AA is Faith-Based, Not Evidence-Based
READ THE FULL ENTRY AT “SCIENCE BASED MEDICINE”
Alcoholics Anonymous is the most widely used treatment for alcoholism. It is mandated by the courts, accepted by mainstream medicine, and required by insurance companies. AA is generally assumed to be the most effective treatment for alcoholism, or at least “an” effective treatment. That assumption is wrong.
We hear about a few success stories, but not about the many failures. AA’s own statistics show that after 6 months, 93% of new attendees have left the program. The research on AA is handily summarized in a Wikipedia article. A recent Cochrane systematic review found no evidence that AA or other 12 step programs are effective.
In The Skeptic’s Dictionary, Bob Carroll comments:
Neither A.A. nor many other SATs [Substance Abuse Treatments] are based on science, nor do they seem interested in doing any scientific studies which might test whether the treatment they give is effective.
In the current issue of Free Inquiry, Steven Mohr has written a thorough and incisive article “Exposing the Myth of Alcoholics Anonymous.”
Mohr characterizes AA as a religious cult. The founder, Bill Wilson, had a religious experience while under the influence of strong psychotropic drugs.
He had a vision of a bright light and the revelation that he could be saved only by giving his life completely and fully to God – and that an important part of his recovery would be to bring the news of his epiphany and recovery to other suffering alcoholics.
The 12 steps of AA refer repeatedly to God. They require admitting you are powerless, accepting that only a Higher Power can help you, turning your will and your life over to God, taking a moral inventory, admitting your wrongs, being ready to let God remove your shortcomings, making amends to those you have harmed, improving your conscious contact with God through prayer and meditation, and spreading the word (proselytizing).
Criticism of the religious orientation led AA to switch emphasis from “God” to any “higher power.” One member allegedly designated a doorknob as his higher power and believed that praying to the doorknob helped him maintain sobriety.
Acupuncture Does Not Work for Back Pain
Here goes Steven Novella’s take on the latest acupuncture study.
A new study which randomized 638 adults to either standard acupuncture, individualized acupuncture, placebo acupuncture using tooth picks that did not penetrate the skin, and standard therapy found exactly what previous evidence has also suggested – it does not seem to matter where you stick the needles or even if you stick the needles through the skin. The only reasonable scientific conclusion to draw from this is that acupuncture does not work.
But let me back up a minute. Imagine if we were evaluating the efficacy of a new pain drug. This drug, when tested in open trials (no blinding or control) has an effect on reducing pain – it is superior to no treatment. When compared to a placebo, however, the drug is no more effective than the placebo, although both are more effective than no treatment.
Now imagine that the pharmaceutical company who manufactures this drug sends out a press release declaring that their drug is effective for pain, but that their research shows that a placebo of their drug is also effective (FDA applications are pending). Therefore more research is needed to determine how their drug works. Would you buy it?
That is the exact situation we are facing with acupuncture research.
Acupuncture is the traditional Chinese medicine practice of placing thin needles to a specific depth through the skin in specific acupuncture points in order to treat illness and relieve symptoms. Claims for acupuncture, including the number and location of acupuncture points, have changed greatly over the centuries, but there is no scientific evidence base for any of these claims. Acupuncture is philosophy-based medicine, not science-based medicine. The presumed mechanism for acupuncture, according to TCM, is that the needles unblock the flow of chi (life energy) through the body. Acupuncture points are supposed to corresponds to the pathways through which chi flow, correlating to specific organs or functions in the body.
Modern proponents of acupuncture come in two basic flavors – those who promote so-called medical acupuncture, and those who restrict their claims to symptomatic relief of pain, nausea, and other symptoms. Medical acupuncture is the claim that acupuncture can actually treat real medical diseases, like cancer. It is dependent entirely on the TCM philosophy of acupuncture, including the flow of chi. Medical acupuncture is pure pseudoscience without any basis in science or evidence and does not require further consideration.
Some proponents of symptomatic acupuncture have divorced their claims from the original philosophy of acupuncture, claiming that the needling works through more prosaic mechanisms, such as the release of pain-relieving endorphins or through nerve stimulation. While these explanations are plausible, they are post-hoc speculations and have not been demonstrated to occur to a clinically relevant degree.
But before we speculate about possible mechanism, we need to establish that acupuncture has an effect – that it works for some specific indication. This has not been established, despite rather robust clinical research efforts. If there were not a cultural inertia to the notion of acupuncture the existing research would have been sufficient to abandon this modality as a dead end.
Acupuncture for IVF Revisited – More Tooth Fairy Science?
