Herbs and Supplements for Pets: What Is a Vet to do?

I’ve written extensively about herbal remedies and dietary supplements both because these seem among the most likely to be useful of CAM therapies and also because they are widely used despite the lack of good evidence that they are safe and effective in most cases. The success of pharmaceutical medicines and vitamin supplements to treat deficiency diseases has created an expectation that taking a pill can have beneficial effects. When combined with the naturalistic fallacy (that we can identify some things as “natural” and then trust that these are safe) this predisposes people to believe dietary supplements and herbal medicines are good for them.

At least one NIH study suggests that about 18% of adults in the U.S. take some form of “natural product,” that is an herb or remedy that is not a vitamin of mineral. These consist mostly of herbal remedies, with Echinacea, Gingko biloba, garlic, glucosamine, St. John’s Wort, Ginseng, and fish oil being among the most popular. However, there is growing research evidence that these popular products don’t have the health benefits for which most people take them.

Echineacea does not appear to have consistently demonstrable benefits for cold and flu sufferers (1, 2), and there is even less evidence to support other purported benefits (3). The strongest evidence of benefit for Gingko biloba initially was for Alzheimer’s and dementia (4), however two large, long-term clinical trials have failed to support this hoped-for effect (5, 6). I’ve already written repeatedly about the consistent failure of glucosamine to perform better than placebo, and about the equivocal findings for garlicGinseng doesn’t perform much better, with mixed results in generally small and not high-quality research studies. (7)

Among the strongest cases for herbal or other “natural” supplements are those made for St. John’s Wort and fish oil. St. John’s Wort does appear to have some benefit for mild depression, though no greater and with no fewer risks than conventional pharmaceuticals, which aren’t themselves always consistently better than placebo (8). Not exactly a ringing endorsement for one of the most intensively studies herbal remedies, to say that it works about as well as the lousy conventional therapies it is meant to replace or complement.

The evidence is better for fish oils, which have shown some consistent, repeatable benefits in clinical studies (9). However, additional recent work has called into question even this widely accepted conclusion (10). I myself have taken fish oil supplements for years, though I have recently decided to skip the capsules and just eat more fish since, as seems to be turning out to be true most of the time, the health benefits associated with eating particular foods don’t necessarily translate into benefits from supplements based on those foods. (For what it’s worth, I also took glucosamine for a while, with no obvious effects, until the evidence against a real benefit became strong enough to convince me I was wasting my money. The key to an evidence-based approach to healthcare is both being open to new ideas and willing to abandon ideas that fail to live up to their early promise). 

So while there is support for using some popular herbal remedies and other supplements, generally the evidence is far weaker than most people suppose. And the Decline Effect is readily apparent in the research on such remedies, with pre-clinical evidence and small, low-quality early trials showing apparent benefit which then gets progressively smaller and often disappears entirely and the amount and quality of the research grows. Promising ideas are worth investigating, but most fail to live up to their promise, so jumping on a new supplement bandwagon early is usually a mistake.

Vitamin and mineral supplements are the other major piece of the supplement market. Unquestionably, there is a real benefit for these in preventing specific nutritional deficiencies. However, the optimal intake of most vitamins and minerals for most individuals isn’t known. Age, sex, lifestyle, health, and many other variables affect how much of what we need to be as healthy as possible, and almost all recommendations to take more of these products than needed to prevent a deficiency are simply made up. General and irrational use of vitamin and mineral supplements not based on specific scientific evidence has consistently proved not only to not be beneficial but in some cases to be actively harmful (11, 12, 13, 14, 15, 16).

Of course, it is a given that people will continue to take supplements even based on flimsy evidence or even when the evidence is clear that benefits are lacking and there is real risk. The desire to control our health through therapeutic rituals, to believe what we wish were true even if it may not be, and the cognitive dissonance involved in letting go of deeply held beliefs when there is strong evidence against them are all factors that make it hard to give up behaviors that we feel, even mistakenly, are beneficial for us. So what should doctors do about our patients’ supplement use?

There is a lack of consistent and coherent policies among regulators and healthcare institutions to help doctors and patients manage the use of supplements concurrently with conventional medical therapies. Many patients (or veterinary clients) don’t tell their doctors about supplement use. Given that these products can interact in dangerous ways with conventional medicines, this present a real risk. So there are a number of things doctors should do, regardless of how favorably or skeptically they view herbal remedies and supplements, to minimize the risks to their patients associated with these products. 

  1. Know What Your Patient is Taking

Doctors should ask their patients or clients about supplement use at every visit. I always ask my clients if their pets are on any medications. If they say “No,” I then ask about vitamins, supplements, herbal remedies, or other healthcare products, and they very often then reveal a whole host of things they are giving their pet.

Despite their belief that these products treat or prevent disease in their pets, these owners don’t think of the products as medicine since that word is generally associated with pharmaceutical products. Only specific and detailed questioning is likely to yield a true picture of what chemicals an owner is putting into their pet’s body. 

  1. Understand the Evidence

We cannot counsel our clients effectively without being knowledgeable about the products they are interested in using. If a supplement or herbal remedy is truly beneficial, we should know this and know how to use it to help our patients. And if such a product presents a danger to our patients, or is simply a waste of our clients’ money, we should know that as well.

Obviously, I am skeptical about the value of many supplements. But I own quite a few references and textbooks about such products which I consult regularly, I maintain a subscription to the Natural Medicines Comprehensive Database, and I make the effort to be informed about the current scientific evidence regarding herbs and supplements (and to make that information available to others through this blog when I can). This seems a crucial part of being a truly useful resource for my clients and patients, even if often I end up having to tell that that the evidence is inconclusive and what they are giving their pets may or may not be in their best interests.

This is not to say that all veterinarians or veterinary students should undergo specialized training in herbal medicine or the use of supplements. All too often, such training is produced by individuals with firm beliefs about the value of such products who recommend them on the basis of historical use, personal experience, or kinds of evidence weaker than, and often in conflict with, the evidence of scientific research. To have an educated, informed, and science-based understanding of supplements does not require one to be trained in their use by practitioners already committed to their worth any more than being an educated, informed, and science-based critic of astrology or homeopathy requires one to train as an astrologer or homeopath.

  1. Communicate Effectively

I see educating and informing my clients as a crucial part of my job. I cannot care for my patients effectively if I cannot communicate effectively with their owners. This means presenting the facts as I understand them, and my informed opinions (which, after all, is what the client is paying me for), clearly and in a way my clients can understand. This also means not taking an adversarial position against the values and beliefs my clients hold. I see it as an ethical duty to tell my clients when I believe they are treating their pets in a way that is useless or harmful, but this message cannot be heard unless it originates from a position of respect for their intentions and their feelings and a shared desire to do what is best for the animal.

My critics would likely be surprised at how many of my clients, with whom I have long-standing relationships of trust and cooperation, utilize therapies that I actively recommend they not use. Disagreement need not lead to personal antipathy, and my clients understand that even when I tell them something they don’t believe or don’t want to hear, I am not challenging their commitment to their pets’ wellbeing or their own competence as an owner.

Veterinarians need to be honest and explicit with their clients about the evidence concerning the therapies we offer and those we recommend against, and we need to not only share what we know but also admit what we do not know. When it comes to counseling clients about the use of supplements, making clear the uncertainty about these products, and that this uncertainty applies to their safety as much as to their purported benefits, is a necessary part of helping our clients make rational, informed decisions about their pets’ care. The biggest problem with the promotion and advertising of such supplements is that they make confident claims well beyond anything even remotely justified by real evidence.

Bottom Line

Overall, there is some reason to hope that some herbal remedies and nutritional supplements will one day be a useful tool in treating our patients. However, even the best-studied of such remedies currently have only weak evidence to support safety and efficacy, and most have nearly nothing but wishful thinking to justify their widespread use, especially in veterinary medicine where good quality clinical trials of such products are almost non-existent.

This means that we need to be aware of the evidence that does exist and explicit with our clients about what it does and does not tell us. And we need to be vigilant in watching out for harm from products that are often mistakenly assumed to be inherently safe. Clearly, such products will continue to be in fairly widespread use until the political climate changes to allow meaningful regulation of them and requirements that they be validated through proper, rigorous scientific study. Until then, veterinarians need to make the effort to be a source of reliable and honest information for our clients in order to protect and care for our patients.

Posted in Herbs and Supplements | 4 Comments

The Harm Complementary and Alternative Medicine Can Do

What’s the Harm

I have written often about ways in which complementary and alternative medicine (CAM) can be harmful. This is not because I believe CAM is necessarily always unsafe, or that I think conventional medicine doesn’t have significant risks as well. Any therapy that is doing anything at all is likely to have potential risks as well as benefits. It simply isn’t possible to tinker with as complex a system as a living organism without affecting elements of the system one does not intend as well as those one is targeting.

However, the advantage to science-based medicine is that the risks and benefits of individual therapies are often well understood. If we have sufficient information about what an intervention does and what the risks and benefits of it are, we can then make rational choices about using it. The problem with CAM is that there is often very little information about risks and benefits and yet strong claims are frequently made that these therapies work and are safe. The lack of real, scientific information, and beliefs about safety which are not founded on reliable evidence can generate harm.

The two types of harm that can be seen with CAM therapies are direct and indirect. Direct harm is injury or illness experienced by a patient from the treatment itself. This is similar to the side effects one can see with conventional treatment. Indirect harm is the harm that comes from acting on misinformation or false beliefs even when the treatment itself is not dangerous. This usually involves the harm experienced by patients who avoid conventional therapy in favor of unproven or clearly ineffective CAM remedies.

I have put together a list of articles from scientific journals and the news media illustrating both the direct and indirect harm of CAM therapies: What’s The Harm? The name is in honor of the web site What’s the Harm, which is a collection of anecdotes illustrating the dangers of all kinds of pseudoscientific and superstitious thinking, including that behind much of alternative medicine.

