Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Have a Slow, Quiet Friday the Thirteenth

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

 

Superstitious appears to be common among medical people, so this may be seen as offensive. If you doubt me, comment that it is slow or quiet and see how many respond negatively, while they do not receive any criticism for their superstition-based complaints. Rather, people will make excuses for coddling the superstitions of those who are entrusted with the lives of patients.

The evidence does not support their superstitions.

One study did appear to show that women die in motor vehicle collisions more often on Friday the 13th, but that appears to be due to a lack of understanding of statistics by many who cite the article.
 

An additional factor is anxiolytic medication, used by significantly more women than men in Finland (7), which has been reported to reduce attention span and worsen driving performance (8). . . . Why this phenomenon exists in women but not in men remains unknown, but perhaps the twice-as-high prevalence of neurotic disorders and anxiety symptoms in women (7) makes them more susceptible to superstition and worsening of driving performance.[1]

 

The author suspects that those people with conditions that could be diagnosed as neuroses or anxiety disorders may be disproportionately affected by superstition.

In other words, superstition is not an external force affecting you. You are doing it to yourself.

The sample size was national, but still small, and was not able to adjust for many possible confounding variables, so the study would need to be replicated using a much larger data base to be useful.

In other superstition news – the next apocalypse, in a long line of predicted apocalypses, is going to be this Sunday – the 15 of October, 2017, according to David Meade. Meade twice previously predicted that a magical planet would hit the Earth and kill us all. This time he claims that his calculations are accurate, because that was the problem with his previous calculations – inaccuracy, not that they were a superstition deserving of derision.

If you are superstitious, and feel that your neuroses/anxieties will cause you to harm others, or yourself, you may want to stay home today and Sunday – perhaps even until you are capable of grasping reality.

Of course, we would never base treatment on superstition in medicine.

Amiodarone is the go to antiarrhythmic drug for cardiac arrest and ventricular tachycardia, but there are much safer much more effective drugs available. We have our own prophets misrepresenting research results to make it seem that using amiodarone for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[2],[3]

Ventilation during cardiac arrest has been shown to be a good idea only for patients who arrested for respiratory reasons. We do a great job of identifying these patients. We have our own prophets misrepresenting research results to make it seem that providing ventilations for these is a good idea. The research says these preachers are wrong. The next guidelines will probably promote the superstition and reject the science.[4]

Medicine is full of superstition and superstitious people.

Why?

Too many of us believe the lie that, I’ve seen it work.

I have also written about the superstition of Friday the 13th here –

Acute coronary syndrome on Friday the 13th: a case for re-organising services? – Fri, 13 Jan 2017

The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

T G I Friday the 13th – Fri, 13 Nov 2009

Happy Equinox! – Thu, 20 Mar 2008

Footnotes:

[1] Traffic deaths and superstition on Friday the 13th.
Näyhä S.
Am J Psychiatry. 2002 Dec;159(12):2110-1.
PMID: 12450968

Free Full Text from Am J Psychiatry.

[2] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

There are a dozen links to the research in the footnotes to that article. There are also links to other articles on the failure of amiodarone to live up to its hype.

[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[4] Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence
Fri, 09 Dec 2011
Rogue Medic
Article

.

The Medical Journal of Australia is Scammed by Acupuncturists

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

Acupuncture has been thoroughly studied in high quality studies. The result is that we know, yes we know, that acupuncture is just an elaborate placebo – a scam. A reputable journal is claiming that low quality evidence contradicts what we know and we should ignore the high quality evidence.[1]

So why did the Medical Journal of Australia fall for this? Are their reviewers incompetent, dishonest, or is there some other reason for misleading their readers with bad research?

What is acupuncture?

You stick special needles into magic qi spots on the patient’s body, in order to affect the body’s magic energy. Not mitochondrial energy. Not any real measurable energy, but some psychic powers, some Stephen King kind of energy.

Any competent/honest researcher would compare acupuncture with a valid placebo. What is a valid placebo? A valid placebo is one that the patient believes is the treatment being studied. If the treatment comes in a pill, you provide a pill that is indistinguishable from the pill, but without the active ingredient. If the treatment is to jab you with needles, you provide an experience that is indistinguishable from the needles, but without influencing any mechanism of action the proponents claim makes the needles work.
 


