CAM and the Law Part 2: Licensure and Scope of Practice Law

This is a cross-post from Science-Based Medicine- CAM and the Law Part 2: Licensure and Scope of Practice Law

This post is intended to illustrate a bit about how medicine, including alternative medicine, is defined and limited legally by state licensure. This is, of course, an enormous topic, especially given the variety of laws and regulations among the 50 states and District of Columbia, and the many, often mutually inconsistent, court decisions interpreting them. A comprehensive survey would resemble Gibbon’s history of Rome and would likely be out-of-date the moment it was finished. My more modest goal here is to highlight a few of the ways in which licensure and scope of practice laws intersect the practice of CAM and give a few representative examples. 

The Rise of Medical Licensure

In the 19th century, a bewildering variety of different approaches to maintaining health and treating disease competed for the trust, and dollars, of prospective patients (or their owners, in the case of animal patients). Caveat emptor was the rule in an unregulated medical marketplace. Mainstream medicine was a competitor in this marketplace, though it was hardly science-based to any great extent compared to conventional medical practices today. Homeopathy was another pretty big player, along with osteopathy and numerous other more or less organized schools, as well as many individual snake oil salesmen, faith healers, local providers of folk remedies, and so on.1,2

Throughout the 19th and early 20th centuries, state legislatures passed medical practice acts defining the practice of medicine, the criteria for medical licensure, and the criminal penalties for the unlicensed practice of medicine. The American Medical Association, founded in 1846, played a powerful role in driving and shaping these early enactments of the state police authority to regulate medicine. The AMA-sponsored Flexner Report on medical education released in 1910 did much to shape the criteria states used to award licensure, and thus to shape the content of accepted medical practices. Veterinary medicine lagged a bit behind in this initial licensure movement, with California apparently being the first state to license vets in 1893, but the general legal trend has been much the same as for regulation of human medicine.1,3

What is the Practice of Medicine?

There is some variation in the details of how the practice of medicine is defined in different state practice acts, but all the definitions are quite broad. They give physicians great latitude in the therapies they provide, but  they also leave some uncertainty as to what actually constitutes practicing medicine, and there is room for the courts to interpret and clarify the law.

In New York, for example, the law reads:

The practice of medicine is defined as diagnosing, treating, operating or prescribing for any human disease, pain, injury, deformity or physical condition.4

In California, the definition is even broader:

[A]ny person who practices or attempts to practice, or who advertises or holds himself or herself out as practicing, any system or mode of treating the sick or afflicted in this state,  or who diagnoses, treats, operates for, or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury, or other physical or mental condition of any person…5

State veterinary practices acts are also very broad, sometimes even more so than medical practice acts. For example, in California:

A person practices veterinary medicine, surgery, and dentistry, and the various branches thereof, when he or she does any of the following:
(a) Represents himself or herself as engaged in the practice of veterinary medicine, veterinary surgery, or veterinary dentistry in any of its branches.
(b) Diagnoses or prescribes a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure or relief of a wound, fracture, bodily injury, or disease of animals.
(c) Administers a drug, medicine, appliance, application, or treatment of whatever nature for the prevention, cure, or relief of a wound, fracture, bodily injury, or disease of animals…
(d) Performs a surgical or dental operation upon an animal.
(e) Performs any manual procedure for the diagnosis or pregnancy, sterility, or infertility upon livestock or Equidae.
(f) Uses any words, letters or titles in such connection or under such circumstances as to induce the belief that the person using them is engaged in the practice of veterinary medicine…6

With such general legal language, it might seem that physicians and veterinarians could do almost anything and call it practicing medicine. And it might also seem dangerous for people who are not licensed to practice medicine to do anything at all to a sick person or animal for fear of violating their state’s medical practice act. However, the states and the courts have created numerous exceptions and limitations to these very general standards. 

Some common exceptions are quite sensible and obvious. For example, nurses and other healthcare providers working under physician supervision, physicians working for federal agencies, properly supervised students, lay people providing reasonable first aid or lifesaving care or using widely accepted over-the-counter remedies, and many other similar activities are defined as legitimate and not the unlawful practice of medicine.1 

Other exceptions are sometimes less obvious, and they may provide loopholes for alternative medical providers to ply their trades. For example, animals are considered property, not persons, under the law, so their owners and anyone they authorize can do almost anything they like to treat them, within only the limitations of animal cruelty laws, which have very high standards of proof and lax enforcement.3 Some states, such as California, also provide other specific exemptions, such as this one:

Nothing in this chapter [the Medical Practice Act] shall.…regulate, prohibit, or apply to any kind of treatment by prayer, nor interfere in any way with the practice of religion.7

In addition to defining the practice of medicine, the state practice acts also define the criteria required to obtain and maintain a medical license. These often include graduation from an approved educational program with coverage of specified subject matter, practical clinical training, a passing score on licensing examinations, and ongoing professional education. In the early days of medical licensure, it was the development of these criteria that had the greatest impact in terms of promoting scientific medicine and limiting the ability of practitioners of alternative approaches to continuing practicing their forms of medicine. 

Licensure of Non-Physicians

In addition to physicians, states also license a number of other medical professions, including providers of alternative therapies. The relevant legislative acts define the scope of practice and criteria for licensure for these providers just as they do for physicians and veterinarians, though the scope of acceptable activities is often far more limited and narrowly defined. 

The major CAM methods are the most commonly licensed. Chiropractors are licensed in all 50 states, non-M.D. acupuncturists are licensed in 37 states, naturopaths are licensed in 17 states (though they are specifically prohibited from practicing in 2 states), and “homeopathic physicians” are licensed in 3 states.8 States that do not license such providers do sometimes still explicitly regulate the more common alternative methods, such as acupuncture, within other health or professions statues. 

Laws licensing alternative therapists are often very specific, while still leaving a surprising amount of room for subsequent interpretation and controversy. In California, for example, the Acupuncture Licensure Act defines acupuncture directly while also managing to fit in a much broader ideological statement:

In its concern with the need to eliminate the fundamental causes of illness, not simply to remove symptoms, and with the need to treat the whole person, the Legislature intends to establish in this article, a framework for the practice of the art and science of Asian medicine through acupuncture…

“Acupuncture” means the stimulation of a certain point or points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions, including pain control, for the treatment of certain diseases or dysfunctions of the body and includes the techniques of electroacupuncture, cupping, and moxibustion.9

The relevant legislation in California concerning chiropractic licensure defines the scope of practice for chiropractors very specifically:

(1) A duly licensed chiropractor may manipulate and adjust the spinal column and other joints of the human body and in the process thereof a chiropractor may manipulate the muscle and connective tissue related thereto. 

(2) As part of a course of chiropractic treatment, a duly licensed chiropractor may use all necessary mechanical, hygienic, and sanitary measures incident to the care of the body, including, but not limited to, air, cold, diet, exercise, heat, light, massage, physical culture, rest, ultrasound, water, and physical therapy techniques in the course of chiropractic manipulations and/or adjustments. 

(3) Other than as explicitly set forth….a duly licensed chiropractor may treat any condition, disease, or injury in any patient, including a pregnant woman, and may diagnose, so long as such treatment or diagnosis is done in a manner consistent with chiropractic methods and techniques and so long as such methods and treatment do not constitute the practice of medicine by exceeding the legal scope of chiropractic practice as set forth in this section. 

(4) A chiropractic license issued in the State of California does not authorize the holder thereof: 
(A) to practice surgery or to sever or penetrate tissues of human beings, including, but not limited to severing the umbilical cord; 
(B) to deliver a human child or practice obstetrics; 
(C) to practice dentistry; 
(D) to practice optometry; 
(E) to use any drug or medicine included in materia medica; 
(F) to use a lithotripter; 
(G) to use ultrasound on a fetus for either diagnostic or treatment purposes; or 
(H) to perform a mammography.

(5) A duly licensed chiropractor may employ the use of vitamins, food supplements, foods for special dietary use, or proprietary medicines, if the above substances are also included in section 4057 of the Business and Professions Code, so long as such substances are not included in materia medica as defined in section 13 of the Business and Professions Code…

(6) Except as specifically provided in section 302(a)(4), a duly licensed chiropractor may make use of X-ray and thermography equipment for the purposes of diagnosis but not for the purposes of treatment. A duly licensed chiropractor may make use of diagnostic ultrasound equipment for the purposes of neuromuscular skeletal diagnosis. 

(7) A duly licensed chiropractor may only practice or attempt to practice or hold himself or herself out as practicing a system of chiropractic….A chiropractor may not hold himself or herself out as being licensed as anything other than a chiropractor or as holding any other healing arts license or as practicing physical therapy or use the term “physical therapy” in advertising unless he or she holds another such license.10

The Devil in the Details

Despite the specificity of such laws and regulations, there is a fair bit of ambiguity as to exactly who is allowed to do what, and state attorneys general and the courts are frequently called upon to interpret these laws. In some states, physicians have been held to be legally permitted to practice alternative therapies even without specific licenses in those approaches, under the general provisions of medical practice. Other states, however, have required physicians to be licensed in these approaches before offering them. And, of course, given the controversial nature of many CAM therapies, physicians run some risk of being sanction for “unprofessional conduct” by their state medical board for offering some unconventional therapies. 