This post will be a collection of links to previous posts I’ve written and links to articles elsewhere illustrating the harm CAM can do.

General CAM Use:

Association between CAM use and decreased success of IVF in Holland.

Association between CAM use and decreased survival in cancer patients in Norway.

Boström H, Rössner S. Quality of alternative medicine–complications and avoidable deaths. Qual Assur Health Care. 1990;2(2):111-7.

Yun YH, Lee MK, Park SM, Kim YA, Lee WJ, Lee KS, Choi JS, Jung KH, Do YR, Kim SY, Heo DS, Kim HT, Park SR. Effect of complementary and alternative medicine on the survival and health-related quality of life among terminally ill cancer patients: a prospective cohort study. Ann Oncol. 2013 Feb;24(2):489-94. doi: 10.1093/annonc/mds469. Epub 2012 Oct 30.

Johnson SB, Park HS, Gross CP, Yu JB. Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable CancersJAMA Oncol. Published online July 19, 2018.

Acupuncture

While generally safe if performed by a licensed, properly trained acupuncturist, acupuncture does pose direct risks, including side effects such as dizziness and nausea, infection from improper technique, and trauma from needles.

A Review of Reviews of Acupuncture for Pain: Might Work, Might Not, Could Kill You, Probably Won’t

Veterinary Acupuncture

Cho YP, Jang HJ, Kim JS, Kim YH, Han MS, Lee SG. Retroperitoneal abscess complicated by acupuncture: case report. J Korean Med Sci. 2003 Oct;18(5):756-7.

Choo DC, Yue G Acute intracranial hemorrhage in the brain caused by acupuncture. Headache 2000 May;40(5):397-8.

Chung SJ, Kim JS, Kim JC, Lee SK, Kwon SU, Lee MC, Suh DC. Intracranial dural arteriovenous fistulas: analysis of 60 patients. Cerebrovasc Dis 2002 Feb;13(2):79-88

Cole M, Shen J, Hommer D. Convulsive syncope associated with acupuncture. Am J Med Sci 2002 Nov;324(5):288-9

Ernst E, Sherman K. Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies. J Gastroenterol Hepatol. 2003 Nov;18(11):1231-6.

Ernst E. Deaths after acupuncture: A sytematic review. Int J Risk and Safety in Med 2010;22(3):131-6.

Wenju He, Xue Zhao, Yanqi Li, Qiang Xi, and Yi Guo. Adverse Events Following Acupuncture: A Systematic Review of the Chinese Literature for the Years 1956–2010. The Journal of Alternative and Complementary Medicine. E-pub ahead of print. doi:10.1089/acm.2011.0825.

Iwadate K, Ito H, Katsumura S, Matsuyama N, Sato K, Yonemura I, Ito, Y. An autopsy case of bilateral tension pneumothorax after acupuncture. Leg Med (Tokyo). 2003 Sep;5(3):170-4.

Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B Cardiac Tamponade Following Acupuncture. Chest 2000 May;117(5):1510-1511

Laing AJ, Mullett H, Gilmore MF. Acupuncture-associated Arthritis in a Joint with an Orthopaedic Implant J Infect 2002 Feb;44(1):43-4

Nambiar P, Ratnatunga C. Prosthetic valve endocarditis in a patient with Marfan’s syndrome following acupuncture. J Heart Valve Dis 2001 Sep;10(5):689-90

Peuker E Case report of tension pneumothorax related to acupuncture. Acupunct Med. 2004 Mar;22(1):40-3.

Saw A, Kwan MK, Sengupta S. Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus. Singapore Med J. 2004 Apr;45(4):180-2.

Sun CA, et al. Transmission of hepatitis C virus in taiwan: prevalence and risk factors based on a nationwide survey. Sun J Med Virol 1999 Nov;59(3):290-6

Jayne Wheway, Taofikat B. Agbabiaka, Edzard Ernst. Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. The International Journal of Risk and Safety in Medicine. 2012;24(3):163-169.

Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-7. Epub 2009 Apr 9

Woo PC, Leung KW, Wong SS, Chong KT, Cheung EY, Yuen KY. Relatively alcohol-resistant mycobacteria are emerging pathogens in patients receiving acupuncture treatment. J Clin Microbiol 2002 Apr;40(4):1219-24

Woo PC, Lin AW, Lau SK, Yuen KY. Acupuncture transmitted infections. British Medical Journal 2010;340:c1268.

Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med 2001 Jun;9(2):98-104

 

Chiropractic

There is little research on the risks of chiropractic treatment in dogs and cats (or on any possible benefits). However, there is clear evidence of harm in humans, particularly with manipulation of the neck. Given the limited evidence of benefit (for back pain) in humans and the absence of clear evidence of benefit in veterinary patients, significant caution is warranted. 

Veterinary Chiropractic

SBM–Neck Manipulation:Risk vs Benefit

SBM–Chiropractic’s Pathetic Response to Stroke Concerns

SBM–Chiropractic and Stroke: Evaluation of One Paper

SBM–Chiropractic and Stroke

Albuquerque FC, Hu YC, Dashti SR, Abla AA, Clark JC, Alkire B, Theodore N, McDougall CG. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011 Dec;115(6):1197-205. Epub 2011 Sep 16.

Herbs and Supplements

Herbs and dietary supplements are among the most plausible and likely to have real physiologic effects of all CAM therapies. This also means, they are the most likely to have potential risks. As things currently stand, most of these products, particularly herbal remedies, should be viewed as drugs that have not been rigorously tested for safety and efficacy (as pharmaceuticals are) and that are not regulated for quality to any meaningful extent (again, unlike pharmaceuticals). Under these circumstances, there are unknown but potentially significant risks to using these products.

Unregulated Herbal Products and Supplements Send 23,000 People to the Emergency Room Annually in the U.S.

FDA Finds Serious and Widespread Violations of Safety and Quality Control Regulations for Dietary Supplements

What’s in Chinese Medicine? New DNA Study Finds Some Unpleasant Answers

Herbal Remedies Can Interfere With HIV Treatment

Less is More—A Reminder of Why Irrational Dietary Supplement Use is a Bad Idea

Neoplasene—Benefits Unproven and Risks Severe

Neoplasene—The Latest head of the Escharotic Hydra

Vitamin Supplements-Do They Prevent Cancer?

GAO Reports on Deceptive Marketing and Contamination of Herbal Products

Risks of Herbs and Supplements Finally Getting Some Attention

Use of Herbals Associated With Lower Quality of Life in Asthma Patients

Orthomolecular Medicine–Big Talk, Little Evidence, Real Risk

GAO Acknowledges FDA Oversight of Dietary Supplements Inadequate 

Consumer Reports—The Dangers of Supplements

Doctor Lies to Dying Cancer Patients about Herbal “Cure”

Vitamins & Supplements

Vitamin C can interfere with chemotherapy.

Unregulated Dietary Supplements Still Killing People

Thomas LK, Elinder C, Tiselius H, Wolk A, Åkesson A. Ascorbic Acid Supplements and Kidney Stone Incidence Among Men: A Prospective Study. JAMA Intern Med. 2013;():1-2. doi:10.1001/jamainternmed.2013.2296.

Vitamin E can increase cancer risk.

Vitamin E not useful for prevention for prostate cancer and can increase risk of congestive heart failure.

Vitamin E supplements increase risk of hemorrhagic stroke

Vitamin E supplements may increase risk of heart attacks and stroke

Vitamin E increases risk of prostate cancer

Vitamin supplements may associated with overall increase in mortality and no benefit in preventing gastrointestinal cancer.

Omega-3 Fatty Acids may increase risk in ventilator patients with acute lung injury

Mursu J, et al. Dietary supplements and mortality rate in older women: The Iowa Women’s Health Study. Archives of Internal Medicine. 2011;17(18):1625-33.

Widespread Failures in Quality Control of Dietary Supplements

Herbal Preparations

Bashir Ahmad, Samina Ashiq, Arshad Hussainb, Shumaila Bashir, Mubbashir Hussain. Evaluation of mycotoxins, mycobiota, and toxigenic fungi in selected medicinal plants of Khyber Pakhtunkhwa, Pakistan. Fungal Biology. 2014;118(9–10):776–84.

Aliye Uc, MD, Warren P. Bishop, MD, and Kathleen D. Sanders, MD, Camphor hepatoxicity. South Med J 93(6):596-598, 2000,

Angers RC, Seward TS, Napier D, Green M, Hoover E, Spraker T, O’Rourke K, Balachandran A, Telling GC. Chronic wasting disease prions in elk antler velvet. Emerg Infect Dis. 2009 May;15(5):696-703.

Angkana R, Lurslurcharchai L, Halm E, Xiu-Min L, Leventhal H, et al. Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients. Annal Allerg Asthma Immunol 2010:104(2);132-138.

Berberine. Inbaraj JJ, Kukielczak BM, Bilski P, Sandvik SL, Chignell CF. Photochemistry and photocytotoxicity of alkaloids from Goldenseal (Hydrastis canadensis L.) Chem Res Toxicol 2001 Nov;14(11):1529-34

Cheung E, Ng C, Foote J. A hot mess: A case of hyperemesis. Canadian Family Physician July 2014 vol. 60 no. 7 633-637.

Geller, A. et al. Emergency Department Visits for Adverse Events Related to Dietary Supplements. N Engl J Med 2015; 373:1531-1540

Lauren Blacksell, Roger W. Byard, Ian F. Musgrave. Forensic problems with the composition and content of herbal medicines. Journal of Forensic and Legal Medicine. Volume 23, March 2014, Pages 19–21

Booth JN 3rd, McGwin G. The association between self-reported cataracts and St. John’s Wort. Curr Eye Res. 2009 Oct;34(10):863-6.