 

How do we get people to believe they are being stabbed with needles in magic qi spots, without actually stabbing them with needles in magic qi spots? Use toothpicks at spots that acupuncture specialists specify are definitely not magic qi spots.

Every study of acupuncture that has used a valid placebo has failed to show benefit over placebo.[2],[3],[4],[5],[6],[7],[8]

Does this study use a valid placebo?

No. This study uses jargon and misdirection to distract us from the only important part of this study.

This study is just propaganda.

It doesn’t matter where you put the needles.

It doesn’t matter if you use needles.

All that matters is that you believe in voodoo.

We already knew that acupuncture is merely fancy voodoo, with the needles going into the patient, rather than the doll. These researchers want us to ignore the high quality evidence and pretend that the man behind the curtain is as great and powerful as he initially claims to be.

Footnotes:

[1] Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial
Marc M Cohen, De Villiers Smit, Nick Andrianopoulos, Michael Ben-Meir, David McD Taylor, Shefton J Parker, Chalie C Xue and Peter A Cameron
Med J Aust 2017; 206 (11): 494-499. || doi: 10.5694/mja16.00771
Abstract from MJA

Free Full Text in PDF format from MJA

[2] A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
Arch Intern Med. 2009 May 11;169(9):858-66. doi: 10.1001/archinternmed.2009.65.
PMID: 19433697

Free Full Text from PubMed Central

[3] Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
Clin J Pain. 2008 Mar-Apr;24(3):211-8.
PMID: 18287826 [PubMed – indexed for MEDLINE]

[4] Sham device v inert pill: randomised controlled trial of two placebo treatments.
Kaptchuk TJ, Stason WB, Davis RB, Legedza AR, Schnyer RN, Kerr CE, Stone DA, Nam BH, Kirsch I, Goldman RH.
BMJ. 2006 Feb 18;332(7538):391-7. Epub 2006 Feb 1.
PMID: 16452103 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] Another acupuncture study misinterpreted
Science Blogs – Respectful Insolence
Orac
May 13, 2009
Article

[6] Acupuncture in the ED
Steven Novella
Neurologica
Article

[7] Emergency acupuncture! (2017 edition)
Science Blogs – Respectful Insolence
Orac
June 20, 2017
Article

[8] On the pointlessness of acupuncture in the emergency room…or anywhere else
David Gorski
Science-Based Medicine
July 25, 2016
Article

.

The Irony of being listed on BadBusiness dot org


 

Late entry 15:12 4-20-2017 – Badbusiness dot org does not appear to be a valid site for criticism of legitimate business problems.

Badbusiness dot org is a site that appears to be set up with the same goal as my blog, so it is ironic that their most recent article is about my blog (roguemedic.com). On their front page, they do state –
 

Please note that (badbusiness dot org) does not guarantee the authenticity or verifiability of complaints posted by its users.[1]

 

The person/people/business writing about me should be the focus of badbusiness dot org. The person/people/business behind the article appears to have three complaints. I will address the second complaint first, then the third, since these second complaint appears to be the reason for concluding the first.
 

This character will defame pharmaceutical companies online with no evidence or proof.[2]

 

The first irony of this complaint is that it is on a site set up to criticize bad business, but it is a complaint that I am criticizing bad business by someone defending the bad business of some pharmaceutical companies.

I am very critical of those who endanger patients with inadequately tested medications and/or with medications that have evidence of producing more harm than benefit.

The second irony is that I am accused of not providing evidence. I provide evidence. My critics provide excuses. The people, and companies, I criticize are the ones who do not provide evidence. If they did provide valid evidence, I would write about someone else.

Do you want to be a guinea pig for people who do not care enough to provide treatment that is safe? Do you want to be a guinea pig for people who do not care enough to provide treatment that works? Do you want snake oil?

I have been threatened with a law suit from SWAT Fuel, Inc. for writing that their product appears to be just another health food scam. I responded by challenging SWAT Fuel, Inc. to sue me and let the evidence speak in court. I provided links to evidence.[3],[4]

I have not heard anything in the six months since I responded. Apparently, SWAT Fuel, Inc. recognizes that the evidence supports my criticism. Maybe the lawyers for SWAT Fuel, Inc. probably were awaiting the final outcome of the Tobinick lawsuit.