In one well-known example, a North Carolina doctor was disciplined by the state medical board or administering homeopathic treatments. The board concluded that since homeopathy “does not conform to the standards of acceptable and prevailing medical practice,” using it constituted unprofessional conduct. After this sanction was reversed by two lower courts (one asserting there was not sufficient evidence to support the board’s conclusions about homeopathy, and the other arguing that it didn’t matter because homeopathy was harmless), the state supreme court upheld the board’s decision.11

The majority argued, quite sensibly, that “a general risk of endangering the public is inherent in any practices which fail to conform to the standards of ‘acceptable and prevailing’ medical practice” regardless of whether the specific treatment was directly harmful. The justices also recognized that “certain aspects of regulating the medical profession plainly require expertise beyond that of a layman” and that “while questions as to the efficacy of homeopathy….may be open to debate among members of the medical profession….the courts are not the proper forum for that debate.”12 

Unfortunately, the legislature of North Carolina took a different view, preferring to protect consumer choice and the autonomy of individual providers, and the law was subsequently amended to specifically protect physicians who offer treatments that are “experimental, nontraditional, or that [depart] from acceptable and prevailing medical practices” unless they can be clearly shown to be more harmful than conventional treatments.12

A variety of legal opinions and rulings also exist that clarify (or sometimes obscure) the limits of acceptable therapies licensed alternative practitioners can provide as well. For example, in some states chiropractors can legally provide colonic irrigation, perform pelvic and rectal exams, perform electrocardiograms, provide herbal remedies or nutritional supplements, or perform acupuncture under generous interpretations of the definition of chiropractic.13 However, other states have ruled it a violation of their scope of practice limitations for chiropractors to utilize herbal or nutritional substances in treating patients, perform pelvic exams, perform or order diagnostic blood or urine tests, and engage in other such practices deemed outside of their licensed activities.13 There are similar inconsistencies in the interpretation of what therapies are permissible for other licensed alternative providers as well.

Faith Healing and Secular Spiritual Practices

A particularly interesting area of medical jurisprudence is the relationship of licensing laws to spiritual and religious practices. The tension between individual liberty and freedom of economic activity on the one hand and the role of government in protecting the public health on the other is weak tea compared to the conflict between government police powers and the legal and cultural imperatives in the U.S. to protect religious freedom. Religion may be specifically excluded from medical regulation, as in the California code above or in states like Minnesota and Ohio, which specifically exempt Christian Science faith healing from the definition of medical practice for example.14 And even in the absence of specific exemptions for religious activity, medical regulations are often required to meet a very high standard of justification if they are perceived to interfere with religious practices. The decisions made by courts and state legislatures on such matters often hinge more on the issue of religious liberty versus state police powers than on the question of whether spiritual healing practices have any medical benefit.

This controversy also has implications for so-called “secular spiritual” approaches, such as the various energy therapies like Reiki, Thought Field Therapy, Healing Touch, some meditation or mind-body therapies, and so on. Are such methods the practice of medicine? Are they religious practices and so protected to some extent from regulation? Does it matter if they work? Or if they are harmless? These are questions that have been raised by advocates of these approaches and legal scholars but which have not often been directly or clearly addressed in law or judicial rulings.

In cases involving ostensibly religious healing practices, courts have both supported and overruled restrictions imposed by medical regulations. In one Florida case, a man who claimed to heal through prayer and laying on hands was accused of practicing medicine. He claimed his activity was protected under the provision indicating the state practice act did not apply to “the practice of the religious tenets of any church.” The state supreme court ruling in the defendant’s favor did point out that his actions did not “invade the province of the medical profession and assume the ability to diagnose diseases and prescribe drugs or other medical or surgical or mechanical means to restore the health” of his clients. However, the bulk of the opinion was concerned with the issue of religious liberty and with the apparent lack of any direct harm done by the healing practice, as well as the more general epistemological argument that science doesn’t know everything:

…from ancient times down to this modern and so called materialistic age, there have always been quite a large percentage of people who believed in the efficacy and availability of Divine power, not only to save the souls but also the bodies and lives of men and to heal all the ills that flesh is heir to….And if this class of people hear and believe that some person can and does invoke the power of Most High to heal people of their ills, or that in his own person such individual possesses some strange mental, magnetic or psychic power to banish disease from the human body….[they] will seek him out. And it is not the policy of our laws to prevent them; nor to punish those to whom they go, and who endeavor to heal the ills of men by such mental or spiritual means…

The reason for this policy is founded upon the liberty of the individual citizen under our bill of rights, and the fact that so long as these faith healers or spirit mediums rely upon their power, by prayer or faith, to invoke the exercise of the power of the Almighty, if indeed they fail to cure, they at least can do no harm…

Now this appellant testified that the power which he invoked was not his own, but that it was the power of God. And if some of the uncontradicted witnesses are to be believed, he was instrumental in accomplishing some remarkable cures….Now, to most of us, this matter of healing ‘by faith and the laying on of hands,’ ancient as it is, is still beyond us. But according to Shakespeare’s Hamlet, ‘There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.’ And in that magnificent speech of St. Paul’s before King Agrippa, he said to the king: ‘Why shuld it be thought a thing incredible with you, that God should raise the dead?’ So the legislature and the courts might well accord our citizens the liberty to decide such questions as these for themselves.”15

Other rulings on the question of whether religious practices are subject to the regulations that govern the practice of medicine have been more pragmatic and less prolix. A California case concerned a healer who imposed on people not only prayer and laying on of hands but strict fasting and dietary requirements and a prohibition on conventional medical diagnostics or treatment. He attempted to defend his practices as religious rather than medical, even after the death of one person and significant injury to others following his approach. Despite the state’s exemption of religious practices from the medical practice act, the court ruled that the methods used went well beyond protected religious activity and invaded the domain of secular medicine. 

There is no question that the described activities constitute the practice of medicine; that the Board has a substantial interest in preventing such activities, which are demonstrably harmful on this record; …[and] there is [no] serious argument made that the injunction infringes appellants’ constitutional rights of free exercise of religion under the First Amendment. Cases are legion which hold that freedom of religious belief may be absolute but freedom of action is not.[citations omitted] The state may legitimately regulate dangerous conduct regardless of religious content. It is therefore universally held that in the interest of protecting its citizens’ health, the state may regulate health treatments which are potentially dangerous to the patient….In reaching this decision we do not deem it necessary to question the bona fides of appellant Andrews’ religious faith; that fact is not relevant…16

Of course, there are salient differences in the facts in these cases, as well as the historical moments in which they were heard. The practical question of whether direct harm is done by a spiritual healing approach is weighed by the courts in adjudicating such cases. However, as is frequently the case, the reasoning that informs the courts’ decisions often fail to address the scientific question of the efficacy of such treatments or the potential indirect harm they may do in discouraging effective medical care. And the issues of individual and religious liberty are often given as much or more weight than the question of whether the interventions are demonstrably effective or not.

Is Medical Licensure Fair and Does It Protect the Public?

Medical licensure is widely accepted as a legitimate use of state authority to protect the public health by preventing people from being exposed to dangerous and ineffective therapies in an unrestrained medical market. Proponents of CAM, as well as opponents of government regulation generally, sometimes cast the promulgation of medical licensing laws as a straightforward protectionist campaign by “allopathic” doctors to wipe out the competition. While it would be disingenuous to suggest that professional organizations such as the AMA or the American Veterinary Medical Association (AVMA) have no political or economic agendas beyond the protection of the public good, it is a convenient but inaccurate exaggeration to say that concerns for territory or income have been the prime motivators of efforts to license and regulate medicine. Concerns for the actual, verifiable scientific truth behind medical practices and the welfare of patients have always been a genuine and important reason for encouraging government to regulate healthcare. 

Even in the notorious antitrust case Wilk v. American Medical Association, in which chiropractors succeeded in using anti-trust laws and allegations of protectionism to weaken the ability of the AMA, and other professional organizations, to marginalize unscientific medical practices, the court was “persuaded that the dominant factor [in the AMA’s efforts] was patient care and the AMA’s subjective belief that chiropractic was not in the best interests of patients.”17

Licensure and scope of practice limitations do leave enormous room for physicians and others to engage in ineffective and dangerous medical practices, and the spirit and letter of the law is subject to wide-ranging interpretations in different states and courts. And while licensing CAM professions arguably gives the state some ability to enforce reasonable standards of training and practice, there is an element of Tooth Fairy Regulation in this (with apologies to Dr. Hall). 

For example, the California law regulating acupuncturists requires a minimum of 2250 hours of clinical training and 1548 hours of theoretical and didactic training to apply for a license. Some of this, such as how to avoid transmitting infectious diseases with needles, is legitimate training that protects public health. But it is debatable how helpful it is to require many hours of study of Qi Gong, Traditional Oriental Medicine Theory, Moxibustion, Ear Acupuncture theory, and so on.
And, of course, licensure creates a perception of legitimacy and accuracy to the claims of CAM providers in the minds of the public, who generally don’t appreciate the extent to which decisions about medical regulation are made less on the basis of scientific facts than on the basis of political and philosophical issues. 

On balance, the regulation of conventional medical practice, and to a lesser extent alternative therapies, probably is reasonably effective in protecting the public. The popularity and availability of dangerous and clearly ineffective approaches is certainly less than it was during the age of medical anarchism, and such laws have doubtless played a role in this. 

Why We Should Understand Medical Licensing Laws

While we must always maintain our emphasis on verifiable scientific facts about the safety and efficacy of proposed therapeutic approaches, those of us dedicated to science-based medicine may also be able to play a role as a constituency in shaping the writing and interpretation of medical laws and regulation to better protect the public. And we must certainly be aware of what our own state’s laws are, and participate in seeing that they are properly executed. 

In researching this subject, for example, I became aware that the California veterinary practice act has very strict requirements for veterinary supervision of chiropractic applied to animals, and also a requirement that “the veterinarian shall obtain as part of the patient’s permanent record, a signed acknowledgment from the owner of the patient or his or her authorized representative that [musculoskeletal manipulation] is considered to be an alternative (nonstandard) veterinary therapy.”18 I am certain most of the vets I know who refer patients for chiropractic treatment do not comply with these guidelines, and if wider compliance can be achieved it would likely reduce the utilization and potential harm of this unproven, and possibly dangerous, therapeutic approach. 

A familiarity with the laws govern medical practice is an important element in advocating for good quality scientific medicine and discouraging unproven or unsafe interventions. Part of my goal in this series is to encourage such familiarity. The references I cite in these posts are a good starting point, though they have their limitations and biases. Most relevant state laws and regulations are easily accessible on the internet. 

