Saturday, August 16, 2014

The modern shamans

kw: book reviews, nonfiction, medicine, alternative medicine

TMTOWTDI – There's more than one way to do it – is the mantra of computer programmers and engineers. It applies to most things in life. We can call this "Principle 1", or P1.

There are few ways to succeed but many ways to fail. Let's call this "Principle 2", or P2.

But, a big but, TOOBWTDI – There's only one best way to do it. The trouble is, folks disagree on that one way. I'd like to call this "Principle 3" (P3), and the caveat, "3a" (P3a).

Thus we come to that nice, stealthy word "alternative". If P1 applies, you have alternatives. Therefore, suppose someone complains to you of pain. Anything from a paper cut to diabetic neuropathy to bone cancer. What are the alternatives?

  1. OTC painkillers such as Aspirin, Ibuprofen, Acetaminophen, or Naproxen.
  2. Prescription painkillers such as Hydrocodone, Morphine, or (in Europe) Heroin.
  3. The age-old remedy of a quart of whiskey.
  4. A stiff bonk on the head.
  5. Death.
All these have their uses and all have side effects. Alternative #1 helps only low-level pain. For #3, a second quart may be needed to induce total unconsciousness. #5 is unethical and usually illegal, unless you are Dr. Kevorkian. #4 is also unethical, and the ensuing concussion causes pain of its own later on.

Depending on whom you ask, there are further alternatives, including acupuncture and distraction such as the "laugh therapy" that helped Norm Cousins, and me, endure chemotherapy. There are also homeopathy, coffee enemas and other kinds of "detox" procedures, and a really incredible list of nostrums promoted by everyone from your Aunt Tillie to the quack-of-the-month using back-page ads.

In America and the West generally, doctors are no longer the knights in shining armor we imagined right after WW2. Like all science, medical knowledge grows by stages, so it is necessarily limited. We are a long way from Dr. McCoy and his Tricorder, curing almost anything putting the Tricorder next to someone's forehead or over their chest and calling their name. When a doctor must admit helplessness, patients don't like it. Particularly the Boomer generation. This pampered, overindulged, self-indulgent generation simply won't take NO for an answer, so they look for "alternatives".

Practitioners of "Alternative Medicine" have stepped into the gap. In fact, they have opened the gap and driven through in a locomotive. They rely on P1 and say they have P3, but there are so many different ones, we come up against P3a. Thus the new book by Paul A. Offit, MD: Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine. He doesn't start with a definition, but gets there eventually, so I'll save you the suspense:
If a medical treatment is effective it is Medicine. If a so-called alternative—something not being done by MD's—is effective, it is also Medicine. If it is not effective, it is not medicine, alternative or otherwise. Thus there is no "alternative medicine". If it works, it is medicine.
Do note that the book's subtitle says, "Sense and Nonsense". In Chapter 4, "Fifty-One Thousand New Supplements", a number of popular treatments are discussed:
  • Ginkgo for dementia.
  • St. John's Wort for depression.
  • Garlic to lower cholesterol.
  • Saw Palmetto for enlarged prostate.
  • Milk Thistle for liver problems.
  • †Chondroitin and Glucosamine for joint pain.
  • Echinacea for colds.
† I take these, and I'll discuss it a bit later.

None of these 7 is effective. All have been tested and none stood up. Four more items were mentioned that do have some benefit:
  • Omega-3 supplements do improve heart and vascular health, and perhaps brain health. However, too much is not better, and can lead to prolonged bleeding from minor injuries, or even stroke. (†I have to find out how much "too much" is).
  • Calcium for bone health in older women, and probably older men.
  • Vitamin D (specifically D3) works with Calcium for bone health. Here also, too much is harmful, more than 3,000 units or so.
  • Folic Acid (Vitamin B9) prevents many birth defects during pregnancy.
Medical testing is either A-B or A-P. An A-B test compares a new substance "A" against the standard substance "B". For example, a new painkiller might be tested against aspirin if its target use is headaches or sprain soreness, or against morphine if its target use is postoperative pain or terminal cancer pain management. A-P tests compare a substance to a placebo, a "sugar pill". This brings up an interesting matter, discussed in Chapter 11, "The Remarkably Powerful, Highly Underrated Placebo Response".

Placebos! The name comes from a Latin phrase meaning "I please you". Doctors and their shamanic forebears have been handing out pills or potions "to please the patient" for at least 5,000 years. They well know that if a doctor at least does something, a patient will feel better for that reason alone. This was thought to be a purely psychological trick until endorphins were discovered. The first endorphin was so named because it was called "endogenous morphine". These chemicals, produced in the brain, bind to receptors that reduce the feeling of pain, and can nearly eliminate it. Morphine binds to the same receptor, hence it reduces pain.

If you trust and like your doctor, being given a pill will in itself prime you for an endorphin release whenever you take the pill, and it will reduce pain, sometimes by quite a lot. Thus, to say that this or that "alternative remedy" is no better than a placebo can mean one of two things. Firstly, it may simply be another placebo, one that may have been a little more complicated to make than the standard coated sugar pill. Secondly, it may actually be effective, whether or not the placebo response is involved.