The Tobinick lawsuit? I have criticized Dr. Edward Tobinick for doing the same thing SWAT Fuel does, only with a medical license. Dr. Tobinick is a doctor, but he is making claims that are not supported by valid evidence. Dr. Tobinick sued Dr. Steven Novella, Yale University, and Science-Based Medicine to stop valid criticism of Dr. Tobinick’s magical treatment.[5],[6],[7]

Dr. Tobinick appealed the decision against him, but his case was so bad, he was ordered to pay a significant part of Dr. Novella’s legal expenses.[8]

An apparent minion of Dr. Tobinick has accused me of many things, including being a terrorist for my criticism of Dr. Tobinick.[9],[10]

I also criticize acupuncture, homeopathy, Reiki, faith healing, and other alternative medicine for a lack of evidence of safety and a lack of evidence of benefit.

I provide evidence. My critics provide excuses.
 

The third complaint is that I aim to frighten, intimidate, and cause emotional distress to those who harm patients.

Based on what they claim, the goal of badbusiness dot org appears to be the same as mine –
 

Bad business postings are reports from your average consumers (our users) who are fed up with corporate bullies, and with overall BS. If it’s bad business, people oughta know.[11]

Why is badbusiness dot org posting a complaint by someone defending the bad business of some pharmaceutical companies whining about valid criticism?
 

What was the primary point from this defender of the bad business of some pharmaceutical companies?

1. I am accused of being an assholethe biggest asshole.

Gosh. Last month I was a terrorist, but now I am only an asshole. I never expected to please everyone, but I have aggressively criticized bad patient care and bad business. Our patients are more important than my reputation.

If that makes me an asshole, then I would rather be an asshole than defend bad patient care and/or defend bad business.

Why is badbusiness dot org providing a forum for companies upset by valid criticism?

PS – I attempted to comment, and post a link to this response, on the site. I received the following reply.
 

Your comment has been blocked because the blog owner has set their spam filter to not allow comments from users behind proxies.

If you are a regular commenter or you feel that your comment should not have been blocked, please contact the blog owner and ask them to modify this setting.

 

If resolving conflicts is part of their goal, preventing communication does not seem to be a reasonable approach.

Footnotes:

[1] Badbusiness dot org
homepage

[2] Timothy Noonan of RogueMedic.com is bad business
badbusiness dot org
By admin
March 24th, 2017
Article

[3] How to scam the police – SWAT Fuel
Thu, 26 Jul 2012
Rogue Medic
Article

[4] SWAT Fuel – Suing Me to Defend Their Scam
Thu, 06 Oct 2016
Rogue Medic
Article

[5] Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Thu, 24 Jul 2014
Rogue Medic
Article

[6] Tobinick Lawsuit Update – Justice Has Prevailed
Science-Based Medicine
sbmadmin
October 6, 2015
Article

[7] Tobinick v. Novella
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF FLORIDA
CASE NO. 9:14-CV-80781-ROSENBERG/BRANNON
Decision

[8] Edward Tobinick et al. v. Steven Novella et al.
Case number 15-14889
U.S. Court of Appeals for the Eleventh Circuit
Decision

[9] When Minions Attack
Sun, 26 Feb 2017
Rogue Medic
Article

[10] The Boy Who Cried Terrorist
Wed, 01 Mar 2017
Rogue Medic
Article

[11] Badbusiness dot org
homepage

.

The Boy Who Cried Terrorist

 
This is the latest comment from Frederick Blum in response to what I wrote about his absurd defense of Dr. Tobinick.[1].[2] As you can see, in labeling appropriate respect for patients as terrorism, Frederick Blum completely lacks perspective.
 

I think a more apt description of what you are is ” Rogue Terrorist ” . Forget ” Rogue Medic. ” It’s not really you. Think about it.[3]

 

Think like Frederick Blum?

That might be torture.

If you honestly think that I am a terrorist, turn me in.

Go ahead.

It may be even worse to not turn in a terrorist, than to treat patients with inadequately tested medications.
 

If you see something, say something 1
 

“War is peace. Freedom is slavery. Ignorance is strength.”[4]

 

What do terrorists do?
 

You hide behind a cowardly mask exactly as terrorists do.[3]

 

Cowardly?

I have allowed Frederick Blum a forum to make baseless accusations.