Proponents of alternative therapies are aware of the importance of understanding and helping to shape medical laws and regulations, and they explicitly encourage CAM practitioners to be knowledgeable and involved (see, for example,  these resources for acupuncturists, naturopaths, and chiropractors). Since professional organizations such as the AMA and AVMA are limited by political and legal considerations from aggressively working to shape legislation and public policies that discourage alternative therapies, those of us who would promote science-based medicine would do well to be as familiar with medical laws and the agendas that influence them as we try to be with the scientific facts concerning questionable medical practices. 

References

  1. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010.  Return to text.
  2. Ramey DW, Rollin BE. Untested therapies and medical anarchism. In: Complementary and alternative veterinary medicine considered. Ames (IA), USA: Iowa State Press, 2004. p.168-9. Return to text.
  3. Wilson JF, Rollin BE, Garbe, JAL. Law and ethics of the veterinary profession.Morrisville (PA), USA: Priority Press Ltd, 1993. Return to text.
  4. N.Y. Educ. Law § 6521. Cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 36. Return to text.
  5. Cal. Bus. & Prof. Code § 2052(a). Cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 36. Return to text.
  6. Cal. Bus. & Prof. Code § 4826. Cited In: California Veterinary Medicine Practice Act. 2010 Ed. Charlottesville (VA), USA: LexisNexis, Matthew Bender & Company, Inc, 2010. p. 5-6. Return to text.
  7. Cal. Bus. & Prof. Code § 2063. Retrieved Sept. 9, 2010 from California Law Website: http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=02001-03000&file=2050-2079 Return to text.
  8. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p.56. Return to text.
  9. Cal. Bus. & Prof. Code § 4026-4027. Retrieved Sept. 9, 2010 from California Law Website: http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=04001-05000&file=4925-4934.2 Return to text.
  10. Cal. Admin. Code tit. 16, § 302 Retrieved Sept. 9, 2010 from webite: http://weblinks.westlaw.com/result/default.aspx?cite=16CAADCS302&db=1000937&findtype=L&fn=%5Ftop&ifm=NotSet&pbc=4BF3FCBE&rlt=CLID%5FFQRLT2612239251299&rp=%2FSearch%2Fdefault%2Ewl&rs=WEBL10%2E08&service=Find&spa=CCR%2D1000&sr=TC&vr=2%2E0 Return to text.
  11. Guess v. Board of Medical Examiners 393 S.E.2d 833 (1990). Cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 42-44. Return to text.
  12. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p.50. Return to text.
  13. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p.87-88. Return to text.
  14. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p.61-62. Return to text.
  15. Curley v. State of Florida Supreme Court of Florida, en Bacn 16 So. 2d 440 (1943). Cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 58-60. Return to text.
  16. Board of Medical Quality Assurance v. Arthur Andrews Court of Appeal, Sixth Distr., California 211 Cal. App. 3d 1346 (1989). Cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 60-63. Return to text.
  17. Wilk v. American Medical Association 671 F. Supp 1465 (N.D. Ill.) 1987. Cited in: Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 230-241. Return to text.
  18. Cal. Code of Regulations § 2038. Cited In: California Veterinary Medicine Practice Act. 2010 Ed. Charlottesville (VA), USA: LexisNexis, Matthew Bender & Company, Inc, 2010. p173. Return to text.
Posted in Law, Regulation, and Politics | 4 Comments

CAM and the Law Part 1: Introduction to the Issues

This is a cross-post for the first in a series from Science-Based Medicine: CAM and the Law Part 1 Inroduction to the Issues

When I write or talk about the scientific evidence against particular alternative medical approaches, I am frequently asked the question, “So, if it doesn’t work, why is it legal?” Believers in CAM ask this to show that there must be something to what they are promoting or, presumably, the government wouldn’t let them sell it. And skeptics raise the question often out of sheer incredulity that anyone would be allowed to make money selling a medical therapy that doesn’t work. It turns out that the answer to this question is a complex, multilayered story involving science, history, politics, religion, and culture. 

While we science types tend to be primarily interested in what is true and what isn’t, that is a sometimes surprisingly minor factor in the process of constructing laws and regulations concerning medicine. What I hope to do in this series of essays is look at some of the major themes involved in the regulation of medical practice, particularly as they relate to alternative medicine. I will begin by touching on some of the general philosophical and legal issues that have defined the debate among the politicians and lawyers responsible for shaping the legal environment in which medicine is practiced. The I will review some of the specific domains within this environment, including: medical licensure and scope-of-practice laws; malpractice law; FDA regulation of drugs, homeopathic remedies, and dietary supplements; truth-in-advertising law; and anti-trust law.

But first…

The Disclaimer

Obviously, an exhaustive and comprehensive look at the Byzantine and unstable landscape of medical law is beyond the scope of both this blog and my own knowledge and expertise. I am no lawyer, and for the details of the laws and judicial opinions concerning this subject I must rely on sources whose accuracy I am not qualified to verify independently. Much of the published material I have found on CAM and the law seems written from a political and ideological perspective sympathetic to the postmodernist notion of multiple equally legitimate “ways of knowing,” and also to a laissez-faire approach to regulation generally. So clearly the details provided and the interpretations given in such writings may not fairly represent the legal or regulatory environment. In any case, while I hope to provide some useful insight into how CAM fits into the system of medical law and regulation in the United States,  nothing I say should be taken as the definitive word on the law or as legal advice.  

Caveat Emptor v. Caveat Venditor

There is a deep ideological divide in America on the subject of who is responsible for ensuring that the products we buy are safe and perform as advertised, and the area of medicine is not exempt from this political debate. On one extreme is the self-identified “health freedom” lobby, which argues that the consumer and the market should be the only forces to regulate healthcare products and services. As an example, economist Randall Holcombe has written:

An auto mechanic does not have to be a medical expert to use market information to find good health care, any more than a doctor has to be an automobile expert to find a good car…Deregulation not only provides incentives for patients to look for, and physicians to offer, better care, it permits all parties concerned the freedom to decide what better care is. For instance, in the debate over alternative medicine, such as herbal treatments, chiropractors, acupuncture, and so on, the question is not only whether alternative medicine is effective, but whether people should be allowed to use these alternatives even if their physical health may not improve or may even suffer….In a free country, people should be free to choose whatever health care options they want for whatever purpose…even if healthcare professionals believe that care is substandard.1

Those more sympathetic to laws and regulations intended to protect consumers from unsafe and ineffective therapies argue against this concept of “medical anarchism:”

Why not let the market decide? Why not trust the citizenry to sort out what works from what doesn’t work in medicine as we do in other aspects of life?

The answer has to do with knowledge and risk. People do let the market decide with regard to goods like ice cream cones and baseball bats, and services like travel booking. If the ice cream is not good, people won’t buy it; if the service is defective, people will go elsewhere. However, in such situations, people are easily able to evaluate the quality and value of the goods and services they receive…Nor are such services administered under duress, nor are they represented as necessary for one’s health or well-being…

But in the area of medicine, too much is at stake. If one chooses the wrong therapeutic modality, once can lose health, life, and limb. Furthermore, few individuals are sufficiently wealthy, educated, or possessed of the resources to test putative medical therapies. In fact, there are so many putative therapies, that it is impossible for an individual to try them all. When people are ill, they do not have time to test even a handful.2

These arguments tend to run in parallel, and to be only tenuously connected, with the usual focus of this blog; the question of how one evaluates medical therapies and what the evaluation indicates about safety and efficacy. Of course, many proponents of  CAM who invoke the “health freedom” position do actually believe the therapies they promote are beneficial. But the fundamental position itself does not hinge on this, since from a perspective such as Dr. Holcombe’s people should be free to choose even therapies that are ineffective or harmful without “burdensome” government regulatory interference. The self-evident notion that it is the role of government to protect the public from quackery turns out not to be self-evident to many Americans, and thus demonstrating that a given approach is quackery may not be sufficient to convince them that it should be prohibited or even officially discouraged. 

The Right to Privacy v. State Police Powers

In the legal arena, the political conflict between those favoring or opposing aggressive consumer protection regulations in the area of healthcare takes the form of statutes and judicial opinions balancing the competing constitutional principles of an individual right to privacy and a governmental authority, or even mandate, to protect the public health. Neither a right to privacy or absolute authority over one’s own body nor a government role in regulating healthcare are specifically mentioned in the U.S. Constitution, but both are held to exist by long-standing interpretation. A right to privacy, including control over one’s own body and the care of it, is generally believed to be established by a broad reading of the 14th Amendment, though there is some controversy about this as about most areas of constitutional law. The authority of the state to abrogate this right in the process of protecting the public health is usually understood to be based in the “police powers” established by the 10th Amendment.

In 1824, the Supreme Court made reference to “health laws of every description” as encompassed within the “state police powers,” those powers not specifically delegated to the federal government nor prohibited to the States which are thus held, under the Tenth Amendment, to be the prerogative of the individual states.3 The court cited and expanded this opinion in a subsequent case in 1905, in which a state mandate to protect the public health was held to override, at least in some circumstances, the individual right to control one’s own body. The case involved a man prosecuted for refusing a mandatory smallpox vaccination. The opinion stated:

The authority of the state to enact this statute is to be referred to what is commonly called the police power…this court …distinctly recognized the authority of a state to enact quarantine laws and “health laws of every description…”

The defendant insists that his liberty is invaded when the state subjects him to fine or imprisonment for neglecting or refusing to submit to vaccination…and that the execution of such a law…is nothing short of an assault upon his person. But the liberty secured by the Constitution of the United States…does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good.4

The court went on to specifically balance the “liberty secured by the 14th Amendment,” including “the control of one’s body” against “the power of the public to guard itself against imminent danger” and concluded that under at least some circumstances the authority to protect the public health trumps he right of an individual to control his or her own body. 