Burkhard PR, Burkhardt K, Haenggeli CA, Landis T.Plant-induced seizures: reappearance of an old problem. J Neurol 1999 Aug;246(8):667-70

Chung-Hsin Chen, Kathleen G. Dickman, Masaaki Moriya, Jiri Zavadil, Viktoriya S. Sidorenko, Karen L. Edwards, Dmitri V. Gnatenko, Lin Wu, Robert J. Turesky, Xue-Ru Wu, Yeong-Shiau Pu, Arthur P. Grollman. Aristolochic acid-associated urothelial cancer in Taiwan. Proceedings National Academy of Sciences, April 2012. Panax ginseng: A Systematic Review of Adverse Effects and Drug Interactions. Drug Saf 2002;25(5):323-44 Drug Saf 2002;25(5):323-44

Cupp MJ Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999 Mar 1;59(5):1239-45

Debelle FD, Vanherweghem JL, Nortier JL.Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008 Jul;74(2):158-69. Epub 2008 Apr 16.

Douros, A., Bronder, E., Andersohn, F., Klimpel, A., Thomae, M., Ockenga, J., Kreutz, R. and Garbe, E. (2013), Drug-induced acute pancreatitis: results from the hospital-based Berlin case–control surveillance study of 102 cases. Alimentary Pharmacology & Therapeutics.

Emery DP, Corban JG Camphor toxicity. J Paediatr Child Health 1999 Feb;35(1):105-6

Ernst E Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000 Nov;143(5):923-

Fugh-Berman A Herb-drug interactions. Lancet 2000 Jan 8;355(9198):134-8

M.L. Hoang et al., “Mutational signature of aristolochic acid exposure as revealed by whole-exome sequencing,” Science Translational Medicine, 5: 197ra102, 2013.

Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997 Apr;37(4):344-50

Kutz GD. Herbal dietary supplements: Examples of Deceptive or questionable marketing practices and potentially dangerous advice. General Accounting Office. May 26, 2010.

Lai MN, Lai JN, Chen PC, Tseng WL, Chen YY, Hwang JS, Wang JD. Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrology (Carlton). 2009 Apr;14(2):227-34.

Lawrence JD. Potentiation of warfarin by dong quai. Page RL 2nd, Pharmacotherapy 1999 Jul;19(7):870-6

Mangala, P. Study of Lead Content in Ayurvedic and Homeopathic Medicines Commonly Used for the Treatment of Cold, Cough & Body Aches. IOSR Journal Of Environmental Science, Toxicology And Food Technology. 2014;5(3):8-12.

Means C. Selected herbal hazards.Vet Clin North Am Small Anim Pract 2002 Mar;32(2):367-82

National Toxicology Program. Technical Report on the Toxicology and Carcinogenesis Studies of Gingko Biloba extract in F344/N Rats and B6C3F1/N Mice. March, 2013.

Victor J. Navarro, Huiman Barnhart, Herbert L. Bonkovsky, Timothy Davern, Robert J. Fontana, Lafaine Grant, K. Rajender Reddy, Leonard B. Seeff, Jose Serrano, Averell H. Sherker, Andrew Stolz, Jayant Talwalkar, Maricruz Vega, Raj Vuppalanchi. Liver injury from Herbals and Dietary Supplements in the US Drug Induced Liver Injury Network. Hepatology; Article first published online: 25 AUG 2014 DOI: 10.1002/hep.27317

Steven G Newmaster, Meghan Grguric, Dhivya Shanmughanandhan, Sathishkumar Ramalingam, Subramanyam Ragupathy. DNA barcoding detects contamination and substitution in North American herbal products. BMC Medicine 2013, 11:222

Nizsly N, Grizlak B, Zimmerman M, Wallace R. Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem? eCAM 2010 7(1):107-113

Norred CL, Finlayson CA Hemorrhage after the preoperative use of complementary and alternative medicines. AANA J 2000 Jun;68(3):217-20

O’Connor A, Horsley CA. Yates, KM “Herbal Ecstasy”: a case series of adverse reactions. N Z Med J 2000 Jul 28;113(1114):315-7 Pittler MH.

S.L. Poon et al., “Genome-wide mutational signatures of aristolochic acid and its application as a screening tool,” Science Translational Medicine, 5: 197ra101, 2013.

Ernst, E Risks associated with herbal medicinal products. Wien Med Wochenschr 2002;152(7-8):183-9

Poppenga RH.Risks associated with the use of herbs and other dietary supplements. Vet Clin North Am Equine Pract. 2001 Dec;17(3):455-77, vi-vii

Pies R Adverse neuropsychiatric reactions to herbal and over-the-counter “antidepressants”. J Clin Psychiatry 2000 Nov;61(11):815-20

Prakash S, Hernandez GT, Dujaili I, Bhalla V. Lead poisoning from an Ayurvedic herbal medicine in a patient with chronic kidney disease. Nat Rev Nephrol. 2009 May;5(5):297-300.

Raman P, Patino LC, Nair MG. Evaluation of metal and microbial contamination in botanical supplements. J Agric Food Chem. 2004 Dec 29;52(26):7822-7

Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll G Acute heart transplant rejection due to Saint John’s wort. Lancet 2000 Feb 12;355(9203):548-9

Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. JAMA. 2008 Aug 27;300(8):915-23.

Shad JA, Chinn CG, Brann OS Acute hepatitis after ingestion of herbs. South Med J 1999 Nov;92(11):1095-7 Smolinske SC J Am Med Womens Assoc 1999 Fall;54(4):191-2Dietary supplement-drug interactions.

Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular disease. J. Am. Coll. Cardiol. 2010 55: A32 ,

H.-H. Tsai, H.-W. Lin, A. Simon Pickard, H.-Y. Tsai, G. B. Mahady. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review. International Journal of Clinical Practice, 2012; 66 (11):

Wang JD, Lo TC, Chen PC. Increased mortality risk for cancers of the kidney and other urinary organs among Chinese herbalists. J Epidemiol. 2009;19(1):17-23. Epub 2009 Jan 22.

Zhang SY, Robertson D. A study of tea tree oil ototoxicity. Audiol Neurootol 2000 Mar-Apr;5(2):64-8

Posted in Topic-Based Summaries | 13 Comments

Veterinary Acupuncture

What is it?

Because of the wide variety of theories, approaches, and specific practices acupuncturists use, it is difficult to find agreement as to what exactly acupuncture is. At its core, acupuncture is the practice of inserting needles into the body in an attempt to relieve suffering, treat disease, or improve the quality of a patient’s life.

Though needling and other interventions at points on the body have been practiced in various cultures around the world, acupuncture today is usually associated with needling practices that originated in China. Some acupuncturists claim that they base their treatments on the Chinese concept of Ch’i, which is usually described as a vital force which flows through channels in the body (often called meridians). These practitioners may also claim that imbalances or blockages of Ch’i can cause disease, which can then be treated by inserting needles into meridians at specific points. Ch’i is not detectable by any known means, and neither acupuncture points nor meridians can be identified as physical structures in the body or through any kind of medical imaging.

Other acupuncturists disavow mystical concepts such as Ch’i and claim their treatments work by stimulating release of natural pain control chemicals, such as endorphins, or by affecting blood flow, the function of nerves, and other scientific physiological means. However, none of these proposed mechanisms are supported by any consistent research evidence.

Still other schools of acupuncture claim that the entire body can be mapped onto one part, such as the hand (e.g. Korean Hand Acupuncture) or the ear (a system developed in France in the 1950s), and that needling or other manipulations of points in this location can affect distant organs. Again, no identifiable connections between these proposed local maps and distant organs have been found.

The number and location of acupuncture points has changed often through history, and today there is great variety among acupuncturists as to the sites used. In fact, some proponents of acupuncture, including Felix Mann, past president of the British Acupuncture Society, deny that specifically identifiable point for applying acupuncture exist at all.

In addition to needle insertion, some acupuncturists burn herbs at acupuncture points, pass electric current through the needles or pads placed on the skin, massage or inject vitamins at acupuncture points, or use laser light or other methods to treat patients. Thus, there is no agreement among proponents of acupuncture about the underlying basis for the practice, the specific points to be used, or how these points are to be stimulated.

The popularity of acupuncture has risen and fallen many times in China and the West. After being largely replaced in China by Western medical practices in the 19th and early 20th centuries, the practice underwent a resurgence in the 1950s and 1960s, as an effort by the Communist Party to provide cheap health care in places without modern facilities or trained doctors. It has since become a relatively minor element of medical care in China among those with access to more popular, Western scientific medical. The current interest in acupuncture in Europe and the United States began in the 1970s, following the reopening of China to outsiders.

Historically, acupuncture as understood today was never applied to animals in China. Other interventions, such as bleeding or burning herbs at points on the skin were practiced on animals, but animals were considered fundamentally different from humans in ways that made the methods which have since been developed into modern acupuncture inappropriate for veterinary patients.

Nevertheless, with the rise in interest in acupuncture in the West during the 1970s, the acupuncture points in use for animals today were invented by Western practitioners extrapolating from charts made for humans. The logic of this is sometimes questionable, as for example in the use of a “gallbladder meridian” for acupuncture treatment in horses despite the absence of a gallbladder in this species. As with humans, there is no consistency among acupuncturists as to the rationale for therapy or the specific points or methods to be used.

Does It Work?

There is an enormous amount of scientific research devoted to acupuncture in humans. As always, some studies support its use and others find no evidence of benefit. It can be difficult to sort out the real answer from this confusion.

Studies performed by proponents of acupuncture or published in journals devoted to the practice are almost always positive. Studies performed by critics or neutral researchers are generally negative or inconclusive. Furthermore, as with any medical therapies, negative studies on acupuncture are less likely to be published since they are disappointing to the researchers and not attractive to journals, so there is some inherent bias in the literature for positive results. This is especially true in China, where many of the studies of acupuncture have been published and where 98% of all medical studies published (and 100% of studies in alternative methods such as acupuncture) report positive results.

