CAM Under Attack!

At some point, nearly 4 of every 10 American adults use complementary and alternative medicine, or CAM; often to treat various types of acute or chronic pain. Personal, out-of-pocket expenditures for CAM each year add up to roughly $43-billion, even though many CAM therapies have not been scientifically established as beneficial. So, it is somewhat surprising that a recent news report challenges expenditures by the U.S. government to evaluate the safety and effectiveness of those therapies.

Under the headline, “Funding of Alternative Treatments Questioned,” in a recent edition of the Los Angeles Times [January 23, 2012], writer Trine Tsouderos explains, “Some see tax dollar waste in spending by the National Center for Complementary and Alternative Medicine. The NCCAM director, though, sees a need for scientific attention.” Along with that, several examples of allegedly frivolous funding are provided in the article:

• NCCAM awarded a $374,000 grant so scientists could determine that inhaling lemon and lavender scents does not improve wound healing.
  
  
• Another $666,000 in federal research funding established that distant prayer cannot heal AIDS.
  
  
• Americans also paid $406,000 to learn that coffee enemas do not help treat pancreatic cancer.
  
  
• Finally, $1.25 million was devoted to discovering that massage makes people with advanced cancer feel better.

NCCAM [website here] — a small branch of the U.S. National Institutes of Health — was launched in 1998 to study alternative treatments that are used by the public but are not typically accepted by mainstream medicine. The Center has a staff of 65 and its fiscal year 2011 budget was $128-million. According to the news article, NCCAM has spent $1.4 billion since its founding, mostly on research and much of it to fund studies of CAM modalities with “questionable grounding in science.” Some observers have been highly critical of the NCCAM mission:

“Some of these treatments were just distinctly made up out of people's imaginations,” states Wallace Sampson, MD, of Stanford University, in the news report.

David Gorski, MD, PhD, adds “How can we justify wasting money on something like this when there are so many other things that are much more plausible and much more likely to result in real benefit?” Gorsky is a researcher at Wayne State University in Detroit and a frequent critic of NCCAM who blogs at ScienceBasedMedicine.org.

Another highly vocal critic, Steven Novella, MD — a neurologist at Yale School of Medicine who authors the NeuroLogicaBlog — says, “The intellectual dishonesty is just astounding.”

In rebuttal, the director of NCCAM, Josephine Briggs, MD — a respected NIH researcher and physician who has headed the Center for nearly 4 years — says it is worthwhile to use taxpayer dollars to study certain alternative treatments. "They deserve scientific attention," she states, noting that she is dedicated to evidence-based medicine and that the Center is committed to rigorous scientific investigations. Additionally, she observes, the Center's annual budget allotment amounts to less than half a percent of the total NIH budget.

NCCAM’s current focus is on studies of supplements and other natural products, along with the effects of therapies like yoga, massage, and acupuncture on pain and other symptoms. Briggs asserts that studies of energy healing or distant prayer probably would not get further funding from NCCAM; still, the news article notes, treatments like acupuncture and qigong “involve the purported manipulation of a universal energy or life force that is incompatible with scientists' understanding of how the body works.”

Furthermore, Tsouderos claims in the news article, NCCAM's interest in acupuncture continues even after many studies found that it and similar therapies are no better than sham or placebo treatments at easing symptoms like pain and fatigue. In defense of this, Briggs notes the difficulties of designing trials of complex therapies like acupuncture: “It is generally impossible to isolate a single element. A sham control in a mind-and-body study could easily miss answering the most important question of whether the patient experiences benefit.” The most important outcome is if patients report a therapy helped them, even if those in the sham/placebo group also appear to benefit.

According to Steven DeKosky, MD — a neurologist who sits on the NCCAM advisory council and is dean of the University of Virginia medical school — conducting scientific studies to determine whether these treatments work is a valuable service: “I don't know who else would do that other than NCCAM.” DeKosky had received $25 million from NCCAM to help fund a randomized, placebo-controlled study of whether ginkgo biloba protects against dementia and Alzheimer's disease. “He concluded that the popular supplement did not reduce the overall incidence of either condition in elderly people who were normal or already had mild cognitive impairment,” the news article states.