This precedent was further developed and expanded in subsequent cases to validate the state’s authority to define and regulate medical practices, to control what practices could be offered and by whom via licensing and scope-of-practice laws, and to prohibit individual’s from choosing specific medical treatments if these were considered to be ineffective or dangerous. I will discuss the specifics of these cases in subsequent posts. But for now I simply want to illustrate that the legal basis for the regulations of medical practice which today pertain to CAM, as well as scientific medicine, is generally seen by the courts as a balance between the individual right to privacy and the state authority to protect public health.1,5

Just the Facts, Ma’am?*

I feel it is important to emphasize again that the question of the medical facts in such cases, and how these are established, are not always seen by the courts to be as relevant as the legal or political issues. For example, in Jacobson v. Massachusetts the court specifically addressed the factual claims by the defendant that the vaccine was ineffective and unsafe. The court’s reasoning will seem familiar, and disturbing, to those of us dealing with the anti-vaccination movement today:

The appellant claims that vaccination does not tend to prevent smallpox, but tends to bring about other diseases, and that it does much harm, with no good. It must be conceded that some laymen, both learned and unlearned, and some physicians of great skill and repute, do not believe that vaccination is a preventative of smallpox. The common belief, however, is that it has a decided tendency to prevent the spread of this fearful disease…While not accepted by all, it is accepted by the mass of the people, as well as by most members of the medical profession…A common belief, like common knowledge, does not require evidence to establish its existence, but may be acted upon without proof by the legislature and the courts…The fact that the belief may be wrong, and that science may yet show it to be wrong, is not conclusive; for the legislature has the right to pass laws which, according to the common belief of the people, are adapted to prevent the spread of contagious diseases. In a free country, where the government is by the people, through their chosen representatives, practical legislation admits of no other standard of action, for what the people believe is for the common welfare must be accepted as tending to promote the common welfare, whether it does in fact or not. Any other basis would conflict with the spirit of the Constitution, and would sanction measures opposed to a Republican form of government.4

While the decision in this case, to support the authority of the state to enforce mandatory vaccination as a public health measure, might be welcomed by supporters of science-based public health policy, the decision itself was by no means based in science or scientific reasoning. 

The laws and judicial opinions which govern the practice of medicine may sometimes support and sometimes oppose legitimate, science and evidence-based medicine. But the legislators, lawyers, and judges responsible for these laws and opinions are not scientists, and their reasoning about scientific and medical issues often has a philosophical and epistemological basis often incompatible with the scientific approach. Such policy mistakes as DSHEA and NCCAM are much easier to understand, and hopefully prevent, if we clearly understand this.

If we are to be effective at promoting scientific medicine and containing unscientific approaches and ineffective or unsafe therapies, we must be aware of the limitations of scientific and fact-based arguments in persuading legislators and judges, as well as the general public. Though science and facts derived from scientific knowledge and investigation must be the foundation of our medical approach, they are not always the most effective means of making the case for this approach, even with our colleagues much less with the citizens, politicians, and legal professionals who ultimately control what sort of influence and oversight government has on medicine. Non-scientists tend to view debates about regulation of CAM in terms of individual rights, consumer protection, truth-in-advertising, fair competition in the marketplace, and other such political and philosophical frames which are as important, or even more important, to them as the issue of what is factually true about CAM and whether particular therapies help or harm. 

In this series of essays, I will look at laws and regulations concerning CAM primarily from these perspectives. The kinds of questions that arise in this process may initially seem odd to those of us accustomed to a straightforward emphasis on the relevant facts and evidence. Are doctors allowed to offer unproven or even clearly bogus therapies? Are they required to offer them if a patient wants them? Can a mainstream doctor, be sued for providing or failing to provide an alternative therapy? Can an alternative practitioner be sued for providing, or failing to provide, mainstream scientific medical care? Can and should patients have whatever care they want regardless of whether science supports it? And from my perspective as a veterinarian, since pets are legally property not persons, is there any legal or regulatory control over alternative veterinary medicine at all? Such questions and the reasoning behind asking and answering them, shapes the landscape within which we operate as healthcare providers and advocates for science-based medicine, so I hope an examination of them will be interesting and useful.

* Our friends at snopes.com tell me that Joe Friday never actually said this, but due to its cultural resonance I choose to invoke the phrase anyway. Oh, I hope all this exposure to legal argument and reasoning hasn’t damaged my respect for actual facts! Return to text.

References

  1. Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 279. Return to text.
  2. Ramey DW, Rollin BE. Untested therapies and medical anarchism. In: Complementary and alternative veterinary medicine considered. Ames (IA), USA: Iowa State Press, 2004. p.168-9. Return to text.
  3. Gibbons v. Ogden, 22 U.S. 1, 78 (1824). cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 26. Return to text.
  4. Jacobson v. Massachusetts, 197 U.S. 11 (1905). cited in Jesson LE, Tovino SA. Complementary and alternative medicine and the law. Durham (NC), USA: Carolina Academic Press, 2010. p. 26-29. Return to text.
  5. Cohen MH. Legal issues in alternative medicine: A guide for clinicians, hospitals, and patients. Victoria (BC), Canada: Trafford Publishing, 2003. Return to text.
Posted in Law, Regulation, and Politics | 3 Comments

Another Homeopathy Study: Mastitis in Dairy Cows

Science is ultimately an epistemological enterprise. The purpose of scientific research is to understand how things work, often with the goal of influencing them. Clinical trials in medicine aim to confirm or disprove hypotheses about diseases or medical therapies. However, no research study is perfect, and all have flaws or limitations in their methodology that casts some doubt on their findings. And even with appropriate controls and methodology, it is possible for biases and other factors to influence the results of any experiment. A real scientific truth must be robust enough to be demonstrable repeatedly and by different investigators. The balance of the evidence, and the consistency of a theory with established knowledge, not the results of any particular experiment, are the most reliable guides to what is true of false.

Ultimately, though, science is pointless if it doesn’t at some point allow us to decide that some hypotheses are true and others are false. All scientific truths may be provisional, “truth” with a small “t” as it were, but there comes a point when the evidence is strong enough that doubting an established scientific truth is unreasonable. Perhaps it is theoretically possible that previous experiments have been in error and the sun actually does circle the earth, but the evidence against this hypothesis is overwhelming that believing it is possible requires at least willful ignorance, if not outright blind faith.

And while it is true that absence of evidence is not necessarily evidence of absence, when you have looked hard enough for long enough for evidence that an idea is true and you have failed to find any, it becomes reasonable to take this failure as at least some evidence against the idea. So when I see clinical trials published concerning hypotheses that are implausible in themselves and that can only be true if mountains of evidence against them are all mistaken, I tend to give an exasperated sigh and set to reading the paper with some a priori bias against the hypothesis. Is this closed-minded? Only if expecting that an experiment designed to show the sun revolves around the earth will fail to do so is closed-minded. To be open-minded about ideas with a long history of failure to demonstrate their veracity and which require giving up much more solidly established ideas is not a virtue, it is wishful thinking or cognitive dissonance in action.

Homeopathy is an idea whose time has come and gone. It is theoretically implausible in the extreme, and decades of research have failed to support its theories or show any meaningful clinical effects. It is a flat-Earth hypothesis, and the expenditure of resources on further clinical trials to investigate it is the epitome of Tooth Fairy Science.  Trials such as these, however honest the intent behind them, merely muddy the waters by providing proponents of a failed idea with what would appear to be evidence to support their claims but what is in reality, if the balance of the voluminous research available is considered, not meaningful.

So whenever I see a study purporting to demonstrate a clinical effect of homeopathy, I look carefully at the designs, the statistics, and all the markers of quality for a scientific paper. I also look at the publication in which the study appears. There are some journals devoted exclusively to alternative medicine, and these exist only to publish CAM studies not judged to be of sufficient quality to be published in standard journals. These journals rarely publish negative findings (though to be fair neither do most mainstream journals), so a degree of skepticism about papers that appear in them is warranted.

I want to be fair to such studies, and to their authors who undoubtedly honestly believe that they are trying to use real, legitimate science to investigate a practice which their experience suggests has value. However, even if such studies are methodologically no more flawed than many which investigate truly legitimate ideas, they frustrate me. Especially in veterinary medicine, where resources for clinical research are so limited and where there are a multitude of serious problems and plausible potential solutions to investigate, it seems a shame to spend intellectual and material capital on an idea which a dispassionate analysis of the voluminous evidence would have long since caused us to abandon.

I recently came across a paper investigating the potential therapeutic use of homeopathy for mastitis in dairy cows, and I wanted to examine it closely both to see whether it met the standards for real evidence homeopathy might have clinical benefits as well as to provide an example of  how one approaches an evidence-based reading of a scientific publication. The first step in such a reading is to recognize the limitations of one’s own knowledge and expertise. As a small animal vet, I know very little about bovine mastitis, and I am certainly no statistician. So I sought help from colleagues more familiar with these subjects than I, and many people generously offered their perspective on this paper. I have incorporated these perspectives in my analysis, though any errors or misinterpretations arising from them are strictly my responsibility.

Werner, C. Sobiraj, A. Sundrum, A. Efficacy of homeopathic and antibiotic treatment strategies in cases of mild and moderate bovine clinical mastitis. Journal of Dairy Research 2010;77:460-467

The study design was a bit odd. Initially, 136 cows (147 affected udder quarters) were randomly allocated to treatment with antibiotics, homeopathy, or placebo, which is standard practice. The sickest cows, those with signs of systemic illness or a fever, were excluded. This introduces a possible bias as these are the cases most likely to need an effective therapy, whereas less ill animals are more likely to recover on their own regardless of the effectiveness of treatment. Most cases of mastitis are mild and may be self-limiting, depending on the organism involved, so it is appropriate to study interventions for these, but we must simply bear in mind that the effect of treatment may be harder to judge accurately when the diseases often resolves by itself.