The best quality scientific studies require blinding, where the patients and researchers not know whether each subject is getting the real acupuncture treatment or a fake (placebo) treatment. Unfortunately, it can be very difficult to fool a person about whether or not they are receiving real or fake acupuncture, and it is impossible to fool the acupuncturist doing the treatment.

Many other factors complicate interpretation of human clinical trials. Confidence in the results can only come from consistent, repeatable outcomes of many well-designed trials conducted by different investigators. However, despite decades of studies in acupuncture, there is still no such body of evidence that shows acupuncture to be consistently effective for any condition.

When the best quality studies, with reasonable numbers of subjects and good controls for bias, are reviewed they find no benefit from acupuncture for most conditions. The evidence is mixed or shows some benefit for some types of chronic pain, and for nausea following chemotherapy or surgery. The largest, best designed, and most recent studies have found that sham or fake acupuncture (using random locations or not actually puncturing the skin with the needles) seems to have about the same benefit as real acupuncture treatment. And patients who believe they are getting real acupuncture even when they aren’t get more relief than those who actually get acupuncture but think they are getting the placebo treatment. The degree of benefit, when any is seen, is generally very small and considerably less than most conventional therapies when these are used for comparison.

So the evidence for humans indicates that acupuncture may make people with chronic pain or nausea feel more comfortable, though this is probably due to altering their perception or awareness of the discomfort rather than actually treating the source of the discomfort in the body. This may have some benefit as an adjunct to traditional scientific medical treatment.

Does it work for animals? This would seem to be easier to determine than it is for humans because no effect from the patients’ attitudes or beliefs would be expected in animals. However, it is currently impossible to determine if there is any benefit of acupuncture for veterinary patients because of the lack of well-conducted research studies. The quality of the acupuncture studies that have been done in veterinary medicine is generally very low. A recent systematic review in the Journal of Veterinary Internal Medicine found so few controlled trials of such poor quality that despite reports of benefit from acupuncture in some studies and no benefit in most, the authors concluded that “there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals.”

For now, we can only say that it appears somewhat helpful for subjective discomfort, such as pain or nausea, in humans, especially if the patient believes it will be helpful. The evidence is not available to say with certainty whether it is helpful to veterinary patients, but the apparent importance of patient attitudes or beliefs for benefit in humans make it doubtful that animals will experience the same benefits, since their experience is unlikely to be affected by such factors. However, the caretakers of veterinary patients, who evaluate the effectiveness of therapy and make medical decisions for the patients, can be influenced by their own experiences and beliefs, which makes objective assessment of the effect of acupuncture in the clinical setting very difficult.

Is it Safe?

The incidence of complications from acupuncture in humans is low. It has been reported to cause minor local pain and bleeding fairly commonly. More serious side effects, including fainting, vomiting, hepatitis, permanent nerve damage, and death from collapsed lungs have been reported, but these appear to be extremely rare. Adverse effects of acupuncture in animals have not been reported in the sparse literature that exists on the subject.

Summary

  • There is no evidence for the reality of the more mystical principles underlying some acupuncture practices, such as Ch’i, yin/yang, specific acupuncture points, or meridians. There is also no verifiable way to locate or identify specific locations for applying acupuncture.
  • More scientific concepts, such as endorphins and neuronal gating, are at least potentially testable, but as yet the evidence does not show that these explanations justify the clinical use of acupuncture.
  • In humans, acupuncture may have some benefits for reducing the perception of chronic pain and nausea, but it is doubtful that our animal patients will experience this same benefit since it seems to be highly dependant on what the subject believes about their condition and treatment. There is no consistent evidence for a benefit in the outcome of any disease in humans treated with acupuncture.
  • In animals, there is no reliable, high-quality research evidence for the benefits of acupuncture. The studies that have been done have found both positive and negative results, but the poor quality and lack of replication make the existing evidence insufficient to recommend acupuncture therapy.
  • Acupuncture is unlikely to be harmful to most patients.
  • With very little risk of harm, and no convincing evidence of benefit, the use of acupuncture in animals should be seen as an experimental adjunct to conventional therapy, not a replacement for proven medical treatments.

References and More Information
Barker Bausell, R., Snake Oil Science: The Truth About Complementary and Alternative Medicine, Oxford University Press, 2007

Ernst, E., White, A.R., Prospective studies of the safety of acupuncture: a systematic review. Am J Med Apr 2001;110(6):481-5

Habacher, G., Pittler, M.H., Ernst, E., Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet Int Med May-Jun 2006;20(3):480-8.

Mann, Felix. Reinventing Acupuncture, Butterworth Heinemann, 1992

Ramey, D., Rollin, B., Complementary and Alternative Veterinary Medicine Considered, Iowa State Press, 2004

Sing, S., Ernst, E., Trick or Treatment: The Undeniable Facts About Alternative Medicine, W.W. Norton & Company, 2008

The Cochrane Collaboration, The Cochrane Reviews, a searchable database of systematic reviews of the human medical literature at http://www.cochrane.org/reviews/

 

Posted in Acupuncture | 11 Comments

The Danger of Choosing Alternative Therapies over Conventional Care

One of the most common responses to criticisms of alternative medicine is that, whether it is effective or not, at least it can’t do any harm. There is ample evidence, unfortunately, that this is not true. Any therapy with a potential benefit also has potential harms, so if CAM interventions do anything at all, one would expect some side effects. But even for those that are completely ineffective, there are risks.

Some of these risks are direct. Herbal remedies and supplements can be toxic or contain toxic contaminants (1, 2, 3). And other CAM therapies can be directly harmful, such as chiropractic (4), herbal remedies (5), and even acupuncture (6). But even for therapies that are inherently safe because they contain no active ingredients, such as homeopathy (7), there are indirect risks. Avoiding effective conventional therapies because of a false belief in the value of alternatives can lead to significant harm. A new study illustrates this in women with breast cancer.

Kurian Joseph, Sebastian Vrouwe, Anmmd Kamruzzaman, Ali Balbaid, David Fenton, Richard Berendt, Edward Yu and Patricia Tai. Outcome analysis of breast cancer patients who declined evidence-based treatment.World Journal of Surgical Oncology 2012, 10:118.

This study compared the survival of women diagnosed with breast cancer for those who accepted standard medical care and those who did not. The authors concluded:

A total of 185 (1.2%) patients refused standard treatment…The 5-year overall survival rates were 43.2% (95% CI: 32.0 to 54.4%) for those who refused standard treatments and 81.9% (95% CI: 76.9 to 86.9%) for those who received them. The corresponding values for the disease-specific survival were 46.2% (95% CI: 34.9 to 57.6%) vs. 84.7% (95% CI: 80.0 to 89.4%).

Women who declined primary standard treatment had significantly worse survival than those who received standard treatments.

Of the women who declined care, 54% pursued some form of alternative therapy instead, and overall 5-year survival for this group was 57.4% (95% CI: 42.7 to 72.1%).

It is important not to over interpret these results. To begin with, the number of women who refused standard treatment was very small, which suggests that most understand the value of conventional therapy for this disease. And of those who refused treatment, many may have done so for reasons having nothing to do with their beliefs about conventional versus alternative therapies. There are many perfectly sound reasons for choosing not to pursue treatment depending on the extent of disease, the chances of benefit and harm from therapy, and personal circumstances and values. No clear reason was given for almost half of the women who refused, so it is impossible to know whether or not CAM played any role in their decision or their outcomes.

And choosing CAM instead of conventional therapy may not have been the only reason for the difference in survival between women who did or did not have standard treatment. Women who were sicker, had more advanced disease, or had other diseases as well may have been less inclined to pursue therapy, and also more likely to die sooner than women with a better chance of a good outcome with standard treatment.

And women who pursued CAM therapy instead of standard treatment did do slightly better than women for whom no reason for refusing traditional care was given (57.4% 5-year survival versus 43.2% 5-year survival). This would make sense if women who refused all care, even CAM, did so because they had more aggressive or advanced disease or other health problems.

However, there is no question that women who chose standard treatment did far better than those who choose CAM. The difference in 5-year survival between CAM (57.4%) and standard care (81.9%) was huge and unequivocal. And while the specific CAM used was not known in each case, overall there is no reason from these data to believe CAM in general has anything like the efficacy of conventional breast cancer treatment. If there is some form of CAM that performs as well as conventional care, no one has yet presented the data to show this, so claims that this is a legitimate alternative and that refusing standard care is a reasonable choice for women who want to treat their disease are not supported by any evidence and are, in fact, contradicted by the evidence of this and other similar studies (8, 9)

This is yet another study which emphasizes that importance of not substituting unproven alternative therapies for science-based medical care. While investigating the possibility that some plausible alternative therapies may have benefit is reasonable, choosing CAM over standard care is not and is likely to result in real harm.

Posted in General, Miscellaneous CAVM | 2 Comments

The Pseudoscience of Veterinary Chiropractic

The defining characteristic of pseudoscience is an idea which sounds scientific, which claims to be scientific, but which isn’t actually based on legitimate scientific research or is theoretically inconsistent which established scientific knowledge. There can be some subjectivity in the characterization of something as pseudoscience, and of course no one promoting an idea would ever accept the label for their own beliefs. However, an article I recently read concerning veterinary chiropractic exemplifies many key features of a pseudoscientific idea.

Maler, MM. Overview of veterinary chiropractic and its use in pediatric exotic patients. Vet Clin Exot Anim. 2012;15:299-310

The article spends a great deal of time describing the Vertebral Subluxation (VS), which the author states “is at the core of chiropractic theory, and its detection and correction are central to chiropractic practice.” The only problem with this claim is that the vertebral subluxation, as defined by chiropractic theory doesn’t exist. (1, 2, 3)

Historically, chiropractors defined the VS as a misalignment of bones in the spine, leading to interruption in the flow of “innate intelligence,” a magical spiritual force responsible for normal health. Of course, no scientific evaluation of such a supernatural force is possible, and to gain the appearance of scientific legitimacy, most chiropractors gradually moved away from this concept and argued that the misalignment of vertebrae damaged health by impinging on nerves leaving the spine. This theory makes some sense when used to explain musculoskeletal pain, though it doesn’t make any sense when used to justify chiropractic as a treatment for ear infections, asthma, allergies, or other such complaints.