I have responded with evidence.

I have not made threats.

Frederick Blum calls this cowardly?
 

You fabricate lies about people and assault them with ad hominem attacks, also exactly as terrorists do.[3]

 

Frederick Blum, provide some sort of evidence to support your imaginative accusations.

I have stated that Dr. Tobinick has failed to produce valid evidence of safety.

Do you have any evidence to show that this is not completely true?

I have stated that Dr. Tobinick has failed to produce valid evidence of efficacy.

Do you have any evidence to show that this is not completely true?

I have not lied.

I have criticized Dr. Tobinick for a failure to provide evidence of safety and efficacy. Using safe and effective treatments is an important part of what separates ethical medical practice from alternative medicine.

If people conclude that Dr. Tobinick is unethical because of what I have written, that is only reasonable.

Neither of you have provided even an iota to suggest any other conclusion.

By the way, have terrorists switched from killing people to using honest criticism? I wish it were so.
 

Really, you’re just another unremarkable terrorist.[3]

 

Is your unremarkable remark intentionally ironic?
 

You should change your anonymous cowardly handle to ” Rogue Terrorist. ” At least in doing so you would be honest about yourself.[1]

 

Without valid evidence of safety, we must conclude that Dr. Tobinick cannot honestly demonstrate safety.

Without valid evidence of benefit, we must conclude that Dr. Tobinick cannot honestly demonstrate any benefit.

If Dr. Tobinick’s treatment is safe and effective, why hide the evidence?

Footnotes:

[1] Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Thu, 24 Jul 2014
Rogue Medic
Article

[2] When Minions Attack
Sun, 26 Feb 2017
Rogue Medic
Article

[3] The comment where Blum cried Terrorist
comment on Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Frederick Blum
Comment

[4] 1984
George Orwell
Free Full Text from The University of Adelaide Library

.

When Minions Attack

Minion vampire 1a
Image credit.
 

In the comments to Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish,[1] Frederick Blum (sometimes Frederick S. Blum) states that he does not like my criticism of Dr. Edward Tobinick for using inadequately tested treatment, on patients.
 

The fact that you’ve censored my comments speaks volumes about the kind of person you are, ” Rogue Medic.”[2]

 

I have not censored Frederick Blum’s comments. All comments are moderated. Not all spam is caught by the spam filter.

Since Frederick Blum’s earlier, similarly absurd, comment was approved and appeared in the comments hours before this comment, what leads Frederick Blum to conclude that this is censorship?
 

What are you afraid of being found out for, that you’re no more than a charlatan ?[2]

 

You chose to use the word charlatan. Since the topic is Dr. Tobinick, is this use of charlatan a Freudian slip?
 

Frederick Blum also obsesses about my use of a pseudonym, although I provide links to valid evidence and Frederick Blum only makes excuses to distract from the absence of valid evidence for Dr. Tobinick’s treatment.

Frederick Blum complains that it is wrong to criticize Dr. Tobinick for his failure to post valid evidence, since Dr. Tobinick uses his real name.

Is valid evidence less valid when I use a pseudonym?

No.

This gullibility is one of the primary reasons scams are so successful.

Bernie Madoff, perhaps the biggest thief of all time, had people, like Frederick Blum, defending his business. A lot of people trusted that con man for the same reason.

What was Bernie Madoff’s motto?
 

Also to his advantage, Madoff was adept at both selfpromotion and client relations. His corporate slogan, “The Owner’s Name Is on the Door,” would reinforce his managerial image, as well as provide his growing list of wealthy clients with a reassuring declaration—a personal acknowledgement of his fiduciary responsibility to them.[3]

 

Is Dr. Tobinick a medical, and much more dangerous, version of Bernie Madoff? Is Dr. Tobinick’s name on the door just a confidence gimmick?
 

You can’t hide the truth about yourself forever. Eventually it is seen for what it really is – the truth.[2]

 

We would be able to determine the truth about Dr. Tobinick, if Dr. Tobinick would adequately test his treatment.

Is the treatment safe, as Dr. Tobinick uses it?

Is the treatment better than a placebo, as Dr. Tobinick uses it?

Is the treatment as good as any adequately tested treatments, as Dr. Tobinick uses it?

The only suppression of the truth is from Dr. Tobinick and his worshipers, such as Frederick Blum.