The initial randomization was counteracted to some extent, however, by the fact that cases not responding to treatment in the first 5 days were shifted from whatever treatment group they were in to the other (antibiotic or homeopathic treatment), or from the placebo group to one of the two treatment groups. This decision was made at the discretion of one of the investigators, which introduces another potential bias.

Blinding of the farmers/owners to treatment group was incomplete as the antibiotic treatment approach differed significantly from the homeopathic and placebo treatments (which also differed somewhat from each other). After the first 5 days, the farmer took over treatment and was able to distinguish antibiotic treatment form the other two groups, which might have affected other aspects of their care and evaluation of the animals. So any assessments made after the first 5 days could be influenced by bias associated with the farmers knowing what treatment the cows were receiving and thus managing them differently.

The antibiotic treatment also involved local therapy applied directly to the teat, whereas the homeopathic and placebo treatment involved only oral medication administration. This, again could have influenced results if local treatment alone, regardless of agent or use of systemic treatment, had an impact on outcome.

The homeopathic treatments used were “low dilution” preparations, which unlike most common homeopathic remedies could actually contain some residual amount of the substance the remedies were prepared from. This raises the question of whether or not any effect seen would be due to homeopathic methods or to potential physiological effects of the original agents. This is significant since even is these agents have some effect, the majority of the homeopathic remedies in use no longer contain any of them, so most of these remedies would not be able to take advantage of any such effect.

The results mostly showed no difference between treatments, though cases of mastitis with positive bacterial cultures did seem to respond better to antibiotic treatment compared to homeopathic and placebo treatment. In fact, the authors themselves remarked, “in our opinion, contagious pathogens had to be excluded from mastitis studies dealing with alternative medicine because of their epidemiological background and the existence of well-proven conventional elimination strategies.” Essentially, they acknowledge that mastitis with infection already has an effective treatment and it would be unethical to deny this to patients in order to test alternative treatments.  Of course, this only leaves again the cases most likely to get better on their own to test and treat with alternative therapies.

The homeopathic treatment appeared to be statistically different from the placebo only at one of the 6 evaluation time points, Day 56 after the beginning of treatment, and only for the subgroup with positive bacterial cultures. The rate of total cure seen with antibiotic treatment was lower than reported elsewhere, which raises the possibility that the lack of a clear superiority of antibiotic treatment over homeopathy might be due to the failure of the antibiotic treatment applied in this trial rather than a true equivalence between antibiotic and homeopathic treatment.

Finally, from the point of view of statistical analysis, there were several issues that would decrease confidence in the conclusions. The sample size was relatively small, and the number of animals in the study may not have been enough to justify the statistical conclusions reached (not all the relevant information to judge this was provided in the methods section). The biggest problem with the statistical methods, however, and by far the most common statistical error made in papers reporting the results of clinical trials, is the use of multiple comparisons at multiple time points without correction for the probability of random positive results.

The threshold for statistical significance is usually set at 5%. This means that if you plan to compare two treatments in terms of a single measurement, say the percentage of animals cured in each group, then a statistically significant difference between the groups would only happen by chance 5% of the time, which is pretty unlikely. The difference could, of course,  be due to many other factors besides the original hypothesis of the investigators. Statistical significance does not mean the hypothesis is true, only that random chance by itself is unlikely to explain the difference seen.

However, the more comparisons you make, the more likely you are to get some that show a difference which isn’t real just by chance. There are statistical tools for correcting for this, but they do not appear to have been used in this study. Thus, comparing multiple measures (somatic cell counts, milk score, palpation score, etc) on multiple days is likely by random chance alone to lead to some difference that looks significant even though it isn’t. For such a difference to be accepted as real, it either needs to be evaluated by proper statistical methods or at least be seen repeatedly in multiple studies by different investigators.

If a large number of studies are done without appropriate correction for making multiple comparisons between groups, and if each one shows a couple of significant differences but these are not consistently the same measurement in every study, then it is likely that each study found a couple of false differences by chance. Yet in alternative medicine, such differences, even if only found in a couple of studies without appropriate statistical methods, is often cited as proof of a treatment effect. This is misleading. It allows one to cite many papers purporting to show an effect of a treatment, which conveys an impression of scientific legitimacy even if the difference shown by each paper is not real and there is no consistency among the papers as to what exactly the effect is.

Another methodological concern is the apparent use of unplanned subgroup analysis. This means that after the study data was collected, the authors divided the study groups into subsidiary groups (e.g. mastitis cases with positive bacterial cultures and with negative bacterial cultures) and then compared the responses of these subgroups to the different treatments. As with multiple outcome measures, subgroup comparisons can lead to false conclusions without appropriate statistical controls and careful interpretation of the results.

The study was published in the Journal of Dairy Science, which is a reputable scientific publication.

So overall, what can we conclude from this paper? Does it demonstrate “an effectiveness of the homeopathic treatment strategy as a ‘regulation therapy’ stimulating the activity of immune response and resulting in a long-time healing” as the authors conclude? Not at all. It is unclear exactly what this statement means in any case, but it is certain that the weaknesses in designs and execution of the study and data analysis do not allow a great deal of confidence in the hypothesis that homeopathy is as good as or better than antibiotic treatment, or even superior to no treatment, for mastitis in dairy cattle. In cases without bacterial infection and with only mild or moderate localized diseases, which are likely to get better without treatment anyway, homeopathy was not demonstrated to be any more or less effective than the antibiotic therapy used in this study, which was itself less effective than other studies have reported. By itself this would be pretty weak evidence for using homeopathy to treat mastitis.

Again, most scientific studies have such flaws or weaknesses, and this one is not exceptionally inferior in design or executions. However, when the specific flaws of the study are considered in conjunction with the weaknesses of the theory underlying the homeopathic approach and the overall failure of decades of scientific research to show any benefit to homeopathic treatment, the results are essentially meaningless. To overcome the theoretical issues and the failure of any evidence of effectiveness to accumulate despite the amount of research so far done on homeopathic remedies, a quite dramatic and unequivocal result would be necessary to raise any reasonable question of whether homeopathic treatment might be beneficial. This study provides no such results.

Could studies such as this be done better, with fewer methodological flaws? Sure? Should they be? Do we really need still more negative or inconclusive studies of homeopathy before we are allowed to judge it a useless therapy without being accused of unscientific closed-mindedness? Or must we continue to test every possible hypothesis that has its advocates indefinitely? If we are never allowed to declare an idea dead, thenwhat purpose does science serve?

Posted in Homeopathy | 20 Comments

All Natural Advertising for Alternative Veterinary Medicine

I couldn’t resist passing along this little gem. A veterinarian named Dr. Margo Roman, who practices and advocates for the usual hodgepodge of alternative veterinary therapies, has a project called Dr. DoMore which is focused on producing DVD “documentaries” (a.k.a. one-sided propaganda films) to promote alternative veterinary medicine. As a fund raiser for this project, she has created the 2011 Dr. ShowMore Calendar. This “educational and entertaining” calendar features “au natural” photographs of holistic veterinarians demonstrating alternative procedures or approaches. Or as the cover of the calendar puts it, “Veterinarians naturally expose options.” Really, what else is there to say?

I can’t actually recommend buying the calendar, though as a novelty item it is tempting, since the proceeds fund what looks, by the preview, to be an egregious misinformation campaign. But I do have to admire the creativity and communications savvy of the folks involved. I think it’s high time we had a Sexy Skeptics Calendar, don’t you!?

**A reader has already informed me that I’m late to the party, and that a Sexy SKeptics calendar to fund Skepticon 3 already exists. Enjoy!

http://skepticon.org/shop/

Posted in General, Humor, Miscellaneous CAVM | 24 Comments

HuffPo Offers Vet Woo Too, Courtesy of Dr. Palmquist

The folks at Science-Based Medicine and Respectful Insolence have been pointing out for a while that the Huffington Post has become a mainstream media champion for unreliable alternative medical information. And fortunately for us, HuffPo isn’t ignoring the veterinary side of alternative medical propaganda. Dr. Richard Palmquist, President-Elect of the American Holistic Veterinary Medical Association (AHVMA), of which I recently ran afoul, contributes a column to HuffPo. His latest commentary is instructive in that it illustrates the free mixing of reasonable ideas and science with nonsense made up out of thin air, in order to make the two indistinguishable and paint opinion and unsupported belief with a patina of scientific respectability.

In Veterinarians Team with Mother Nature for Better Results, Dr. Palmquist begins with the tried and true appeal-to-nature fallacy:

Scientists are pretty smart, but give them a bucket of carbon, oxygen, hydrogen, sulfur, iron, nitrogen and a few other miscellaneous things and see how many tomatoes they can make from scratch.

Nature is smarter.

Of course, scientists can’t whip up rattlesnake venom, syphilis, hookworms, tsunamis, or many other natural phenomena from scratch either. What’s the point here? If it is that what nature comes up with is better than what humans can make, I think that’s childish reasoning. “Nature” is just our personification of impersonal and undirected processes that have resulted in everything that exists, including human beings and their inventions, and it cares not a whit for our happiness and well-being. We like to say nature makes the good stuff, like puppies and strawberries, and we make all the toxic waste, but the reality is that nature made polio and we made the vaccine, so sometimes we are the good guys..

Dr. Palmquist then proceeds to make the true and quite reasonable observation that many useful medicines come from plants. Of course, this requires humans to analyze, purify, process, mimic, and test all sorts of compounds to find a few useful ones, none of which come without drawbacks, so how natural or inherently benign all of this is open to question. In any case, he inserts another assumption into this otherwise reasonable point, namely that the plants that contain substances useful as medicines were identified as medicinal and used to heal diseases by folk traditions a long time before science stumbled across their usefulness.