As it turned out, however, chiropractors have never been able to demonstrate that the bones they are supposedly adjusting into proper position were ever out of position. In other words, they have never been able to show any misalignment in the spine treatable by their form of manipulation. Studies involving imaging, such as x-rays, don’t show the misalignments, and when radiologists or chiropractors look at x–rays of patients diagnosed with a VS on physical examination, they can’t consistently find a lesion in the area identified as abnormal during the exam.

In response to this failure, chiropractors have once again modified the definition of the VS, this time describing the subluxation not as a misalignment of bones but a “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ function and general health.” How’s that for a definition vague enough to qualify as a horoscope? Basically, chiropractors are now saying that a VS cannot be seen or measured or identified in any way other than the subjective impression of a chiropractor during an examination, yet it is still an appropriate basis for an entire approach to maintaining health and treating innumerable diseases.

But the situation is even worse than it sounds. When chiropractors examine the same patient multiple times, they cannot consistently locate a VS in the same location each time. And when multiple chiropractors examine the same patient, they all claim to find abnormalities in different places. So they can’t even agree with themselves or each other on where a VS is in any particular patient. Again, it is hard to imagine such a nebulous entity being the foundation of comprehensive healthcare approach, much less one claimed to be scientific in its foundations.

To their credit, a growing minority of chiropractors recognize that the VS is a myth and seek to identify legitimate, scientific explanations for the limited but well-demonstrated benefits of chiropractic therapy in treating lower back pain. Such evidence-based chiropractors have been trying to reform their profession since the 1960s, with pretty limited success. Some of the most conclusive evidence against the existence of the VS comes from chiropractors themselves applying truly scientific methods to the evaluation of this pseudoscientific concept.

A review of the literature which appeared in a chiropractic journal in 2009 evaluated the research evidence concerning the VS to see if it met standard criteria for a cause-effect relationship between the VS and disease.

Miritz TA. Morgan L. Wyatt LH. Greene L. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropr Osteopat 2009;2:17-13.

The criteria for causation in epidemiology are strength (strength of association), consistency, specificity, temporality (temporal sequence), dose response, experimental evidence, biological plausibility, coherence, and analogy. Applied to the subluxation all of these criteria remain for the most part unfulfilled.

There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.

The fact that in over 100 years since the beginnings of chiropractic no one has been able to demonstrate the existence of the foundational concept for the method, the vertebral subluxation, doesn’t prevent the author of the veterinary clinics article from describing it in detail, with diagrams and lots of scientific terminology. She then goes on to make a wide variety of therapeutic claims, identifying chiropractic as a successful intervention for disease in exotic species.

As evidence for these claims, she cites quite a few textbooks and other writings of her fellow chiropractors, but virtually no relevant clinical trials. The author acknowledges this lack of research support but, in a technique common among practitioners of unproven approaches, she places the blame for this everywhere except on the chiropractic community:

Chiropractic research is in it’s infancy compared to traditional medicine largely due to lack of funding and proprietary interest in chiropractic as well as historical staunch opposition from the American Medical Association and other medical groups.

For a treatment approach that has been in existence for a century, with 50,000 licensed chiropractors in the U.S. alone, and with annual revenue for chiropractic treatment estimated at $10 billion in the U.S., it is hard to justify failing to subject the practice to rigorous scientific scrutiny due to lack of funds.

And while there once was organized opposition to chiropractic on the part of the American Medical Association, this vanished after an antitrust lawsuit finally settled in 1987. The judge found that while the AMA had a legitimate concern about the unscientific nature of chiropractic and the inadequate evidence for safety and efficacy, it did not have the right to organize a boycott against the practice. Organizations representing conventional healthcare providers have done nothing to stop chiropractors from pursuing rigorous scientific evidence to support the theory of the VS or the safety and efficacy of chiropractic treatment.

Yet despite all of that, the only convincing evidence that has emerged to support chiropractic treatment is in the care of humans with lower back pain, in which chiropractic is about as effective as conventional care. This does not justify the application of chiropractic for any other medical condition or the use of chiropractic in non-human animals without appropriate research to justify this. And it certainly does nothing to support the pseudoscientific nebulosity that is the vertebral subluxation. As long as chiropractors cling to this notion and make claims for their practices beyond what is justified by real evidence, the practice will continue to be a pseudoscientific one.

Posted in Chiropractic | 2 Comments

Ozone Therapy for Pets

I’ve recently run across some advertising for the wonders of ozone therapy in pets. This is a treatment that hasn’t caught on much in veterinary medicine (fortunately), but I thought I’d take a look at it before it becomes the next big fad.

What Is It?
According to the Food and Drug Administration (FDA),

Ozone is a toxic gas with no known useful medical application in specific, adjunctive, or preventive therapy. In order for ozone to be effective as a germicide, it must be present in a concentration far greater than that which can be safely tolerated by man and animals.

According to the Environmental Protection Agency (EPA),

ozone is an air pollutant that is harmful to breathe and it damages crops, trees and other vegetation. It is a main ingredient of urban smog.

Ordinary oxygen gas consists of two oxygen atoms bound together, hence its chemical name O2. Ozone contains three oxygen atoms (O3), and is very reactive, breaking down spontaneously and combining readily with other chemicals. These oxidation reactions are the reason ozone can be used as a disinfectant, killing microorganisms through production of oxidative free radicals.

Proponents of ozone therapy claim that it can be medically beneficial in several ways. Its ability to kill microorganisms and other living cells has been claimed to make it useful for treating infectious diseases and cancer. It is also thought by some to increase the amount of oxygen available to tissues, which may be useful in preventing or treating disease, and to stimulate or modify the immune system in a beneficial way.

Ozone is employed in medical applications in multiple ways, including direct injection into blood, muscle, joints, or body cavities, autohaemotherapy (removing blood from the patient, exposing it to ozone, and then returning the blood to the patient’s body), insufflation of the rectum, vagina, or other body spaces with ozone gas, administration of ozone treated water or saline, and topical application of ozone gas or ozone-treated substances.

Does It Work?
There are pre-clinical, in vitro, studies of ozone applied to infectious organisms and cancer cells and demonstrating it can kill these. As I have often pointed out, however, so can bleach, hydrochloric acid, and many other substances which are not appropriate to give to patients as a form of therapy. A few animal model studies have also suggested a benefit in cancer treatment.

Several reviews have found little controlled clinical research showing beneficial effects in patients treated with ozone therapy. Here are some of the conclusions from these reviews:

Ozone’s use in medicine has been debated for decades, but references to its use were sporadic in the major medical journals. Most of the claims of its efficacy were anecdotal…Current data on the usage of ozone therapy as therapeutic options for various health conditions lacks sufficient safety and therapeutic advantage over available conventional therapeutic modalities…There is insufficient clinical evidence to recommend ozone therapy as a form of alternative treatment….(Health Technology Assessment Report: Ozone Therapy, Ministry of Health, Malaysia, December, 2005)

Given the high risk of bias in the available studies and lack of consistency between different outcome measures, there is no reliable evidence that application of ozone gas to the surface of decayed teeth stops or reverses the decay process. There is a fundamental need for more evidence of appropriate rigour and quality before the use of ozone can be accepted into mainstream primary dental care or can be considered a viable alternative to current methods for the management and treatment of dental caries. (Cochrane Reviews. Ozone therapy for treatment of dental caries. 2004)

Oxygenation therapists proposed that disease is caused by absence of oxygen and loss of cellular ability to use oxygen for “good energy” metabolism, detoxification, and immune system function. Oxygen therapies are proposed in order to restore the body’s ability to produce “good” energy, to “detoxify” metabolic poisons, and to kill invading organisms. However, over the five decades that have passed since this concept was proposed, scientists have shown that:

  1. Anerobic energy metabolism (fermentation) is not the cause of cancer.
  2. Koch’s glyoxylide does not exist.
  3. Ingestion, infusion, or injection of hydrogen peroxide cannot re-oxygenate the tissues of the body.
  4. Ozone-treated blood infused during autohemotherapy does not kill AIDS virus in vivo. (Green, S. Oxygenation therapy: Unproven treatments for cancer and AIDS. Quackwatch.org)

Ozone therapy has been recommended to treat many conditions. There are numerous anecdotes about successful treatment with ozone therapy, although effectiveness and safety have not been proven scientifically. (Ozone Therapy, Intelihealth article, Natural Standard and Harvard Medical School, 2008)

“Hyperoxygenation” therapy–also called “oxymedicine,” “bio-oxidative therapy,” “oxidative therapy,” and “oxidology”–is a method of cancer management based on the erroneous concept that cancer is caused by oxygen deficiency and can be cured by exposing cancer cells to more oxygen than they can tolerate. The most highly touted “hyperoxygenating” agents are hydrogen peroxide, germanium sesquioxide, and ozone. Although these compounds have been the subject of legitimate research, there is little or no evidence that they are effective for the treatment of any serious disease, and each has demonstrated potential for harm. Therefore, the American Cancer Society recommends that individuals with cancer not seek treatment from individuals promoting any form of hyperoxygenation therapy as an “alternative” to proven medical modalities. (Questionable methods of cancer management: Hydrogen peroxide and other “hyperoxygenation” therapies. CA Cancer Journal for Clinicians. 2008;43(1):47-56.)

There is limited research in veterinary species. A lab animal study of rabbits suggested a benefit for cancer. A couple of recent studies in cows from a single research group in Croatia found a possible benefit of ozone in treating retained placentas and urovagina and in improving reproductive efficiency. An uncontrolled case series in dogs reported improvements in signs of intervertebral disk disease after ozone therapy (though often patients with this disease get better with rest or only supportive care anyway).