I read this Reuters Health article on MedlinePlus, and then I read the study the article referred to (The impact of acupuncture on in vitro fertilization) and now my head hurts. The study found that acupuncture was not effective in increasing the pregnancy rate (PR) during in vitro fertilization (IVF). As quoted on MedlinePlus, the lead author, Alice Domar, seems to blame her patients (the presumably poor quality of their embryos) rather than acupuncture for the lack of success, and then she recommends using acupuncture even if it doesn’t work. That was bad enough, but “poor quality embryos” is a hypothesis that was actually tested and rejected in the study itself. Has Domar forgotten?
The headline of the MedlinePlus article says “acupuncture doesn’t boost IVF success for all” – suggesting that it boosts success for some? Then the first sentence says the study suggested that acupuncture doesn’t work, period. But wait…
The lead researcher says acupuncture may not have worked in her study because, unlike past research, her investigation wasn’t limited to women who had good quality embryos available for transfer. “I’m wondering if my sample was just not a good sample, in that most of the patients in my study were probably not the best-prognosis patients,”
Domar and her team say the most likely explanation for the lack of an acupuncture effect in their study was the fact that they included many women who didn’t have good quality embryos available for transfer. While acupuncture may help a woman become pregnant after the transfer of a healthy embryo, the researcher noted in an interview, it can’t repair an embryo with chromosomal defects or other abnormalities.Hold the boat!! In the Discussion section of the paper itself, Domar et al point out that previous research has included mostly patients with good quality embryos. They ask if perhaps acupuncture only works for good quality embryos? They test that hypothesis by separately analyzing the subjects in this study who had good quality embryos. There was no increase in PR with acupuncture in this sub-group; the results were the same as for the entire sample.
This study not only had an objective endpoint (pregnancy) but it also had several subjective psychological endpoints (optimism, confidence, and anxiety as measured by perceived relaxation). The women who received acupuncture felt more relaxed and enjoyed the IVF procedure more, the researchers found. They were also more optimistic about getting pregnant, but not more confident that they would get pregnant.”
Despite the results of my own study, I still recommend acupuncture to women going through IVF because there’s no downside,” Domar added, aside from the $150 an acupuncturist would typically charge — a small fraction of the $12,000 to $14,000 couples typically spent on a single round of IVF.
It seems to me this translates as: Acupuncture works. It didn’t work in this study, but that can’t be the fault of acupuncture, because acupuncture works. So it must be the fault of the patients for producing poor quality embryos, (our data don’t support that hypothesis, but let’s just ignore that). Acupuncture is harmless and people like it, so let’s use it on every patient whether it works or not. Patients will have to pay $150 extra, but I’m willing to decide for them that the expense is worth it. What?!
Pockets of Vaccine Noncompliance in California
The LA Times recently published their analysis of data provided them by the state of California and found that there are pockets of high rates of exemption from vaccines among kindergarteners. In the US public schools require that all children receive the recommended vaccines. However, states can allow exemptions for the religious beliefs of the parents.
Over the years anti-vaccine activists have been successful in many states in expanding the rules for exemption. In California, for example, parents may seek excemption if they have “philosophical” objections to vaccines – which means there really isn’t any criteria beyond the parent’s wishes. The anti-vaccine movement has been active not only in pushing for the weakening of vaccine requirements but also in teaching parents how to use the laws to evade vaccination for their children.
The LA Times found that, while state wide the exemption rate was only 2%, exemptions were largely clustered in certain schools. They report:
In all, more than 10,000 kindergartners started school last fall with vaccine exemptions, up from about 8,300 the previous school year. In 1997, when enrollment was higher, the number of exempted kindergartners was 4,318.
and
At Ocean Charter School in Del Rey, near Marina del Rey, 40% of kindergartners entering school last fall and 58% entering the previous year were exempted from vaccines, the highest rates in the Los Angeles Unified School District.
Herd Immunity
These numbers are concerning because they threaten herd immunity – when about 90% of the population is vaccinated then there are not enough vulnerable hosts to spread an infection efficiently, so outbreaks are uncommon. When vaccination rates drop significantly below 90% then herd immunity is lost and infectious diseases can spread, resulting in outbreaks.
This is not mere theory – it happens. In the UK fears that the MMR vaccine was linked to autism (even after the original research by Andrew Wakefield was exposed as wrong, subject to undisclosed conflicts of interest, and maybe even fraudulent, and later evidence confidently showed no link between MMR and autism), led to a precipitous drop in the rates of MMR compliance. The UK does not mandate vaccine for entry into public schools, so they lacked the buffer (for what it’s worth) that exists in the US. As a result there was, and continues to be, a resurgence of previously controlled diseases, like measles.