I am not aware of any evidence to support this notion, though it is commonly put forward by advocates of herbal remedies and traditional folk medicine in general. It may be true, but there are several reasons why I am doubtful of this assertion and would like something more than herbalists’ word for it. Prominent among them is confirmation bias, the tendency to focus on those examples which support one’s position and ignore those that don’t.

1. Many pharmaceuticals derived from plants, animals, fungi and other natural sources are discovered for reasons not related to folk medicine use. Someone notices that mold in a petri dish inhibits bacterial growth near it, and penicillin is discovered. Scientists work out that blowfish toxin paralyzes muscles and the chemical turns out to be useful in surgery. There are lots of reasons why a particular compound is pursued as a possible medicine apart from its traditional folk medicine use.

2. Most of the folk remedies one can find in historical documents turn out not to work reliably when tested, so Dr. Palmquist is guilty of counting the “hits” and ignoring the “misses.” If folk tradition were a reliable guide to which plants have medicinal value and which don’t, then the plants used in folk traditions should turn out to produce useful medicine more often and more reliably than those not so used. I have seen no evidence investigating this questions, so while it is possible it is by no means safe to assume it is true.

3. Almost every plant has been identified by some culture at some place and time to have medicinal properties. And when these properties are described, the plants are often said to treat a huge number of unrelated symptoms and diseases. When a plant turns out to contain a substance useful for a particular medical problem, one can almost certainly find a reference somewhere to that plant being used for that problem. This ignores the fact that the vast majority of claims made in traditional use of plants are either untested or shown to be untrue, so again Dr. Palmquist is cherry picking the examples where someone somewhere guessed right and ignoring all the wrong guesses.

4. As the post properly points out, getting medicines from plants almost always requires isolating, purifying, and altering chemicals to get better efficacy and fewer side effects. Most compounds investigated as possible drugs fail because they do more harm than good, or no good at all, and those that do succeed are often quite different from what one gets when eating plant parts directly. But Dr. Palmquist persists in putting forward the notion that a mixture of chemicals found in nature is likely to be safer and more effective than isolated and processed compounds. The evidence of medical history is soundly against this idea.

Certainly, it is true that combinations of medications are often more effective than single medications in managing complex diseases. But these are combinations of individual agents that are well-studied and understood and that have demonstrable benefit alone as well as in combination. And the sad reality is that combinations of drugs often leads to drug interactions which can be harmful. Dr Palmquist can say that Vitamin E is synergistic with NSAIDs for cancer therapy, but it is also true that Vitamin C diminishes the effect of some cancer treatments, so he is again picking examples that support his point and ignoring those that do not.

So why should we believe that the combination of chemicals found in a plant was somehow designed by nature to be ideal for treating a disease? Why should we think the combinations of plant ingredients created by folk medical traditions, arrived at either by uncontrolled trial and error or often fantastical theories based on religion, astrology, sympathetic magic, and so on, should be safer and more effective than medicines tested scientifically? Especially given the far greater success of medical science at treating diseases than any previous system has achieved in human history. And how do we explain the contamination of herbal remedies with toxins or even prescription drugs?[see references below] Dr. Palmquist answers none of these concerns but simply blithely assumes that what is natural and traditional is likely to be better than what is manmade and science-based.

There is no doubt nature, which after all describes everything that exists unless one arbitrarily chooses to exclude humans and their activities, holds many medical therapies yet to be discovered. But there is significant doubt that these therapies have already been identified in their safest and most effective form by herbalists and other folk medicine traditions. The reality is that science has taken not only the theories of these traditions but many other ideas they never conceived and created a wealth of medicines undreamt of before the age of scientific medicine. So to say nature knows best is at least naïve and at most an ideological even religious statement of faith rather than a scientific statement of fact. Dr. Palmquist is entitled to his faith like the rest of us, of course, but it should be clearly identified as such, not put forward by HuffPo as if it were established, accepted science.

References 

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

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

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

Coon JT, Ernst E. 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.

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

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

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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

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

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. 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):191-2 Dietary 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

Yang HY, 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

Kidney failure from aristolochia in TCM herbals preparations.

Lead, mercury and arsenic in herbal preparations.

Lead in TCM preparations.

Lead in ayurvedic preparations.

Lead in herbal preparations.

Tea Tree Oil Can be toxic to cats.

Toxic metals in Brazilian herbal preparations.

Contamination of herbal products with undisclosed pharmaceuticals.

Widespread contamination of supplements with undisclosed toxins and parmaceuticals

Posted in General, Miscellaneous CAVM | 9 Comments

The AHVMA: Bought and Paid for by Big Supplement?

A common complaint about conventional, science-based medicine is that it is unduly influenced by commercial interests and agendas, especially the pharmaceutical industry or “Big Pharma.” There is no question that corporations who manufacture medicines, pet foods, and other products used or recommended by vets are interested in making money, and this colors their judgment. There are legitimate concerns about the influence of industry funding on research and how it impacts the quality and conclusions of the evidence we use to inform our practice. However, none of this automatically invalidates the research or the products of industry, it just gives us a cause for some skepticism and care in the judgments we make.

The implied, and sometimes even explicitly stated, corollary to this concern is that “holistic” or alternative medicine and its practitioners are somehow free from the financial motives that taint the practices of conventional veterinary medicine. I’ve addressed this myth before (Big CAM and the David and Goliath Myth), and I wanted to share a recent reminder that proponents of alternative therapies face exactly the same problem of financial motives and corporate influence.

The American Holistic Veterinary Medical Association (AHVMA) is having its annual conference this month (more about that in a subsequent post), and they have quite appropriately identified and thanked their sponsors on their web site. Let’s have a look at the list, shall we?

Rx Vitamins for Pets
A “Diamond” level sponsor of the keynote address.

This is a corporation selling a variety of vitamins and nutritional supplements. They have a representation at most conventional veterinary conferences, and they are actively recruiting paid veterinary student representatives to give out samples and literature. Sound like a pharmaceutical company?

The supplement line is supposedly invented by Dr. Robert Silver, a “holistic” veterinarian from Colorado, who is also an acupuncturist and practitioner of Traditional Chinese Medicine (TCM) and homeopathy. Clearly, Dr. Silver is a “true believer” in alternative veterinary medicine

VetriScience Laboratories
Diamond level sponsor of the Newcomer Social.

A division of the larger, international company Food Science Corporation, which makes a wide variety of nutritional products for human and animal use. Mom and pop operation? Pure labor of love? Hardly.

Nutramax Laboratories
A Gold level sponsor.

One of the largest corporate manufacturers of veterinary and human nutritional supplements. And something I didn’t know, the company states on its web site that it is “a private, Christian-based, company…” and that “The real strength and prosperity of Nutramax Laboratories, Inc. comes from The Lord.” Faith-based medicine indeed.

Genesis Limited
A Gold level sponsor.

A company founded by Bill Bookout, a businessman and president of the primary veterinary supplement industry lobbying organization, the National Animal Supplement Council. The veterinary name behind its products is that of Dr. Ihor Basko, a career proponent of alternative therapies with many related books, videos, and products to sell. 

PetzLife
Contributed $10,000 to support student chapters of the AHVMA at veterinary schools.

The veterinarian behind this obviously successful commercial firm is Dr. Michael Fox, an advocate for animal welfare and also a firm believer that modern, technological society and its products (including commercial pet food and pharmaceuticals) are physically and spiritually toxic. Despite his concerns about the rapacious behavior of corporations, he does endorse a variety of commercial pet foods and supplements.

So what does all of this mean?

1. Does the acceptance of commercial sponsorship mean that the AHVMA is the dupe or lackey of commercial interests and their medical recommendations are mere parroting of industry marketing? Of course not.

2. Does the fact that these companies and individuals make money selling and advocating for alternative health products mean their motives are purely financial and their advice can be automatically dismissed? Absolutely not.

3. Is it likely that people who are believers in alternative medical approaches write books, give lectures, and start companies selling alternative products because they truly believe in these things? Without a doubt!

So why is it so often assumed by these people that anybody working for a commercial pet food or pharmaceutical company is motivated by greed? While corporations are primarily driven by profit, and individuals are certainly subject to both the blindness of their own biases and subtle influences associated with their sources of income or research funding, the fact is that people practice science-based medicine and work for medical industries because they truly believe they are doing good for patients. The assumption of benign motives in alternative medicine and venal motives in mainstream medicine is pure self-serving prejudice, nothing more.

4. So are advocates of alternative medicine who complain about the influence of corporate money on conventional veterinary medicine total hypocrites? Absolutely!

They may not always be wrong, since such influence is a legitimate source of concern, but it applies every bit as much to the alternative medical industry as to conventional medicine. Big Supplement may be smaller than Big Pharma, but it is the same type of organism, with the same problems.

5. And are advocates of alterative medical approaches open-minded while science-based veterinarians are blind idealogues? Nonsense!

The people behind these corporate sponsors are, as far as I can see, all deeply committed true believers in the ideological, and often religious foundations of alternative medicine. They filter and interpret the evidence of science to confirm their pre-existing prejudices and assumptions and ignore whatever contradicts them. All human beings are prone to do this, of course. The very value of science and scientific evidence is that is diminishes the impact of these kinds of biases and blind spots. True open-mindedness and humility lies not in steadfastly seeing the world as we believe it is or should be but accepting that our vision is blurry and unreliable, and that we must be prepared to give up even cherished beliefs when the more reliable evidence of science shows us they are false.

The vital importance of faith, of belief in the unseen and untestable, to the ideology of alternative medicine is clear. Nutramax is a Christian company, Dr. Basko is a Zen Buddhist, and Dr. Fox is a pantheist, but all hold a strong belief that the true, most real, and most important aspects of reality cannot be seen, demonstrated, or scientifically investigated but must be appreciated through intuition, introspection, and individual spiritual practice. Is it surprising, then, that these same individuals reject the notion that what seems true to the individual in medicine should be rejected as false on the basis of scientific testing?