As is always the case, there are numerous positive anecdotes claiming dramatic success in treating a wide range of diseases, but for well-established reasons, we cannot rely on these stories as a demonstration that this treatment is safe or effective (c.f. here and here). And there are a few clinical studies suggesting a benefit, all with significant limitations. The balance of the evidence, however, does not support the efficacy of ozone therapy for any condition. Given the miraculous results claimed for this treatment, it would not be difficult at all to generate dramatic clinical trial evidence, so the absence of this evidence, despite decades of use, strongly suggest that the anecdotes and testimonials cannot be trusted.

The underlying theories used to justify the treatment are also dubious. As Dr. Green establishes in his article on Quackwatch, it is not plausible that low oxygen levels are responsible for many of the diseases ozone therapy is supposed to treat, and it is not likely that ozone therapy significantly increases the oxygen available to tissues in a patient that is treated with it. And while the hype about the benefits of antioxidants does not appear justified, it is certainly possible that free radicals and oxidative stress could actually cause health problems in patients treated with a potent oxidizing agent like ozone. Which leads to the question…

Is It Safe?
There are anecdotal reports in the media and in the scientific literature of adverse effects and even death following ozone therapy. Patients have died from gas bubbles in their bloodstream following injectable ozone treatment, and patients have suffered injury from the injection of ozone and from the apparatus used to instill ozone rectally, vaginally, and into body cavities. Accidental infection with HIV and hepatitis virus have also been reported from contamination during autohaemotherapy.

According to one scientific review, “The risks of ozone therapy are played down by its proponents. Yet, numerous reports of serious complications, including hepatitis, and at least five fatalities have been reported.”(Ernst E (2001). A primer of complementary and alternative medicine commonly used by cancer patients. Med J Aust, Jun 4; 174(11): 611-2)

The indirect risk of using ozone therapy, if it is ineffective, is that serious disease can progress and the opportunity to treat with truly effective therapies can be lost if one delays conventional therapy in favor of ozone therapy. The FDA referred to this risk, as well as the more direct hazards mentioned above, when reporting its decision in 2009 to seize equipment used for ozone therapy from a company illegally selling these unapproved medical devices. The FDA considers medical use of ozone as an unapproved drug, which makes such use subject to prosecution.

And as mentioned before, ozone has been intensively investigated as a pollutant, and there are many studies reporting harmful effects in humans and veterinary species.

Bottom Line
The theoretical justifications for the medical use of ozone are weak and unproven. There are equally strong theoretical reasons why such use could be harmful.

Actually clinical research in humans is limited, but there is no consistent body of evidence to suggest ozone therapy is effective for any medical condition. There are anecdotal reports of injury, illness, and death caused by ozone therapy in humans.

The research is even more limited in veterinary species, and there is no consistent body of evidence to support the safety or effectiveness of ozone therapy for disease in dogs and cats.

Medical use of ozone is not approved in the U.S., and there have been prosecutions of individuals selling unapproved medical devices for use in ozone therapy.

Any use of ozone therapy in dogs and cats must be considered experimental and should only be conducted in the context of properly controlled, monitored, and approved clinical research trials. As with all unproven therapies, those selling ozone therapy will claim benefits and deny the risks. But in the absence of reliable information about the effects of ozone treatment, the chances of harming your pet are at least as good as the chances of helping them.

Posted in Miscellaneous CAVM | 41 Comments

The Three Most Dangerous Words in Medicine

This slide presentation, and narrated video version, look briefly at the danger of relying on individual clinical experience rather than formal scientific research in making medical decisions.

Slide Presentation

Clinical Trials or Clinical Experience?

Posted in General | 2 Comments

Can Complementary and Alternative Medicine be Evidence-Based?

This slide presentation, and the narrated video version, are part of a talk given at the annual convention of the American Veterinary Medical Association. The subject was whether or not one can apply the approach of evidence-based medicine to complementary and alternative medical practices. The presentation reviews some of the philosophical principles underlying both approaches and discusses potential areas of conflict between them.

A slightly more detailed examination of the subject will also be available as a commentary in the upcoming August 15th issue of the Journal of the American Veterinary Medical Association.

McKenzie, BA. Is complementary and alternative medicine compatible with evidence-based medicine? Journal of the American Veterinary Medical Association. 2012;241(4):421-6.

Slide Presentation (Powerpoint):

Can Complementary and Alternative Medicine be Evidence-Based Medicine?

 

 

 

Posted in General | 2 Comments

Dog Cancer Expert Steven Eisen: Bad Advice from an Unreliable Source (restored)

The direct quotations from Dr. Eisen’s web sites were temporarily removed pending the outcome of a DMCA copyright complaint. Since no legal action was taken during the 14-day waiting period mandated under the DMCA, the original quotations have been restored.

Most of the individuals I write about who are promoting questionable veterinary medicine, or outright nonsense, are veterinarians. Such individuals have some claim to legitimacy and authority in recommending veterinary treatments, and so their voices tend to carry more weight than those of most lay people. This isn’t always a good thing since veterinarians are no less prone than anyone else to getting bad ideas stuck in our heads or to being misled by all the features of the world and our own brains that so easily fool us. Experts, that is individuals with recognized credentials and formal training in a specific area of medicine, do tend to have more factual knowledge in that subject. But they are not immune to making mistakes, so as always it is the ideas and the evidence that must be given the greatest way, not the authority of the individual.

Because advice from veterinarians is more likely to be trusted, even when it’s bad advice, I focus on these sources when pointing out why certain ideas, practices, or products are not supported by good evidence and science. However, once in a while I run across a particularly egregious example of misleading a negative advertising for alternative medicine that I feel obliged to challenge even though the source is not a veterinarian. Here’s a quick example of why I noticed this one:

If your dog has been given the heart-breaking diagnosis of terminal cancer… Just About EVERYTHING Your Vet Told You Is WRONG!

Don’t Let Deadly Mistakes Take Your Beloved Companion Away From You –There IS a Way to Save your Dog

Subtle, thoughtful argument, eh?

Steven Eisen is a “Holistic Dog Cancer Expert.” How did he get to be an expert? Well, according to his website first he read about holistic medicine in college, then he studied at the New Age Esalen Institute, and then he graduated from a college of chiropractic. Oh, and when his own dog got cancer he ignored his veterinarian’s advice and made up a bunch of stuff about diet and supplements, and since his dog lived longer than he says the vet predicted, he must have discovered the cure for dog cancer. Now, he would like you to buy the secret to curing cancer from him in the form of his book, Dog Cancer: The Holistic Answer.

I wasn’t willing to support the promotion of this nonsense by buying the book, but Dr. Eisen does offer some glimpses of his ideas on his web site and in a number of free videos. [except, of course, he will threaten to sue you if you tell anyone what he says in them]. These exhibit nearly all the warning signs of quackery, and Dr. Eisen doesn’t provide any evidence beyond his own opinion and the usual unreliable miracle stories for his claim that he has a simple, safe, effective therapy that scientific medicine either doesn’t know about or doesn’t want you to know about.

His primary web site, DogCancerAdvice.com, offers the usual sorts of unsubstantiated attacks on the ignorance and futility of conventional veterinary medicine. For example:

“The training of these professionals [veterinarians] has superbly equipped them to treat acute problems like infections, heartworm, and trauma. However, there are no standard veterinary protocols for dog cancer. The only treatments taught in veterinary school are the toxic ones…despite the scientific evidence that they are not effective. “

“Although some veterinarians claim to combine conventional and alternative dog cancer treatments, it’s rare to find one that has a thorough understanding of the principles of holistic medicine and holistic treatments for cancer in dogs. An issue that’s consistently ignored is that the two approaches are often incompatible because the underlying assumptions are worlds apart. If a gardener said he would take care of your lawn with both pesticides and organic methods, I think you would wonder about his expertise, his intelligence and/or his honesty.”

“If there were a brush fire in the forest, would it make sense to set the rest of the forest on fire? That is essentially the conventional approach to treating dog cancer.”

“Unfortunately, many have been following dangerously mistaken advice from their vets. The quality of your dog’s life can improve, and even be healed from cancer with the right information. “

“In vet speak, a dog with lymphoma is considered “cured” by conventional treatment if it survives 8 months.” [This is simply untrue. No veterinarian wuth any knowledge of cancer therapy would claim to be able to cure lymphoma. The word he’s looking for is “remission,” and the mean remission time for lymphoma with conventional treatment is about 10-14 months]

Dr. Eisen then gives detailed numbers showing so-called “holistic” treatment is cheaper than conventional cancer therapy, which seems a transparent attempt to prey on people who would like the best care possible for their pets but have significant financial limitations. He lists the potential side effects of conventional treatment without any information about how common or severe these might be and no mention of the benefits of treatment. And he finishes with the usual nonsense that Quote removed which basically says alternative cancer treatments work without any side effects. The bottom line:

“Not only are alternative treatments less toxic and more effective, they also cost just a fraction of what you would pay for conventional treatments. “

So a cheap, simple, effective cure for cancer with no risks or side effects which, for reasons we can only guess at, almost none of the veterinarians (or physicians, for that matter) know about or use. Hmmm, how likely does that seem to you? Well, let’s see what Dr. Eisen’s argument is.

1.      The Toxins Did It!

Part of being an expert in dog cancer is apparently being a toxicologist. Well, ok he’s not actually a toxicologist, but he says dog cancer is all about toxins, so we have to believe him, right?

Most of Dr. Eisen’s rant about toxins as a cause of cancer is indistinguishable from the usual oversimplified, mythologized nonsense about how the whole world is full of poisonous chemicals. The fact that some substances, both natural and human made, can cause disease, including cancer, in some people at some dose has nothing to do with the almost religious notions about contamination and purification behind the notion of “detoxification” as a treatment for disease.