What is the treatment?
 

The list of conditions for which Tobinick claims or even has patented use of Enbrel include Alzheimer’s, stroke, traumatic brain injury, Parkinson’s disease, carpal tunnel syndrome, brain tumor, spinal cord injury, and back pain. That quite impressive for a doctor who isn’t even a neurologist. Tobinick is an internist who, prior to curing a long list of neurological diseases, specialized in laser hair removal.[4]

 

Why doesn’t everyone go to a laser hair removal specialist for inadequately tested treatments?

I am sure that the FDA and the insurance companies are being unreasonable in wanting evidence of safety and efficacy.
 

And, the truth is that you have devised a falsified and libelous campaign against someone who is not only innocent but a truly great medical scientist with a proven honest intelligence that surpasses almost everybody else in medicine today, Dr. Edward Tobinick, only to further your own loathsome self serving agenda.[2]

A proven honest intelligence? Where did you come up with that nonsense? If an intelligent person uses a dangerous treatment, the treatment is still dangerous.

Go ahead. I dare you, Frederick Blum. Stop making excuses and provide evidence to back up your unsupportable claims.

Footnotes:

[1] Dr. Edward Tobinick Sues Barbara Streisand – or something equally foolish
Thu, 24 Jul 2014
Rogue Medic
Article

[2] Censorship comment by Frederick Blum
comment

[3] Catastrophe: The Story of Bernard L. Madoff, the Man Who Swindled the World
Deborah Strober & Gerald Strober
Kindle Locations 1077-1079
Phoenix Books, Inc.

From the website of Bernie Madoff – http://www.madoff.com on December 15, 2008. In Appendix A (Kindle Locations 2760-2765)
 

The Owner’s Name is on the Door

In an era of faceless organizations owned by other equally faceless organizations, Bernard L. Madoff Investment Securities LLC harks back to an earlier era in the financial world: The owner’s name is on the door. Clients know that Bernard Madoff has a personal interest in maintaining the unblemished record of value, fair-dealing, and high ethical standards that has always been the firm’s hallmark.

 

[4] Enbrel for Stroke and Alzheimer’s
Science-Based Medicine
Steven Novella
May 8, 2013
Article

.

I helped a Naturopath kill my son, because I believe in Quackery

tamara-ryan-lovett1

 
Would you kill this kid?

Like clapping for Tinkerbell, killing children for superstition is part of keeping reality at bay.

Am I too harsh?

7 year old Ryan Lovett died of strep, meningitis, and pneumonia. His slow death, over 10 days, is reported to have been extremely painful. His death was also preventable with real medicine, so I am not even remotely harsh.

Ryan Lovett’s mother is a true believer in magic. Defending her irrational beliefs means avoiding everything that has valid evidence of benefit. Oddly, she did call 911, after her son started seizing. Ryan Lovett could not be resuscitated by EMS.

Ryan Lovett’s mother took him to a Naturopathic clinic for an echinacea mixture. Meanwhile, her neighbor, not trained in the deadly art of Naturopathy, was trying to convince Ryan Lovett’s mother to take Ryan to a real hospital.
 

La Pointe (Barbara La Pointe, a former friend of Lovett’s who used to take Ryan to her home on weekends) testified she visited Ryan and his mother the day before he died. She described Ryan as being “in a state of supreme suffering” and offered to take the mother and son to a hospital or doctor, but Lovett refused.[1]

 

Naturopaths claim that they will tell patients to go to a real doctor if the patient has a serious illness, which requires real medicine, not the usual self-limiting illness that patients recover from in spite of the Naturopath’s prescriptions.

Ryan Lovett will tell you that doesn’t work. No, Ryan Lovett can’t tell you, because nobody at Naturopathic clinic did what Naturopaths claim their extensive training in quackery prepares them to do – send the patient to a real doctor.

The neighbor was much smarter than everyone at the Naturopathic clinic, since she does not appear to have been indoctrinated in the death before medicine quackery of Naturopathy.
 

Ryan did not have a birth certificate and had never seen a doctor because his mother “did not believe in conventional medicine,”[1]

 

Evil conventional medicine? Pediatricians use evidence based medicine on their own kids and on themselves. They will even give you copies of research articles that show that their treatments do work. Medicine works even when the manufacturer is not able to influence the results of the research.
 