Medical test results are stated in a form such as "Caused a 50% reduction in symptoms for 75% of patients." If it is being compared to a placebo, and it is further stated, "…no more effective than the placebo", that means for the condition being tested (Migraine, perhaps), a placebo also had a significant effect for 75%, and not for the other 25%. At the risk of doubling testing costs, and they are already staggeringly high!, I'd recommend an A-P-P-A test, where during a second period of time, the patients were switched, and the differences noted for each patient. Then you focus on those patients who did not respond to the placebo, but did respond to the test substance. You may have found something that is genuinely effective for some 25% of the population, and it may be worth finding out why these but not the others were helped.

Not everyone is the same. Optometrists have always known this. My glasses would not work for your eyes. In Optometry, nearly every prescription differs from the others. (Actually, given the granularity in correction parameters, there are probably only about 50,000 unique eyeglass prescriptions, per eye.)

†So now I'll tell you why I still take Glucosamine and Chondroitin. I had a rotator cuff injury nearly 25 years ago. This runs in my family. My father has had both cuffs put back together with nylon straps. I decided to avoid surgery, and just babied the shoulder. Within a few months it was mostly better, but a lingering soreness remained for about 10 years. Then I began to take G+C. The response was slow. After 3 months the soreness began to get better and after a year it was much better. I tried stopping the supplement, and soreness began to return, so I returned to using it, and still do. I judge that is much too slow to be a classic placebo response. Something is doing me good.

Now for the other † symbol. I take a lot of Omega-3 supplement. Years ago a doctor prescribed Lovaza, and recommended I take at least 2 pills daily, primarily for heart health. I have very low cholesterol, around 120 for total, but also very low HDL, typically about 32. The doctor had first prescribed Tricor to raise HDL, and after a couple of years, it reached 38. I also gained 20 pounds in those years. He wanted me to reach an HDL of 40 at the very least, and 50 if possible (my wife's HDL is 60). One better thing the Tricor had done was lower my blood fats from 300 to below 150. So, the Lovaza is supposed to to keep them down also. It did, but it is very expensive. I found that I could get the same DHA and EPA found in 2 Lovaza pills by taking 5 of the 1.2g pills from Walgreen's or BJ's. That is what I do. It costs a lot less, and I don't mind occasional fishy aftertaste. Also, after I stopped taking Tricor I lost 15 pounds.

By the way, I was briefly involved with a project at DuPont to produce EPA from yeast. They market the stuff now. I'm waiting for a similar supplement for DHA. Anyway, they had some highly purified EPA. It has a strong fishy smell all by itself. If you're taking Omega-3 supplements that include EPA (and they'd better, it is the truly essential one), the fishy smell can't be removed, no matter what the manufacturer says. And if they put an "enteric coating" on it so it won't dissolve in the stomach, the pill is very likely to run right through your system unchanged, and you'll see it after a bowel movement, if you care to look. I use pills without special coatings, just ordinary gelatin. Five per day, or 6 grams.

I've skipped over a lot that the book discusses. There is a very enlightening history of quackery and medicine growing together in America. Then the history of regulation including creation of the FDA shows how certain loopholes have been built into the laws because of intense lobbying by people who make a killing from "alternative" treatments. As I wrote above, medicine is medicine, and if something is effective, doctors ought to use it. If it is not, they ought to say why.

All this quackery goes on because people won't accept limits to our knowledge. The medical profession is a work in progress. I am alive today because of 21st Century medicine, including being poisoned with 5FU, a nerve gas from WW1 that happens to be a great chemotherapy agent against colon cancer. And, in my experience, 5FU is the most effective anti-depressant I've ever had (I don't take any AD's now, but I've tried a few). By the way, if you're ever tempted to use Laetrile, the effective agent, if there is one, is the cyanide found in the pits of all stone fruits and in other fruit seeds also. When I eat an apple, core and all, chewing the seeds, I get a bit of cyanide. There is more to "An apple a day keeps the doctor away" than just the anti-constipation properties of apple peel! But Laetrile is concentrated to the point that many folks who take it are damaged by the larger amount of cyanide. You'd do better and be safer eating a peach or apricot, cracking open the seed (use pliers not your teeth), and eating the soft pit inside. No more than one or two per day! But really, if you have cancer, see an oncologist. They aren't out to purposely harm you, really truly!

Dr. Offit's presentation is the most balanced and clear I've seen. His approach is common-sense and sensible. Whether the person who recommends a nostrum is a doctor, a "practitioner" of some alternative or other, or your cousin Joe, ask, "How do you know?" They need to know because you need to know. Had this book cited a study showing harm caused by the G+C I'm taking, I'd stop using them. We all ought to remember that MD's and DO's at least take the Hippocratic Oath, and promise to "do no harm." The purveyors of "alternatives" have not taken that oath.

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