Dr. Eisen lists a myriad of substances that are to blame for your pet’s disease, including vaccines, commercial pet food ingredients (including pretty much every part of the animal except muscle meat), bacteria as well as the antibiotics used to treat them, vaccines, flea and tick control products, and both tap water and bottled water (which are allegedly full of pharmaceuticals and that classic bugbear of quacks—fluoride). All of the accusations are presented as fact despite the absence of real data to support them. Nothing sells like fear!

Examples of Dr. Eisen’s sophisticated, thoughtful reasoning balancing risks and benefits include these remarks:

“If your dog has cancer, it is imperative that they never receive another vaccination. Not ever again for the rest of their life.”

“I can’t emphasize this too much. You need to eliminate the application of all commercial flea and tick products if you want to keep your dog healthy.”

2. My Diet is the Best!

Apparently, despite having no formal training in veterinary nutrition, Dr. Eisen is also an expert in cancer nutrition as well. With his usual abundance of confidence, and lack of evidence, he makes a number of claims about cancer and diet.

First, he recommends a homemade diet because, quote removed due to lega coplaint which basically says no commercial food is good for dogs with cancer. He dismisses the one cancer-specific diet on the market because of the usual myth about “byproducts” (the parts of the animal affluent Americans find yucky but that are routinely eaten by people in other cultures and universally enjoyed by wild and feral carnivores). And he completely ignores the strong evidence that homemade diets are almost always nutritionally incomplete.

Next he recommends a low-carbohydrate diet for dogs with cancer. There is some research which suggests carbohydrate restriction could have benefits for cancer patients. There is, as yet, no consistent body of evidence in humans or in dogs to indicate they actually do have benefits, so the idea is reasonable but still tentative.

He makes some arbitrary restrictions, such as banning pork as a protein source, and recommends a host of herbs which rumor, but no convincing scientific research, suggests might have anti-cancer properties. Despite the lack of any evidence to show this diet is nutritionally adequate, much less that it has a significant impact on the health or longevity of cancer patients, Dr. Eisen concludes, “This truly is healing food for your dog with cancer.”

Why? Apparently because he says so.

3.     #1 Worst Thing

Dr. Eisen states repeatedly, that cancer is growing more and more common in dogs. He bases this on reports indicating cancer is diagnosed more frequently now than ten or twenty years ago. This is likely true, though the data is not from very high quality controlled studies. Unfortunately, one area in which Dr. Eisen is not an expert is epidemiology, the study of the occurrence and causes of disease. He assumes simplistically that more cancer diagnosis means more cancer, which he then goes on to attribute, again based only on opinion, to a more toxic environment. However, more diagnosis of cancer does NOT mean that our dogs are sicker than they once were or that the environment is less healthy. Here are other reasons why cancer diagnoses can increase:

a. An Aging Population– Cancer occurs more frequently in older animals because it is frequently caused by defects in the control of cell division that accumulate over the lifetimes of many cells. The longer you live, the more times your cells have had to divide, and the more opportunities there are for the kinds of errors that can lead to cancer. Every epidemiologic study must account for differences in age between populations when comparing the rates of cancer and other disease. So if our pets are living longer as a result of better nutrition, disease prevention, and medical care, then we will see more dogs with cancer.

b. Better Control of Non-Cancerous Disease– For most of human history, almost half of all people born died before they reached adulthood. Very, very few of these children died of cancer, which is much more common in the elderly. They died mostly of malnutrition, infectious and parasitic diseases, and accidents. As science improved the quality of our food supply, provided the technology that raised our standard of living, and generated vaccines, antibiotics, pediatric and neonatal intensive care units, and all the other healthcare interventions that prevent these kinds of deaths, guess what happened? Yup, more people lived longer, the average age of the population increased, and cancer became a more common cause of death. NOT because the environment got more toxic but because it got healthier and safer! Cancer is one of the things you die of if you succeed in avoiding the age-old standards that used to kill most people.

The same is true for our pets. The very vaccines and pet foods and medicines Dr. Eisen condemns so blithely are responsible for reducing deaths from many non-cancer causes, leading to an increase in the number of cancers seen. This is a sign of past success for scientific medicine, and a challenge for the future. It is not a sign of the failure of conventional healthcare or the poisonous nature of the environment.

c. Better Diagnosis and Treatment– Diagnostic methods like ultrasound, CT scanners, and biopsies are becoming more accurate and more available all the time, and more people are willing to pay for tests to identify cancer in their dogs. This alone can increase the number of cancers diagnosed. And as we develop the ability to diagnose cancer more accurately and at an earlier stage, and as we find treatments for cancer which can (contrary to Dr. Eisen’s misleading claims) benefit cancer patients and even sometimes cure cancer, more people are willing to test their pets for these diseases and consider treating them.

I certainly wouldn’t claim that there is clear evidence cancer rates are not truly increasing. The reality is that we don’t have the appropriate epidemiological evidence to know. What is clear, however, is that the claim that there is more cancer due to increasingly toxic environments is absolutely without legitimate scientific support

So what does Dr. Esien say is the #1 Worst Thing for dogs with cancer? It’s not the commercial pet foods, flea and tick products, and tap water that he claims are contributing to a supposed cancer epidemic in dogs. Bad as these are, apparently they pale before the worst toxin of all–vaccines.

“The #1 worst thing you can do to a pet with cancer is to have them vaccinated.”

“Vaccines are loaded with toxic heavy metals like mercury and aluminum”

“Cancer is an auto-immune disease, so vaccines can cause cancer”

“Most vets administer vaccines routinely to our pets and tell you that they are safe, with very little risk. The fact is, nothing could be further from the truth.”

“Immunity is an all or nothing thing, either you have it or you don’t.”

“Any vaccination given to your dog will further impair their immune system and greatly reduce their likelihood of recovery.”

Now, there is nothing wrong with suggesting that vaccination may not be appropriate for dogs with cancer, or any other serious illness. It is widely accepted and routine to defer vaccination of dogs when they are ill. The problem with Dr. Esien’s diatribe about vaccination is that is takes this sensible recommendation and expands it into an indictment of vaccines as toxic and as a routine cause of cancer. It is like saying that because you shouldn’t drive while drunk, having a glass of wine with dinner is a major cause of auto accidents.

There are examples of vaccines being associated with an increased risk of some cancers. A type of cancer called a sarcoma can occur in between 1 out of 1,000 to 1 out of 10,000 cats vaccinated with an aluminum-containing rabies or feline leukemia vaccine. Such cancer is likely triggered by inflammation, which can also be induced by trauma, parasites, and many other causes. As a result of careful research identifying this problem (which we would not have found out about simply by casual observation or guessing), vaccines and vaccination practices have been altered to reduce this risk.

This example is often misused to suggest that vaccines in general are a risk factor for cancer in general, which is not the case. And such arguments ignore the fact that vaccinations save many, many lives. It is easier to sell an idea that is simplistic and makes the world seem like a place where all risks can be controlled and we can have the outcome we want so long as we do everything “right.” But the world we live in is more complicated than that, and anyone who tells you differently is selling something.

Dr. Eisen also belabors the fact that vaccine manufacturers state their vaccines should only be used in healthy animals. While I agree this is usually true, vaccine manufacturers also state their vaccines are safe and effective. Why does Dr. Eisen reject these claims and yet accept the recommendation not to give vaccines to ill dogs? Simply because it fits his personal beliefs about vaccination and cancer. He picks and chooses which information to accept and which to ignore not based on the strength of any evidence but on his personal prejudices. This is called confirmation bias.

Finally, Dr. Eisen also argues that vaccines aren’t effective in dogs with cancer based on manufacturer cautions about using them in immunocompromised individuals. This is a reasonable hypothesis, but one that has rarely been tested. The only specific study of the subject in dogs actually found no difference between the response to vaccination in dogs receiving chemotherapy and dogs not being treated for cancer.

Effects of chemotherapy on immune responses in dogs with cancer J Vet Intern Med. 2006 Mar-Apr;20(2):342-7. Claudia U Walter, Barbara J Biller, Susan E Lana, Annette M Bachand, Steven W Dow Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Fort Collins 80523, USA.

Abstract- Chemotherapy is assumed to be immunosuppressive; yet to the authors’ knowledge, the effects of common chemotherapy protocols on adaptive immune responses in dogs with cancer have not been fully evaluated. Therefore, a study was conducted to evaluate the effects of 2 common chemotherapy protocols on T- and B-cell numbers and humoral immune responses to de novo vaccination in dogs with cancer. Twenty-one dogs with cancer (12 with lymphoma, 9 with osteosarcoma) were enrolled in a prospective study to assess effects of doxorubicin versus multi-drug chemotherapy on adaptive immunity. Numbers of circulating T and B cells were assessed by flow cytometry, and antibody responses to de novo vaccination were assessed before, during, and after chemotherapy. The T- and B-cell numbers before treatment also were compared with those of healthy, age-matched, control dogs. Prior to treatment, dogs with cancer had significantly fewer (P < .05) CD4+ T cells and CD8+ T cells than did healthy dogs. Doxorubicin treatment did not cause a significant decrease in T- or B-cell numbers, whereas treatment with combination chemotherapy caused a significant and persistent decrease in B-cell numbers. Antibody titers after vaccination were not significantly different between control and chemotherapy-treated dogs. These findings suggest that chemotherapy may have less impact on T-cell numbers and ability to mount antibody responses in dogs with cancer than was previously anticipated, though dogs with lymphoma or osteosarcoma appear to be relatively T-cell deficient before initiation of chemotherapy.

So while there are good arguments for avoiding most vaccination of dogs with cancer, Dr. Eisen isn’t making them. He is simply asserting that vaccinating dogs with cancer is ineffective (which there is evidence may not be true) and harmful (for which there is no evidence at all). In short, he is making stuff up to suit his phobia about vaccines and toxins, and he is willing to borrow and misinterpret any information from any source to do make his case.