 

“The court specifically found that Tamara Lovett actually knew how sick he was and simply refused to do something and therefore gambled with his life,” he (Prosecutor Jonathan Hak) told reporters.[1]

 

That is a misunderstanding of medicine and gambling. Medicine is probabilistic. No treatment is 100% successful, so it depends on being prescribed for the right condition, in the right dose, having the fewest side effects, or having side effects that are least likely to make the patient worse, . . . , in order to make it more likely that the patient has a good outcome. That is gambling (putting the odds in the favor of the patient). Medical education is what helps the doctor, PA, NP, nurse, paramedic, EMT to assess the patient in a way that identifies the actual medical condition, to understand the risks and benefits of the available treatments, and to decide what is best for that individual patient.

Evidence-based medical education is better at putting the odds in favor of a good outcome than anything else.

Ryan Lovett’s mother wasn’t gambling, she was praying that her superstition had real magic powers. Maybe Ryan Lovett’s mother was praying that Ryan had a self-limiting illness, which would get better as long as the Naturopathic chemicals did not poison Ryan. Why take Ryan to the Naturopathic clinic at all, if the Naturopathic clinic just sells chemicals that are merely supposed to distract people and make the Naturopath money?
 

Doctors testified the infection would have been treatable had the boy, who also had meningitis and pneumonia, been taken to a doctor and given antibiotics.[1]

 

But this is just one rare case, so it is not fair to criticize Naturopaths for scamming the gullible. The Quack didn’t know the kid would die.
 

Canadians across the country have kept a close eye on the case. It is one of several in southern Alberta involving parents who were charged criminally after their children died of conditions that could have been treated with conventional medicine.[1]

 

Some people just can’t deal with reality.

Reality will eventually kill us, regardless of what we do. In the mean time, we can increase the odds of living a long healthy life by avoiding unnecessary treatment and limiting the treatments we do use to stuff that has valid evidence that it really works.

Footnotes:

[1] Tamara Lovett found guilty of negligence, failure to provide necessaries of life in death of 7-year-old son
By Meghan Grant, Drew Anderson,
CBC News
Posted: Jan 23, 2017 5:00 AM MT
Last Updated: Jan 23, 2017 5:33 PM MT
Article

.

Acupuncture vs intravenous morphine in the management of acute pain in the ED

ResearchBlogging.org
 

What does elaborate placebo mean?

An elaborate placebo is a placebo that does better than a pill, or injection, apparently because the patient has more invested in the belief the placebo will work. An injection of a placebo (saline solution) may be more effective than a pill of real pain medicine because of the ceremony involved in giving the placebo through IV (IntraVenous) access. A placebo that is more expensive tends to have more of an effect than a less expensive placebo.[1],[2]

Acupuncture requires a lot of investment on the part of the patient. A more elaborate placebo might be fire walking. I don’t know of any research on fire walking as a treatment for pain, but I would not be surprised if it is extremely effective.
 

fire walking 1
Image credit. Do not try at home.
 

We know that acupuncture is just a placebo because research shows that sham (fake/placebo) acupuncture works just as well as real acupuncture. Sham acupuncture generally means using toothpicks (rather than needles), not penetrating the skin, but always using locations that are not qi points.[3],[4],[5]

If the essence of acupuncture is the magic of the qi points, but the same effect is produced when staying away from the qi points, the qi points aren’t doing anything.

This study did not use a sham acupuncture group. We have no reason to expect real acupuncture to provide more pain relief than sham acupuncture, so how should we use this information?

Should we have people providing fake acupuncture in the ED (Emergency Department)?

If so, how should we do this?

Since it is not the acupuncture, but the patient’s reaction to the ceremony of the placebo that appears to be providing the pain relief, how many different ways might we vary the treatment to improve the placebo effect?

Should we set up a fire walking pit?

What are the ethical concerns of using placebo medicine, when the placebo appears to provide similar, but safer, relief than real medicine?

What are the ethical concerns of using deception to treat patients?
 