Faith-based medicine relies on the very same kind of faith behind all religious beliefs; namely that we must trust what we feel and believe more than what we can see, touch, or study by reason; we must trust ideas and beliefs more than observations and facts. There is nothing “open-minded” about such beliefs, so to claim that the science-based perspective is closed-minded by comparison is ludicrous. A philosohy founded on faith is, in most ways, far more dogmatic and blind to the possibility of being wrong than the scientific approach.

The title of this post was intentionally hyperbolic and inflammatory, and untrue,  because I wanted to make what I think is the key point here: The motives of alternative medicine advocates and providers, ideological and altruistic or venal and greedy, are no different from those of science-based medicine advocates or providers. We all tend to live our values and ideologies, and we are all subject to ideological blindness and potential financial influence. The difference between what is true and what is false, what works in medicine and what does not, cannot be determined by looking at only the beliefs or incentives behind different approaches, though these factors do have some relevance. The ultimate answers must come from facts and objective study, and only science is able to provide this, however imperfectly.

Posted in General, Law, Regulation, and Politics | 25 Comments

Orientalism

One of the more subtle flaws in thinking that supports unproven alternative medical approaches is the notion best described by Edward Said in his book Orientalism. Though I don’t agree with Said’s post-modernist approach in general, I see great utility in the concepts labeled by the term “orientalism.” Essentially, this term refers to a process of mythologizing and idealizing non-Western cultures and projecting our own agenda onto them, rather than trying to objectively see and understand the complex, messy reality of such cultures. Said’s focus was the Middle East, but the same process applies to indigenous cultures throughout the world.

Sometimes, orientalism takes the form of obvious prejudice, such as reference to “ignorant savages” and the like. But more often, especially among the post-modern left wing intelligentsia which so often also advocates for alternative medical approaches as “equivalent ways of knowing” alongside science, the form orientalism takes is more sophisticated. It often involves an expression of admiration for the purity or simplicity of cultures not tainted by modern scientific or political ideas or other products of the Renaissance and Enlightenment in Europe. Non-Western cultures, and people, are sanitized and seen as exotic and not polluted by the moral or intellectual conflicts that decadent imperialist Western cultures suffer from.

This, of course, is ignorant and patronizing and merely another form of racism which ignores the fundamental commonalities of human beings and human cultures as well as the complexities and conflicts that characterize non-Western societies as much as our own. But it is difficult to convince the dedicated orientalist of this since their sense of admiration for the exotic seems to them like respect rather than simple patronizing psychological projection.

Cracked.com has an entertaining, but oddly sobering piece up today on the subject which pretty much says it all:

5 Examples of Americans Thinking Foreign People are Magic

Posted in General, Humor | 8 Comments

Cognitive Dissonance In Action: Glucosamine No Matter What!

I’ve discussed cognitive dissonance previously. Briefly, it is the unpleasant feeling that comes from a conflict between beliefs, and its most typical manifestation is a powerful ability to rationalize away evidence that contradicts what we believe. Rather than experience the discomfort of recognizing and accepting that our beliefs are mistaken, and that as a consequence we may have acted inappropriately, we simply find ways to dismiss even powerful evidence and cling to our false beliefs.

I recently came across a classic example on the blog of a “holistic” veterinarian. The evidence, which I’ve reviewed before (HERE, and HERE, for example) is quite clear that in humans oral glucosamine and chondroitin are no better than a placebo for arthritis. And the limited evidence available in veterinary medicine provides no better support for these supplements. As the evidence against these products accumulate, the rational thing to do is to re-evaluate our use of them and honestly advise our clients that the best we can say is they are harmless and may have minimal benefit for selected individuals. This, however, is problematic for those with strong ideological commitment to supplements being superior in terms of safety and efficacy to conventional medicines.

The vet in question acknowledges that recent research suggests a lack of effectiveness for these products, but his response has more to do with his biases than a rational analysis of the risks and benefits of various therapies.

If consumers believe some of the recently published articles that purport to show a lack of effectiveness for joint supplements, my concern is that they will turn to chronic NSAID usage which could be harmful or even fatal due to the well-known side effects (kidney disease, liver disease, worsening of the arthritis, gastrointestinal ulcers and perforations) of this class of medications.

So, if consumers realize glusosamine isn’t doing anything for their pets, they might be tempted to switch to drugs that actually do help? Isn’t that awful!

There is no question NSAIDs have potential side effects. Any medication that has benefits does. The issue is whether we are better off giving our pets an absolutely safe product that does nothing, or a very safe product that really helps. Research clearly shows NSAIDs have undeniable benefits for arthritis patients, far greater than any potential benefits of glucosamine products.[1,2] And the safety record is very good, with serious side effects in only a small percentage of cases, even with long-term use, and with most problems associated with inappropriate use (dose higher than recommended or used at the same time with steroids or other NSAIDs)[3-5] These drugs can worsen pre-existing kidney or liver disease, but this is preventable with appropriate screening and monitoring. The can cause gastrointestinal ulceration in a small percentage of patients, though this is rarely clinically significant. They do not worsen arthritis. And, as the good holistic vet neglects to mention, these medicines actually do treat arthritis effectively, unlike glucosamine.

The mental contortions involved in continuing to recommend an ineffective product can be quite complicated. In addition to ignoring the benefits of NSAIDs and the lack of benefits to glucosamine and focusing only on risks, the denial of reality involves ignoring research findings if one can find anecdotes or personal beliefs that contradict them.

Additionally, many consumers currently using joint supplements experience the positive effects commonly seen with these products, including relief from pain, reduced inflammation, reduce joint swelling, and increased mobility. While skeptics may claim it is only a placebo effect (and in some case they may be correct,) if the end result is an improved quality of life, does it really matter why the patient feels better or gets better?

This response not only inappropriately privileges anecdote over research evidences, it also reflects a common misunderstanding of the placebo effect. It is not a case of “mind over matter” in which the patient gets better because they believe they are being treated. It is a case of patients believing they are better and reporting a positive effect when their disease has not actually changed. One can argue this may be of some real benefit for people with subjective symptoms, like pain and nausea, since thinking you feel better might in some sense actually be feeling better. But the effects are always small (far less than those of  truly effective medicines), they don’t last, they don’t change the underlying disease process, and they require the healthcare provider to either be wrong about whether the treatment actually works or to lie about it. Is this really better than using medicines that have high benefits and some risks?

This vet then exaggerates his own personal experiences and ignores the many ways in which veterinarians and owners can be mistaken about the effects of a treatment, to present what looks like a incontrovertible case against the research findings.

In my own veterinary practice, the placebo effect cannot occur. Either my canine and feline patients improve and begin walking, or they don’t and they remain lame. I have seen thousands of pets improve when administered joint supplements and taken off of NSAID medications. Neither the owners or I were making this up. Either the pet walks or it doesn’t walk: this is not a placebo effect.

This makes it sound like this fellow has seen thousands of pets who couldn’t get up take glucosamine and then rise and walk. If these products really are such a miracle drug, why isn’t this obvious to everybody else taking or prescribing them? I suspect the truth is that he recommends glucosamine for dogs with signs of arthritis, and later the owners say “Gee, I think Fluffy’s walking better!” This may be true, but it’s also quite likely may be a result of the  “placebo by proxy effect.” This is a combination of many of the cognitive errors I’ve written about before: Regression to the mean/natural course of disease (in which a patient with a waxing and waning problem comes in right when the symptoms are at their worst and are just about to get better as part of the natural course of the condition); expectancy (in which the owner expects to see some improvement as a result of the time, effort, and money they’ve spent on seeing the vet and so convinces themselves they have); and all the inadequacies of subjective, external evaluation of an animal’s level of pain that make real, objective research in this area so vital.

Finally, this alternative vet comes right out and says that he doesn’t believe the research, because it contradicts his personal experiences, and that he has no intention of re-evaluating his beliefs regardless of what evidence comes to light.

While I appreciate ongoing research into the use of joint supplements, I still encourage people to use joint supplements for themselves and to administer them to their pets. I have seen the effectiveness of these products and have also seen the horrible side effects of chronic NSAID usage. While researchers can continue to fight over the effectiveness of joint supplements, I will continue to use them and other treatments that help improve the lives of my patients.

This is the paradigm of cognitive dissonance and faith-based medicine. The same reasoning supported millennia of bloodletting and all manner of useless, even harmful therapies that modern medicine has only been able to dislodge by demonstrating that we must have the humility to accept our personal observations are less reliable than true scientific evidence, and the courage to acknowledge when we have been mistaken and change our ways. No such humility or courage is possible with a deep ideological commitment to alternative ways and an irrational suspicion of all things based in mainstream science. For all that advocates of such an approach call for “open-mindedness” regarding their own ideas, they don’t very often evince it when it comes to the evidence against their favorite therapies.

References

1. Aragon, C.L., Hofmeister, E.H., Budsberg, S.C., Systematic review of clinical trials of treatments for osteoarthritis in dogs. J Am Vet Med Assoc 2007; Feb 15;230(4):514-21.

2. Moreau, M., et al. Clinical evaluation of a nutraceutical, carprofen, and meloxicam for the treatment of dogs with osteoarthritis. Vet Rec 2003; 152:323-329

3. Innes JF, Clayton J, Lascelles BD. Review of the safety and efficacy of long-term NSAID use in the treatment of canine osteoarthritis. Vet Rec. 2010 Feb 20;166(8):226-30.

4. Lascelles BDX, Blikslager AT, Fox SM, Reece D. Gastrointestinal tract perforation in dogs treated with a selective cyclooxygenase-2 inhibitor:29 cases (2002–2003). J Amer Vet Med Assoc 2005; 227(7):1112-7.

