseudoscienceClaims of “no side effects”Products claimed to be “natural” – usually are not

اسلاید 22: Misconceptions re Cancer

اسلاید 23: Misconceptions re Cancer

اسلاید 24: Ban Dihydrogen Monoxide?Iowa junior high school student science fair project100 adults surveyed at State Fair

اسلاید 25: Would you sign a petition to ban dihydrogen monoxide?1. It can cause excessive sweating and vomiting 2. It is a major component in acid rain 3. It can cause severe burns in its gaseous state 4. It can kill you if accidentally inhaled 5. It contributes to erosion 6. It decreases effectiveness of automobile brakes 7. It has been found in tumors of terminal cancer patients

اسلاید 26: Ban Dihydrogen Monoxide?Results90 – yes8 – “Get away from me kid! I don’t sign petitions.”2 – “Are you kidding - that is water!”

اسلاید 27: One Reason Why Pseudoscientific Beliefs are Common: Public Education is in DisarrayU.S. Schools ranked lowest among western nations, particularly in science↓ funding, infrastructure decaying1/4 of U.S. Schools have no library1/4 of schools use textbooks from the 1980s or earlier

اسلاید 28: Herbal Remedies$17.8 billion on herbs and supplements in 2001$58 billion on pharmaceuticals12% use herbs in one year (vs. 2.5% in 1990)E.g., between 1996 and 1998, 8% of normal-weight women and 28% of obese women used non-prescription weight loss products

اسلاید 29: Herbal Remedies - DisclaimerMore than ½ of current prescription and OTC medications come from plant productsMany herbs, in pure form, may be beneficialStudies poor, no incentives for industry to rigorously investigateLess than 0.5% of the world’s vanishing tropical plant species have been investigated for their medicinal qualities

اسلاید 30: What is All Natural?“Natural” means eating a balanced diet, favoring organic, local foods, and protecting the environment

اسلاید 31: Gauging Risks Of Herbal RemediesFDA: Manufacturer may claim that the product affects the structure or function of the body, as long as there is no claim of effectiveness for the prevention or treatment of a specific disease, and provided there is a disclaimer informing the user that the FDA has not evaluated the agentsMultiple violations / near violations

اسلاید 32: Why Herbs Are Not Regulated By The FDA1974: (Senator William “Golden Fleece Award”) Proxmire Amendment: -“Nutritional supplements are not drugs”

اسلاید 33: Why Herbs Are Not Regulated By The FDA1994: Dietary Supplement Health and Education Act -supplements excluded from purity, composition, effectiveness and safety review-supported by Orrin Hatch (R-Utah), recipient of $169,000 from pharm and nutraceutical ind. in 2000, more than any other Senator; Utah home to more herbal/nutraceutical companies than any other stateEstablished Office of Dietary Supplements

اسلاید 34: FDA Oversight2100 scientists in 40 labs1100 investigators and inspectorsMonitor and inspect 95,000 businessesVisit >15,000 facilities per yearCollect 80,000 domestic and imported product samples for label checks

اسلاید 35: Risks of Herbal RemediesProducts unregulated/untested Variablecollectionprocessingstoragenamingpurity

اسلاید 36: Risks of Herbal RemediesAdulterants and contaminants include:Botanicals – e.g., digitalis, belladonnaMicroorganisms – Staph aureus, E coli, Salmonella, Shigella, PseudomonasMicrobial toxins – aflatoxins, bacterial endotoxinsPesticides

اسلاید 37: Risks of Herbal RemediesAdulterants and contaminants include:Fumigation agentsToxic metals – lead, cadmium, mercury, arsenicDrugs – analgesics and anti-inflammatories, corticosteroids, benzodiazepines, warfarin, fenfluramine, sildenafil1998: 32% of Asian patent medicines sold in the US contained undeclared pharmaceuticals or heavy metals

اسلاید 38: Risks of Herbal And “Naturopathic” RemediesEst. less than 1% of adverse reactions reported to FDA (vs. 10% est. for prescription drugs)19,468 adverse events reports to poison control centers in 1998, vs. 500 to FDAPotential toxicities: cardiac, CNS, liver, kidney

اسلاید 39: High Risk Users of “Naturopathic” RemediesElderly, pregnant and nursing women, infantsPoor overall health statusChronic users, prescription drug users

اسلاید 40: Risks of Herbal RemediesDietary supplements containing ephedrine, caffeineHTN, MI, CVA, psychosis, seizures Chapparal, germander, comfrey, skullcap, sassafrasHepatotoxic, carcinogenic

اسلاید 41: Risks of Herbal and “Naturopathic” RemediesGE-L-tryptophan → Eosinophilia Myalgia Syndrome (1989): 5,000 in US affected, 37 deaths, 1500 permanently disabledEphedra - heart attacks, dysrhythmias, strokes and seizuresGarlic, gingko, and ginseng – bleedingGinseng - hypoglycemia

اسلاید 42: Risks of Herbal and “Naturopathic” RemediesKava and valerian - potentiation of anesthetic effects St. John’s wort - increased metabolism of many drugs↓CyA effectiveness → transplant rejection

اسلاید 43: ConclusionsCAM is widespread: some may be useful Caveat emptor – know how to recognize quackery and pseudoscienceDo not confuse or conflate CAM with humanistic / integrative / whole person care

اسلاید 44: ConclusionsTraditional medicine is not immune from bad science, misleading advertisements, excessive corporate influence, corruption and support of some therapies offering limited benefit.

اسلاید 45: ConclusionsMedical education and training curricula should include greater emphasis on professionalism, ethics, the humanities, public health, social justice, communication skills, legal issues, and cultural and religious understanding and sensitivity

اسلاید 46: ConclusionsVisit lengths, which have become shorter in the face of financial pressures, need to be increased to allow more time for the development of rapport between doctor and patient, comprehensive screening, accurate diagnosis, and patient counseling and education

اسلاید 47:

اسلاید 48: The National Center for CAMEstablished 1998, 7 yrs. after its predecessor (Office of Alternative Medicine)Annual budget = $110 million/yrRole of Iowa Senator Tom Harkin, Chairman/Ranking Member of Labor, Health and Human Services and Education Subcommittees – “held entire NIH budget hostage”

اسلاید 49: NCCAMBoard populated with discredited, fringe practitionersCulture of fear among academics needing funding and universities establishing “Centers of Alternative Medicine” to not anger NCCAM and Senator Harkin

اسلاید 50: Unethical NCCAM StudiesFringe studies of discredited and highly implausible techniques exploit patients and deplete health care resourcesHomeopathypsychic healingtherapeutic touch

اسلاید 51: Unethical NCCAM StudiesDangerous studies with inadequate informed consent formsE.g., decreased effectiveness of protease inhibitors not mentionedSt John’s Wort for HIVGarlic for hyperlipidemia due to HAART treatment for HIV

اسلاید 52: NCCAMAfter 10 years and $200 million, NCCAM-sponsored research has not demonstrated efficacy for any CAM method, nor has the Center informed the public that any method is useless or harmful

اسلاید 53: ReferenceAdams KE, Cohen MH, Eisenberg DA, Jonsen AR. Ethical considerations of complementary and alternative medicine in conventional medical settings. Annals of Internal Medicine, October 2002; 137:660-664.

اسلاید 54: Contact InformationPublic Health and Social Justice Websitehttp://www.phsj.orgmartindonohoe@phsj.org