Acupuncture versus intravenous morphine in the management of acute pain in the emergency department 1 with caption
 

Overall, 89 patients (29.3%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group; the difference was signi ficant between the 2 groups (Table 3). The most frequent adverse effect was dizziness in the morphine group (42%) and needle breakage in the acupuncture group (2%). No major adverse effect was recorded during the study protocol. (See Table 4.)[6]

 

If we ignore the problems with this study and with the problem of lying to patients to make them feel better, can we expect research journals to look more like alternative medicine magazines with article titles like –

How to lie to patients, so that . . . .

What is the best scam to relieve pain?

How much integrity do we sacrifice?

Since the ED does not appear to be the source of the increase in opioid addiction, should we sacrifice any integrity in pursuit of placebo treatments?

We have an epidemic of opioid addiction because of excessive prescriptions for long-term pain.

The answer is not to try to create an epidemic of magical thinking.
 

This paper was also covered by –

Emergency Medicine Literature of Note

NEJM Journal Watch Emergency Medicine

Life in the Fast Lane

Science-Based Medicine

And thank you to Dr. Ryan Radecki of Emergency Medicine Literature of Note for providing me with a copy of the paper.

Footnotes:

[1] Placebo effect of medication cost in Parkinson disease: a randomized double-blind study.
Espay AJ, Norris MM, Eliassen JC, Dwivedi A, Smith MS, Banks C, Allendorfer JB, Lang AE, Fleck DE, Linke MJ, Szaflarski JP.
Neurology. 2015 Feb 24;84(8):794-802. doi: 10.1212/WNL.0000000000001282. Epub 2015 Jan 28.
PMID: 25632091

Free Full Text from PubMed Central

[2] Commercial features of placebo and therapeutic efficacy.
Waber RL, Shiv B, Carmon Z, Ariely D.
JAMA. 2008 Mar 5;299(9):1016-7. doi: 10.1001/jama.299.9.1016. No abstract available.
PMID: 18319411

Free Full Text in PDF format from Duke.edu

[3] Acupuncture for Menopausal Hot Flashes: A Randomized Trial.
Ee C, Xue C, Chondros P, Myers SP, French SD, Teede H, Pirotta M.
Ann Intern Med. 2016 Feb 2;164(3):146-54. doi: 10.7326/M15-1380. Epub 2016 Jan 19.
PMID: 26784863

Free Full Text in PDF format from carolinashealthcare.org

[4] A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.
Arch Intern Med. 2009 May 11;169(9):858-66. doi: 10.1001/archinternmed.2009.65.
PMID: 19433697

Free Full Text from PubMed Central

[5] Acupuncture for treatment of persistent arm pain due to repetitive use: a randomized controlled clinical trial.
Goldman RH, Stason WB, Park SK, Kim R, Schnyer RN, Davis RB, Legedza AT, Kaptchuk TJ.
Clin J Pain. 2008 Mar-Apr;24(3):211-8.
PMID: 18287826 [PubMed – indexed for MEDLINE]

[6] Acupuncture vs intravenous morphine in the management of acute pain in the ED.
Grissa MH, Baccouche H, Boubaker H, Beltaief K, Bzeouich N, Fredj N, Msolli MA, Boukef R, Bouida W, Nouira S.
Am J Emerg Med. 2016 Jul 20. pii: S0735-6757(16)30422-3. doi: 10.1016/j.ajem.2016.07.028. [Epub ahead of print]
PMID: 27475042

ClinicalTrials.gov page for this study.

Grissa, M., Baccouche, H., Boubaker, H., Beltaief, K., Bzeouich, N., Fredj, N., Msolli, M., Boukef, R., Bouida, W., & Nouira, S. (2016). Acupuncture vs intravenous morphine in the management of acute pain in the ED The American Journal of Emergency Medicine DOI: 10.1016/j.ajem.2016.07.028

Espay, A., Norris, M., Eliassen, J., Dwivedi, A., Smith, M., Banks, C., Allendorfer, J., Lang, A., Fleck, D., Linke, M., & Szaflarski, J. (2015). Placebo effect of medication cost in Parkinson disease: A randomized double-blind study Neurology, 84 (8), 794-802 DOI: 10.1212/WNL.0000000000001282

Waber RL, Shiv B, Carmon Z, Ariely D. (2008). Commercial Features of Placebo and Therapeutic Efficacy JAMA, 299 (9) DOI: 10.1001/jama.299.9.1016