5. Neiger R. NSAID-induced gastrointestinal adverse effects in dogs—can we avoid them? J Vet Intern Med 2003;17:259–261.

Posted in General, Herbs and Supplements | 9 Comments

Home Remedies: A Cautionary Tale

Harriett Hall, The SkepDoc from whom I cribbed my moniker, recently wrote on the science-Based Medicine blog about the new Mayo Clinic guide to home remedies, which sounds like a sensible guide to appropriate kinds of self-treatment for minor medical problems. Despite the accusations of the fringes of the alternative medicine movement, that doctors are driven by greed and love to provide unnecessary treatment for minor ailments, the reality is that doctors prefer to treat the truly ill, not those with problems that will resolve themselves. People who go to the doctor with self-limiting viral infections for which there is no effective treatment are accomplishing nothing other than sharing their virus with their healthcare providers, so if they could treat their own symptoms at home I’m sure their doctors would be thrilled. And I frequently discuss with my clients both indications that a pet needs to come in to see me and indications that they don’t and can be managed by their owners at home.

The thing is, most mild ailments do get better all by themselves. This is one of the reasons nonsense therapies often seem to work. If you have a common cold, a headache, an upset tummy from too much spicy chili, and so on, you are likely to feel better pretty soon no matter what you do. So home remedies are fine if they make you feel better (by placebo or real effects), or if they just give you something to do while waiting to get better.

The key, though, is that while it isn’t so important if home remedies are effective, since they are only appropriate for mild, self-limiting illnesses, it is critical that they be benign. Any remedy that does harm for a mild disease that’s going to get better on its own is automatically doing more harm than good, unlike a medication which may cause harm that is worth tolerating in order to treat a more serious disease.

I had a case the other day which exemplifies the problem with home remedies: ineffective and potentially harmful treatments applied with no understanding of medicine or even common sense. An otherwise healthy cat had developed some patches of hair loss which the owner self-diagnosed as ringworm (a fungal infection). The owner attempted to treat this with a commonly recommended remedy of vinegar and grapefruit seed extract. There is no good quality evidence this mixture is effective even if ringworm is present, though some laboratory research suggests grapefruit seed extract may have little effect on this particular kind of fungus, and like many “natural” remedies may have contaminates that can present a health hazard.

The cat developed vomiting, diarrhea, and a loss of appetite after licking itself where the remedy was applied. The owner attempted to treat this with activated charcoal and probiotics. I’ve written about probiotics in general (as well as about specific uses and studies and some of the more egregiously fraudulent marketing of them), and there is some plausibility to the idea they may be useful for some kinds of diarrhea, though this is not at all proven in dogs and cats. And activated charcoal is an appropriate agent to give animals suspected of ingesting poison, since it can reduce absorption of the toxins. However, a cardinal rule of treating toxin exposures is never give oral medications, especially charcoal, to an animal that is vomiting. Not only will these likely incite more vomiting, but there is a great risk of aspirating the charcoal into the lungs, which can cause a serious pneumonia. This was clearly a case where a home remedy was not indicated.

The client brought the pet in and was given some suggestions about medications and feeding, with the main suggestion being to let the cat alone. The hardest thing for any pet owner to do when their companion is sick is nothing, even when that’s the best thing to do. Like many people who feel they need little or no veterinary advice to treat their own pets, the owner had a stock of left over medications previously prescribed for other pets which the person was eager to use. And in the absence of being told to use them, the client was eager to apply home remedies rather than simply give the cat time to recover naturally.

The next day, the cat was no longer vomiting but didn’t want to eat and still had soft stools. In addition to giving the cat a variety of foods, including some clearly inappropriate for a patient with a gastrointestinal problem, such as egg yolks, the owner then attempted to treat the diarrhea by giving the cat two enemas, one with aloe vera and another with flax seed oil. Apart from the lack of any evidence to suggest either of these substances have benefit for GI upset, and the utter ridiculousness of the colon cleansing and intestinal toxicity ideas, the notion of treating diarrhea by giving enemas is every bit as stupid as it sounds. Such treatment is not only going to further aggravate the original problem but can potentially cause serious injury, especially performed by someone without proper training in an inadequately controlled environment.

The clearest evidence of this person’s complete lack of not only medical knowledge but even common sense was when they seemed both worried and puzzled by the fact that the cat was reluctant to be picked up or touched near the hind end by the owner!

Home remedies are perfectly appropriate for mild, self-limiting conditions, as long as the remedies themselves do no harm. But as this case illustrates, determining when it makes sense to use such remedies, and what kinds of treatments are appropriate for what conditions, is not apparently as straightforward as proponents of treating your own pets at home would have you believe. No doubt most pet owners are sensible enough, and have enough understanding of the limitations in their own knowledge and skill, to be trusted to recognize when their pets need professional care and when they can try using simple home remedies themselves. However, in my years of practicing I have seen many, many cases of unbelievably inappropriate treatments and horrible neglect due to a complete lack of any understanding by owners of what is mild and what is serious disease and what remedies they can reasonably apply on their own, so I believe we must be very cautious when telling pet owners they don’t necessarily need to seek veterinary care when their pets are sick.

The most important part of any guide to home remedies should not be the treatments themselves, those these should of course at least be safe. The most important thing such a guide should emphasize is that owners must recognize the limitations of their own medical knowledge and understanding and know when to call their vet. Ultimately, home remedies may or may not effectively treat symptoms, but they are only appropriate if they do no harm and if they are used for conditions that are going to get better on their own regardless of whether we do anything at all.

Posted in General, Miscellaneous CAVM | 6 Comments

Does the Pheromone DAP Reduce Stress in Dogs Having Surgery?

In June I reported on a systematic review of the behavioral effects of pheromones on dogs and cats. That review examined all the studies to date on pheromone products such as Feliway and DAP (dog appeasing pheromone) and concluded that there was almost no real evidence that these products had meaningful behavioral effects. There is an abundance of literature, most of it produced or at least funded by the companies selling these products, that they have some measurable effects on any number of physical or behavioral measures. But that is entirely different from demonstrating that they actually make pets feel or behave better.

A new study has been published in the most recent Journal of the American Veterinary Association, examining whether or not DAP has an effect of indicators of stress or pain in healthy shelter dogs undergoing routine spaying and neutering:

Siracusa C, Manteca X, Cuenca R, del Mar Alcala M, Alba A, et al. Effect of a synthetic appeasing pheromone on behavioral, neuroendocrine, immune, and acute-phase perioperative stress response in dogs. Journal American Veterinary Medical Association 2010;237(6):p. 673-81.

This is a nicely designed study of 46 dogs in residence at an animal shelter in Spain for at least 20 days. There is no indication of how the dogs were chosen, though the exclusion criteria for the study are clear and appropriate, and the treatment (DAP or an appropriate placebo) was randomly assigned. Investigators were effectively blinded to the treatment assignments.

A large variety of behavioral and physiological variables were assessed. Subjects were videotaped in their usual environment, and then in the surgical area before and after surgery. These videotapes were scored after the fact for 31 behavioral variables. In addition, a previously described interactive test for evaluation of pain was performed after surgery.

Putative physiologic measures of stress (salivary cortisol levels, prolactin levels, white blood cell counts, blood glucose levels, and acute-phase protein levels) were measured before and after transfer of the subjects to the surgical area and after surgery. Having done research on behavioral enrichment and well-being in captive primates prior to veterinary school, I am aware that there are problems with the utility and reliability of these variables in assessing stress or well-being, but they are commonly used and reasonable markers as long as their weakness are kept in mind.

The results were a significant difference between groups for the change in two behavioral variables, visual exploration and alertness. DAP-treated subjects appeared to have less of a decrease in these behaviors after surgery than placebo-treated dogs. The significance of this isn’t really clear. The groups did not differ in any other behaviors, including those more seemingly relevant to discomfort or stress such as vocalizing, licking oneself, moving around, etc. There was also no difference between the groups in pain as assessed by the interactive assessment used in this study.

Of the physiologic variables, the ones traditionally associated with stress (again, with much debate among ethologists about their usefulness), such as cortisol levels and lymphocytes counts, did not differ between the groups. The only physiologic variable that did differ was the level of prolactin in the blood.

Prolactin is a hormone usually associated with nursing, as it is released in response to suckling and is involved in stimulating the release of milk. It does have some other behavioral affects associated with reproduction and maternal care behaviors, but its significance in terms of stress or pain is not clear. Some changes in blood levels have been associated with stressors such as surgery or with the presence of behavioral problems, such as anxiety disorders, but the role of prolactin in behavior and stress is not well characterized.

So in this small but well-designed and conducted study, we see a couple of variables apparently affected by the presence of the DAP, though none of those usually associated with the negative aspects of the surgical experience, such as pain or activation of the stress response system as reflected in cortisol levels. What can we conclude from this? Well, in these dogs under these circumstances, DAP diminishes the decrease in prolactin levels following surgery, and it might have some impact on general alertness and looking around.

Does this have any meaningful significance for the comfort or well being of the dogs in the study, or other patients in similar circumstances? Not that we can conclude from these results. The fact that an intervention appears to do something is a big leap from the kinds of claims made by the manufacturer of the commercial DAP product. These marketing materials describe this as “the secret to happy dogs” and suggest “It is strongly advised that puppies wear a DAP® Collar throughout the socialisation period (from 6-16 weeks) to prevent fear and stress which may lead to anxiety-related behavioural problems later in life [and] to dramatically influence a puppy’s development and help it grow into a well-behaved and confident adult dog.” A good bit beyond the kind of real data seen in this paper or the previous review of the published literature.

It is possible that purified or synthetic pheromones may ultimately have a role to play in treating behavioral problems in dogs and cats, or in otherwise ameliorating the stresses associated with illness and medical care. But the products currently on the market, and widely used, have so far not done a very impressive job of proving their value. Harmless? Probably. But also perfect candidate for placebo-by-proxy effects, making owners and veterinarians feel better rather than our patients.

Posted in Science-Based Veterinary Medicine | 6 Comments