Last post I mentioned how a placebo - dummy or fake therapy, literally meaning “i will please” - can be used in trials of new therapies to help distinguish the effect of the studied treatment from that of “no treatment”. While placebo “controls” are the standard of good research, every scientist knows that even the suggestion of “being under treatment” has a certain effect. In fact, the statisticians that analyze data from various studies have to take into account the fact that placebo's have a certain expected beneficial effect, when they dive into the results. The “placebo effect” is way bigger than you'd guess – 35 to 75% of patients taking a placebo in trials of certain new therapies, report benefits. “But wait” you say, “I'm no sucker, that won’t work on me.” You'd be wrong.

For example, just being told by a trusted provider that a couple aspirins and some heat will help your achy shoulder, is often all it takes.....even if the problem causing your shoulder pain is not something which, with further study, would generally respond to either aspirin or heat. So what gives? The placebo effect. I want to get better, I want something cheap and easy, and guess what, I'm likely to get better regardless of therapy anyhow.

Healers have been taking advantage of the placebo effect for centuries. Sometimes out of rank ignorance, sometimes honestly and knowingly, and too-often fraudulently. If a provider, in their professional opinion, decides that a likely diagnosis has a decent chance of responding to a therapy that is inexpensive and safe but of unproven benefit, I have no problem with the endorsement of such a strategy – even downplaying the placebo part of the equation, but always being upfront about the likelihood of success. What should greatly bother us, from both an ethical and fiscal standpoint, would be the knowing recommendation and delivery of a treatment which has been shown to not have any benefit greater than placebo. Worse yet is the endorsement of such a therapy when another equally or more beneficial and less expensive or less dangerous one, exists.

But surely this does not happen in this day and age? Only every day. It happens in the allopathic doctors office who does not follow well-established evidenced-based protocols or misleads patients as to expected benefits of a drug or surgery. It is an epidemic in the chiropractic profession. Did you know that outside of the treatment of low back pain, there has never been any demonstrated benefit in large and well-designed clinical trials to chiropractic therapy? And even the evidence for it in low back pain is underwhelming, with no advantage over physical therapy, and only “marginal” benefit vs. a back pain. (See educational booklet: www.nejm.org/) Furthermore, chiropractic is not for neck injuries, not for arthritis, and certainly not for hypertension and diabetes and colitis and the litany of complaints that some providers advertise success with. And then we have homeopathy, naturopathy, reflexology and a huge array of “complementary and alternative”, so called CAM treatment approaches. Don't let me forget “medical” marijuana. I am NOT saying that there is NO role for these modalities – but if solid scientific evidence is your basis for choosing a therapy, there are vanishingly few well-designed studies of these techniques. A few notable exceptions are out there: cranberry extract has finally been shown to have some benefit in the prevention of bladder infections, and while inferior to other available therapies, ginko has shown some benefit for circulation problems. So yes, there are some “alternative' treatments out there which have at least some evidence of effectiveness and which rival conventional therapy. In fact, these agents are often prescribed by allopaths too – we have nothing against remedies that have a “natural” or “plant” origin, and have prescribed them for generations – but allopaths, as mentioned in my last post, want to see evidence of effectiveness before prescribing.

The “complementary” part of the CAM title is hugely offensive to many providers – because it implies a degree of cooperation and synergy with traditional medicine which does not exist. It is a crafty marketing strategy, and a reach for legitimacy which, if you believe in science, is shameful. Yes, many CAM providers – and I'll include chiropractors in this category – can provide you with “evidence”. But do a little homework and you will quickly find that the data is tenuous. Often it is industry sponsored, small in numbers of patients tested, and questionable in the endpoints selected and the statistical strength of conclusions. The allopathic literature is plagued by this junk science, too, but is better at rooting it out. Only rarely will you find the large, placebo-controlled, blinded type of optimal study that I referenced in my last post. Far too often it is simply pseudo-scientific fraud. See: www.quackwatch.org/

I am not saying that there is no role for CAM. And really, I don't much care how you spend your money. But if we are talking about shared costs – i.e. insurance premiums which are based, to a degree, on prior year outlays, and Medicare, which is taxpayer funded – then I have a problem asking the public to support the non-evidence based treatment preferences of others. I'd say the same for allopathic providers – they should not be reimbursed for therapies that are proven to be ineffective – and there is in fact a small army of regulators out there tracking down those that do.

So, do your homework. Ask you doctor, your chiropractor, your naturopath some hard questions. What is the data that this therapy will be effective for me? How good IS that data? What are my alternatives? What is the risk of treatment vs the risk of just waiting this out? Be very suspicious if you are not treated respectfully and professionally to these inquiries. Be particularly skeptical of remedies that are actually sold by the provider (this is illegal for MD's but commonplace in naturopathic practices, for example). And finally, be wary if multiple repeat short-interval treatment visits are part of the program.

Stan Seagraves M.D., an internist who has practiced in Missoula for over 20 years. He is currently practicing hospital medicine at St. Patrick Hospital, and is medical director of their hospitalist program..

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