Ee, C., Xue, C., Chondros, P., Myers, S., French, S., Teede, H., & Pirotta, M. (2016). Acupuncture for Menopausal Hot Flashes Annals of Internal Medicine, 164 (3) DOI: 10.7326/M15-1380

Cherkin, D., Sherman, K., Avins, A., Erro, J., Ichikawa, L., Barlow, W., Delaney, K., Hawkes, R., Hamilton, L., Pressman, A., Khalsa, P., & Deyo, R. (2009). A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain Archives of Internal Medicine, 169 (9) DOI: 10.1001/archinternmed.2009.65

Goldman, R., Stason, W., Park, S., Kim, R., Schnyer, R., Davis, R., Legedza, A., & Kaptchuk, T. (2008). Acupuncture for Treatment of Persistent Arm Pain Due to Repetitive Use The Clinical Journal of Pain, 24 (3), 211-218 DOI: 10.1097/AJP.0b013e31815ec20f

.

Natural Alternatives to the EpiPen, Because We Believe in Parachutes

 

The evidence for epinephrine (Adrenaline in Commonwealth countries) in anaphylaxis is not the highest quality available, but that does not mean that the use of epinephrine to treat anaphylaxis is not EBM (Evidence Based Medicine).
 

Evidence Pyramid

Evidence Pyramid


Image credit.
 

The patients are not randomized to placebo vs. epinephrine treatments, but EBM is not limited to placebo studies[1] – unless you believe that the Parachute Study is valid evidence, rather than just satire.[2]

It is entirely appropriate to use logical fallacy for satire, since humor is not expected to be based on valid evidence. It is definitely not appropriate to use logical fallacy as scientific evidence. Logic is essential to science, while logical fallacy and the avoidance of rational analysis are essential to deception.

What does the Parachute study have to do with Natural Alternatives to Epipen?[3] The evidence supporting epinephrine is even weaker than the evidence supporting parachutes, since one of the advantages of parachutes is that their use can be adequately studied without using human subjects. Therefore we actually have excellent evidence that parachutes will deploy as expected (with the obvious error bars that apply to valid science), will slow the descent (again, with the obvious error bars that apply to valid science), et cetera.
 

Even the most dimwitted purveyor of “natural” cures should know that and stay away from “natural” treatments for anaphylaxis, while the smarter snake oil salesmen also know that you can’t afford to mess around with a medical condition that can cause such rapid deterioration from seemingly perfectly health to dead. It’s not good for business.[4]

 

Ignoring the pathetic absence of evidence for alternative medicine, what is the evidence that epinephrine does improve outcomes?

There is an excellent discussion of the evidence in an article available for free at PubMed Central.
 

International guidelines concur that epinephrine (adrenaline) is the medication of first choice in anaphylaxis because it is the only medication that reduces hospitalization and death.[5]

 

There is no reduction of hospitalization and death with Benadryl (diphenhydramine), with any of the steroids, or with any alternative medicine. Go read the full paper.

Also, go read the analysis of the problems in the article advocating the use of Natural Alternatives to Epipen at Respectful Insolence.

Footnotes:

[1] Evidence based medicine: what it is and what it isn’t.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
BMJ. 1996 Jan 13;312(7023):71-2.
PMID: 8555924 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.
 

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

 

Maybe the opponents of Evidence Based Medicine do not understand that using judgment to apply the best evidence to the patient is essential to EBM.

[2] Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20;327(7429):1459-61. Review.
PMID: 14684649 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

The authors searched the literature for parachute research, but eliminated all studies without control groups, which suggests that EBM has some sort of requirement that all research include a control group. That is one of the logical fallacies employed by the authors for humorous intent.
 

We excluded studies that had no control group.

 

Those who cite the parachute study as valid evidence do not seem to understand this sleight of hand. EBM does not exclude studies that have no control group. EBM even includes expert opinion.

[3] Natural Alternatives to Epipen
Gazette Review
Dec 18, 2015
Adam Trent
Cached article

[4] Worst idea ever: “Natural” alternatives to the Epipen
Respectful Insolence
Posted by Orac
December 22, 2015
Article

[5] 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines.
Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A.
World Allergy Organ J. 2015 Oct 28;8(1):32. doi: 10.1186/s40413-015-0080-1. eCollection 2015.
PMID: 26525001

Free Full Text from PubMed Central.

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