4.     Why Buy His Book?

“What I do is help people learn about holistic protocols for treating dog cancer so they can get their dogs better without the side effects and often life-threatening consequences of conventional treatments.”

Dr. Eisen makes the usual misleading arguments for why you should take his advice. He claims his dog lived longer than expected after being diagnosed with cancer, so that proves his treatment works. Such miracle testimonials are not, however, a reliable guide to what works and what doesn’t, for reasons I’ve discussed before. He talks about individualizing therapy, which is a common marketing ploy for alternative medicine that doesn’t mean what he wants you to think it means. And he claims that many of his recommendations are “scientifically proven,” which is another empty marketing phrase. And, with the usual ambivalence towards science that characterizes most promotion of pseudoscience, he claims it as a source of legitimacy while simultaneously deriding it as worthless:

“Limiting your treatment options for dog cancer only to those proven by scientific research could be harmful to your dog’s health.” [he then goes on to talk about how individual observations are often so obvious that clinical research isn’t necessary, which is only rarely true, and how “today’s profit-driven scientific community” isn’t interested in studying treatments which are inexpensive, which is an unjustified slur on veterinarians who are just as committed to the welfare of their patients as Dr. Eisen].

Dr. Eisen offers tidbits of advice on three web sites, dogcanceradvice(dot)com (which mostly serves to advertise the book), dogcanceracademy(dot)com (which has a couple of videos you can watch in exchange for your email address, which allows more direct marketing), and bestdogcures(dot)com, which is a subscription site open to those who buy the book. All of this is classic internet marketing, very similar to what Dr. Andrew Jones does for his Veterinary Secret book and site.

Bottom Line
Dr. Eisen is a chiropractor who claims to be an expert in veterinary nutrition, toxicology, and cancer therapy based on having read a lot of books and invented his own “holistic system” by selecting which information he wanted to believe and which he felt he could ignore. The core of his marketing strategy is 1) to generate fear, by claiming that cancer is an epidemic and that we are surrounded by cancer-causing toxins in the very food and medicine we trust to keep our dogs healthy and 2) to claim that veterinarians have only dangerous and ineffective cancer treatments to offer and are ignorant of, or deliberately ignore, proven safe and effective alternative treatments. He provides no evidence for any of these claims, only his opinion and some testimonials.

A few of his claims are distantly based in real science and then stretched and twisted to support a pseudoscientific approach. Most of his claims are completely made up and contradict well-established science. He gets away with this by offering the usual unjustifiable promise of something for nothing, of effective treatments, or even cures, for cancer that are easy to use, completely safe, and cost little.

His web sites manifest many of the classic warning signs of medical quackery, including:

Claims of miraculous results
Claims of special knowledge unknown to or ignored by mainstream medicine
Claims of scientific legitimacy without any actual research data
Claims of expertise with no relevant credentials
Claims of simple and easy solutions to complex, difficult problems
Reliance on testimonials as proof
Claims that disagreement is driven by ignorance, fear, or greed
Misleading and selective use of real facts mixed in with made-up claims

And I have little doubt that, once his followers see this article, these signs will be joined by the inevitable personal attack on the critic rather than substantive response to the criticism, lots or testimonials supporting Dr. Eisen’s approach, lots of claims about the fear, anger, ignorance, greed or, most ironic of all, the arrogance of anyone who dares to criticize someone who has declared themselves an expert and who claims to know better than everyone with actual training and expertise in the subjects he talks about (true followers rarely see the irony in this).

The saddest thing about this sort of nonsense is that it is far more accessible and palatable to people whose pets have cancer than legitimate scientific information from true experts in veterinary cancer treatment. The bulk of what pet owners find on the internet is marketing materials designed to feed on their hopes and fears while not honestly helping their pets. Compassionate care is not limited to bogus “holistic protocols” like Dr. Eisen’s, despite the fact that he markets himself more effectively than genuine experts. True compassionate care is treatment based on legitimate science, not made up out of myths, misinterpretations, and wishful thinking.

Here are some real experts with real information for you if your pet has cancer:

Veterinary Oncolink, University of Pennsylvania
Pet Owner’s Guide to Cancer, Cornell University
The Cancer Center at Cares Canine Cancer Library, National Canine Cancer Foundation Animal Cancer Center, Colorado State University

Posted in General | 12 Comments

Dr. Eisen Takes Legal Action to Suppress Criticism

In the true spirit of quackery, which cannot bear criticism or the exposure of its absurdities, Dr. Steven Eisen has expeditiously taken action to suppress my criticism of his marketing himself as a dog cancer expert despite no formal training in veterinary medicine, oncology, or any of the other areas of medicine in which he gives advice to dog owners. He has written to my internet service provider claiming that my quotations from his web site constitute copyright infringement. Here is the notice that was forwarded to me:

Sent via email and fax

re: DMCA Notice of Copyright Infringement

To Whom It May Concern:

My name is Dr. Steven Eisen and I am President of Pet Love LLC. A website that your company hosts (according to WHOIS information) is infringing on at least one copyright owned by my company.

Copyrighted text and graphics from several pages of our websites were copied onto your servers without permission. The original material, to which we own exclusive copyrights, ca be found at:

a)     http://dogcanceradvice.com/about-the-book-2/

b)     http://dogcanceradvice.com/canine-cancer-information/dog-cancer-treatments/

c)     http://dogcanceradvice.com/canine-cancer-information/alternative-cancer-treatments-for-dogs/

d)     http://dogcanceracademy.com/cancer-causing-toxins/

e)     http://dogcanceracademy.com/the-dog-cancer-diet/

f)      http://dogcanceracademy.com/canine-cancer-vaccinations

The unauthorized and infringing copy can be found at:

http://skeptvet.com/Blog/2012/07/dog-cancer-expert-steven-eisen-bad-advice-from-an-unreliable-source/

This letter is official notice under Section 512© of the Digital Millenium Copyright Act (“DMCA”), and I seek the removal of the aforementioned infringing material from your servers. I request that you immediately notify the infringer of this notice and inform them of their duty to remove the infringing material immediately, and notify them to cease any further posting of infringing material to your server in the future.

I have a good faith belief that use of the copyrighted materials described above as allegedly infringing in not authorized by the copyright owner, its agent, or the law.

Under penalty of perjury, I certify that the information contained in this notification is both true and accurate, and I have the authority to act on behalf of the copyright(s) involved. I am providing this notice in good faith and with the reasonable belief that rights my company owns are being infringed. Should you wish to discuss this with me please contact me directly.

Thank you.

Dr. Steven Eisen

It is likely that my use of statements made on Dr. Eisen’s site constitutes fair use under copyright law, but that decision would need to be made by a judge in the course of a copyright infringement lawsuit. I am perfectly willing to argue that the fair use provisions apply here, since I believe the attempt to suppress criticism by Dr. Eisen is an illegitimate misuse of intellectual property law.

Unfortunately, my options under the Digital Millenium Copyright Act (DCMA) for response are not great. I can leave the material up, in which case my IP will shut down my entire domain within 48 hours. I can remove the quoted material. I can contest the complaint, in which case my IP will shut down my entire domain for 10 days. If Dr. Eisen doesn’t sue in that time, the domain is reopened. If he does, then it remains closed until the case is decided.

Such flagrant misuse of copyright law deserves to be contested, so I will be seeking legal advice on the best way to do so. In the meantime, if the site diappears for a while, you’ll know why.

7/31/2012 Update

I have temporarily removed the disputed material from the site and filed a DMCA counterclaim. Dr. Eisen now has 10 days to decide whether or not to file for an injunction. If he does not, the original material will be reposted. If he does, then a court will decide whether my use of his words in a journalistic critique on a public interest, non-profit web site constitutes fair use of copyrighted material.

 

JustHost Legal Team:

 

This letter is written in response to your notification to me of a complaint received about my web page(s). The disputed material has been temporarily removed pending a response to this counter complaint. Copies of the disputed material are appended to this counter complaint. The original page has been made private and password-protected and is not publically accessible. This page has been replaced at the URL below with a page that does not contain the disputed material. The page at which the disputed material appeared and from which it has now been removed is at the following URL: http://skeptvet.com/Blog/2012/07/dog-cancer-expert-steven-eisen-bad-advice-from-an-unreliable-source/

My response to this complaint is as follows: Allegations of Copyright Violation / Digital Millennium Copyright Act The claims of copyright violation should be rejected because:

> 

My use of the material is legally protected because it falls within the “fair use” provision of the copyright regulations, as defined in 17 USC 107. If the complainant disagrees that this is fair use, they are free to take up the matter with me directly, in the courts. You, the ISP, are under no obligation to settle this dispute, or to take any action to restrict my speech at the behest of this complainant. Furthermore, siding with the complainant in a manner that interferes with my lawful use of your facilities could constitute breach of contract on your part.

This communication to you is a DMCA counter notification letter as defined in 17 USC 512(g)(3): I declare, under penalty of perjury, that I have a good faith belief that the complaint of copyright violation is based on mistaken information, misidentification of the material in question, or deliberate misreading of the law.

 

Indemnification of Host or Registrar I agree to defend, indemnify and hold the host or registrar, its affiliates and its sponsors, partners, other co-branders and the respective directors, officers and employees of each harmless from and against any and all claims, losses, damages, liabilities and costs (including, without limitation, reasonable attorneys’ fees and court costs). My name, address, and telephone number are as follows:

I hereby consent to the jurisdiction of Federal District Court for the judicial district in which I reside (or, if my address is outside the United States, any judicial district in which you, the ISP, may be found). I agree to accept service of process from the complainant.

My actual or electronic signature follows:
 

Having received this counter notification, you are now obligated under 17 USC 512(g)(2)(B) to advise the complainant of this notice and to allow restoration of the material in dispute unless the complainant files suit against me within 10 days.

 

Posted in Law, Regulation, and Politics | 20 Comments