Tsouderos acknowledges that physicians who treat patients with pain welcome any new tools that might be beneficial, especially ones without the side effects of opioids or other pharmacotherapy, and even if that means offering a treatment that might have strong placebo effects. Similarly, Daniel Cherkin, MD, who studies alternative medicine in Seattle and sits on the NCCAM advisory council, says, “We have lots of people out there with a problem that isn't being addressed with conventional approaches. What do we do with those people? To say we shouldn't do these things because it is a placebo denies them something [that is] safe and available and works.”

However, Tsouderos concludes, critics respond that it is wrong to charge people hundreds or thousands of dollars for treatments that amount to nothing more than an elaborate placebo. For example, Stanford’s Sampson states, “It is essentially deluding somebody. In other parts of our social life, it is a crime.”

COMMENTARY: There is probably no more contentious subject in all of healthcare than CAM. Yet, we are reminded of the admonition from English philosopher Herbert Spencer…

“There is a principle which is a bar against all information, which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance — that principle is contempt prior to investigation.”

We have written, both pro and con, about various research studies investigating Complementary and Alternative Medicine modalities in previous Pain-Topics UPDATES [series here]. CAM is multifaceted and NCCAM defines it as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional Western (or allopathic) medicine as practiced by holders of MD or DO degrees and by their allied health professionals, such as physical therapists, psychologists, nurses, and others.

However, the boundaries between CAM and conventional medicine are sometimes blurred. Whereas “complementary medicine” refers to the use of CAM modalities as an adjunct to conventional medicine, "alternative medicine" refers to the use of CAM in place of conventional medicine, according to NCCAM. So-called “integrative (or integrated) medicine” combines both conventional medicine treatments and those CAM therapies for which there is valid evidence of safety and efficacy.

We would disagree with the absolutist viewpoints of the most ardent critics who claim that all CAM therapies are worthless quackery and NCCAM is wasting taxpayer money. True, there are alleged CAM therapies that defy current understandings of scientific plausibility — such as coffee enemas and distant (or intercessory) prayer, considering just the two referenced above — but it also seems appropriate to invest in scientific research rather than relying on educated opinion alone to repudiate the validity of those modalities. And, if not for NCCAM and agencies like it worldwide, where would the necessary funding come from for unbiased and valid clinical research?

Many CAM therapies are hands-on and/or involve very personalized approaches to patient care. The experience, skills, techniques, and even personality of the practitioner can be important but difficult-to-control or measure variables. This may be a critical reason why for some modalities, such as acupuncture, ongoing trials variously demonstrate favorable, unfavorable, and equivocal results compared with sham/placebo [see discussions in UPDATES here]. So, there can be many variables at work, both known and unknown, controlled and uncontrolled in clinical trials; therefore, it seems imprudently premature to broadly renounce the validity of acupuncture and many other CAM approaches as some critics have done.

However, we would agree with critics that a pernicious danger is when either (a) there might be inherent safety concerns with a CAM therapy making it potentially harmful, or (b) patients seek CAM remedies for their maladies before or instead of considering and exploring science-based approaches offered by conventional medicine. This is especially of concern when conventional therapies might be of greatest benefit during early stages of a disorder but less so after a time delay. There also are disreputable promoters of CAM therapies, and it is dismaying when desperate patients exhaust personal finances and emotional capital seeking promised but elusive “cures” that do not exist; however, the same could be said of rogue practitioners of conventional medicine.

When it comes to the more than 100 million adults in America with chronic pain conditions [assessed in an UPDATE here], conventional medicine approaches are ineffective or inadequate for a great many patients. The integration of select CAM and conventional medicine therapies, within the context of a multimodal pain management milieu, offers patients a potent range of options that can be individualized to their needs and personal preferences. The challenge is to understand what CAM therapies work best, for whom, and under what circumstances; for that, more and better research on CAM should be encouraged and supported.

Certainly, much more can be said about this controversial subject, but we will stop here and allow readers to comment below.

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