The later scare that the mercury-based preservative thimerosal could be linked to autism has had a similar effect, and such fears rapidly spread to the US. This link too has been shown to be false, and in any case thimerosal was removed from the childhood vaccine schedule by 2002, but the this has not stopped the anti-vaccine movement from spreading unwarranted fear.
Rhinos and tigers and bears. Oh my.
This is a must read, a great entry from SBM.
No good deed goes unpunished.
The website whatstheharm.net is a depressing recitation of the harm that humans do to themselves and others from participating in various forms of nonsense in the attempt to do good. It my backfire, and instead pain and death result.
I would bet that most practitioners of medical woo are true believers. They do not intend to harm people, and believe they are doing good for their patients. Certainly the consumers of alternative therapies intend to have good benefits from their use of sCAM modalities. Most want to get better, and do not intend to hurt themselves or others.
Unfortunately, actions always have unintended consequences. Sometimes the harm is directly to the patient. Sometimes the harm in indirect, with collateral damage to people or the environment. My hospital system has an extensive recycling program to handle the huge amounts of waste generated by the need to insure that all manner of materials are sterile. Patients in isolation consume large amounts of paper and plastic to keep infection confined. My hospitals actively look for ways to decrease their environmental impact and carbon footprint and still deliver high quality medical care. Legacy Health System, where I work, is an award winning leader recycling medical waste, which is a lot more difficult to dispose of than the pop cans and paper bags in your house. Hopefully the trash in your house is not covered with pus, blood and other potentially hazardous medical waste. We try to be good global citizens.
I wonder if some branches of the alternative medical industrial complex are so environmentally conscious.
Natural products are at the greatest risk for being adversely affected by a demand for their use. If millions of people want a natural product that has limited supply, soon that product will be exhausted and the product extinct. Adverse effects from alternative therapies can come in many forms, and the alternative practice with the greatest adverse impact on the environment is probably traditional Chinese medicine (TCM). A billion or more people wanting a traditional herbal or animal product is going to have a detrimental effect on the herb or animal being consumed. There are numerous examples of the adverse effects on the environment from traditional Chinese medicine.
For years the Rhinoceros was hunted not for food or sport, but for the horn. There is a form of magical thinking that derives function from the structure of a natural product like a rhino horn. It looks like a penis. I guess. I must not have been paying close attention during in my urology rotation. Because it looks like a penis, it must have efficacy on impotence. So the rhino horn was ground up to treat impotence. For centuries it was the Enzyte of the world. But Rhino horn is more than an aphrodisiac. Although the rhino horn is no more than a fingernail with extra calcium and phosphorus, the horn has been used in Chinese medicine to treat damn near anything.
Acupuncture – Disconnected from Reality
The primary goal of science-based medicine (SBM) is to connect the practice of medicine to the best currently available science. This is similar to evidence-based medicine (EBM), although we quibble about the relative roles of evidence vs prior plausibility. In a recent survey 86% of Americans said they thought that science education was “absolutely essential” or “very important” to the healthcare system. So there seems to be general agreement that science is a good way to determine which treatments are safe and work and which ones are not safe or don’t work.
The need for SBM also stems from an understanding of human frailty – there are a host of psychological effects and intellectual pitfalls that tend to lead us to wrong conclusions. Even the smartest and best-meaning among us can be lead astray by the failure to recognize a subtle error in logic or perception. In fact, coming to a reliable conclusion is hard work, and is always a work in progress.
There are also huge pressures at work that value things other than just the most effective healthcare. Industry, for example, is often motivated by profit. Institutions and health care providers may be motivated by the desire for prestige in addition to profits. Insurance companies are motivated by cost savings. Everyone is motivated by a desire to have the best health possible – we all want treatments that work safely, often more so than the desire to be logical or consistent. And often personal or institutional ideology comes into play – we want health care to validate our belief systems.
These conflicting motives create a disconnect in the minds and behaviors of many people. They pay lip service to science-based medicine, but are good at making juicy rationalizations to justify what they want to be true rather than what the science supports. We all do this to some degree – but, in my opinion, complementary and alternative medicine (CAM) is a cultural institution that is built upon these rationalizations. It is formalized illogic and anti-science conceals as science under a mountain of rationalizations.
Some recent news items and reports dealing with acupuncture demonstrate this disconnect quite well.
2009: Shaping up to be a really bad year for antivaccinationists
[Originally posted at: Science Based Medicine]
I will begin this post with a bit of an explanation. Between one and two weeks ago, there appeared two momentous news about the manufactroversy regarding vaccines and autism. No doubt, many SBM readers were expecting that I, as the resident maven of this particular bit of pseudoscience, would have been here last week to give you, our readers, the skinny on all of this. Unfortunately, as some know, my wife’s mother died, coincidentally enough, on the 200th anniversary of Darwin’s birthday and a day when one of those two momentous bits of news was released to the public, which is why I used one of my handful of posts written and then held in reserve. I’m back now, though, and I don’t think it’s too late to comment on these bits of news because now that over a week has gone by what I’ve seen has led me to draw some conclusions that I might not have been able to do, had I done my usual bit and been first off the mark (at least among SBM bloggers) discussing the story.
[Read the rest of this post at: Science Based Medicine]
Amish Home Burn Treatment: B&W Salve and Burdock Leaves
People in the Amish community have been using “The New Concept in Treating Burns” and their experience is recounted in a little booklet by that title. It is a compilation of articles, testimonials, and letters to the editor of a monthly newspaper Plain Interests, published in Millersburg PA.
The treatment, involving B&W ointment and dressings of scalded burdock leaves, was developed by John Keim, an Amish farmer and natural healer. The Amish have a tradition of taking care of their own, and they try to avoid hospitals whenever possible. In the booklet, they even recommend treating hip fractures at home without surgery. (Which, after all, is what we did before we had hospitals and surgery).
They claim that with the B&W burn treatment:
- Painful burns are rendered non-painful.
- Healing is faster.
- Painful debridement is not necessary.
- Skin grafting is not necessary.
- Scarring seldom occurs.
- Iatrogenic harm from hospitals is avoided.
- Patients can be treated at home at much less expense.
According to Keim, with his method it seldom takes more than seven days to get a completely new skin cover on second and third degree burns, and in over two decades he never had an infection. He saw only 2 cases of scarring, and they were minimal. He does not charge for his services.
Rainman – Link Between Precipitation and Autism
A new study published in the Archives of Pediatrics and Adolescent Medicine shows a positive correlation between counties in California, Oregon, and Washington with greater precipitation and a higher incidence of autism. While the results of this study are interesting, it needs to be put into proper context. Also of note, the authors had presented early results from this data previously.
Correlation is not Causation
This type of study is a correlational study, which means it asks whether or not there is a statistical correlation between two variables – in this case the rate of autism and the amount of precipitation. This type of data is extremely useful to medical science, but it has known limitations, which can be summarized by the statement that correlation is not causation.
I often see this principle used to dismiss correlation data entirely, but that is not the correct approach. Correlation, rather, needs to be considered in the proper context. When A correlates with B there are various possible interpretations: the correlation is a statistical fluke (coincidence); A causes B, B causes A, or both A and B correlate with another variable C, and there can be a variety of causal relationships among the three (or more) variables which would cause A to track with B.
Therefore, finding a correlation is a way to generate several hypotheses which can then be tested by further observations or research. That, in my opinion, is the best way to view correlational data – as a beginning step to help generate hypothesis. But they should not be used to reach firm conclusions.
It should also be noted that further correlations can be used to test various causal theories, and if multiple correlations all triangulate to a single causal hypothesis that can lead to a fairly confident conclusion – even in the absence of other evidence. For example, smoking correlates with certain types of lung cancer. There are no prospective studies in humans to establish that smoking causes lung cancer, but we can be confident that it does because the correlation holds up no matter how you choose to look at it. If smoking causes cancer (as opposed to other causal hypotheses stemming from the correlation) then we predict that increased duration of smoking increases risk of lung cancer, that stopping smoking decreases risk, that smoking unfiltered is more risky than filtered, etc. Each of the predictions turns out to be true, supporting the smoking causes lung cancer hypothesis.
Puncturing the Acupuncture Myth
“Alternative” medicine is by definition medicine that has not been scientifically proven and has not been accepted into mainstream scientific medicine. The question I keep hearing is, “But what about acupuncture? It’s been proven to work, it’s supported by lots of good research, more and more doctors are using it, and insurance companies even pay for it.”
It’s time the acupuncture myth was punctured – preferably with an acupuncture needle. Almost everything you’ve heard about acupuncture is wrong.
To start with, this ancient Chinese treatment is not so ancient and may not even be Chinese! From studying the earliest documents, Chinese scholar Paul Unschuld suspects the idea may have originated with the Greek Hippocrates of Cos and later spread to China. There’s certainly no evidence that it’s 3000 years old. The earliest Chinese medical texts, from the 3rd century BC, don’t mention it. The earliest reference to “needling” is from 90 BC, but it refers to bloodletting and lancing abscesses with large needles or lancets. There is nothing in those documents to suggest anything like today’s acupuncture. We have the archaeological evidence of needles from that era – they are large; the technology for manufacturing thin steel needles appropriate for acupuncture didn’t exist until 400 years ago.
