6. Complementary and Alternative Medicine (2)

Question 1

Theories of the placebo effect

Answer 1

Endogenous opiates, certain stimuli can trigger their release.
– Naloxone-sensitive results? Blockage of their release controls analgesia

Conditioning
– Pavlov’s dog: Bell ringings = salivation of dog. So…. take pill = response.
-Take pill = placebo “drug response”
-Relies on previous response experienced

Expectancy
– Wine and placebo alcohol
– Dopamine and money: reward system
-Doesn’t require a previous response

Motivation
– A more compliant patient?
- For motivational reasons, presenting in a way that is thought to be desired/expected/ compliant

Question 2

Considerations when we test the claims of CAM?

Answer 2

EBM vs Cognition-based medicine.
Homeopathy can be easily testing using EBM as you can change the components of the pill to be taken.
Consideration to be taken as some homeopathies rely on CBM hence a placebo is not a fair control.

Ensure accuracy of scientific rigor: Must test the homeopathic concentration NOT the mother tincture (300 times more conc)

Infallible impact factors: Biased experimenters skew results

Blinding: Problem with acupuncture

Question 3

Role of Emily Rosa in testing CAM claims?

Answer 3

Looked at therapeutic touch to prove that 45% of times it wasn’t valid through experimentation

Question 4

Blinding and acupuncture, how to test sham location?

Answer 4

Variation anyways, could hit meridians by chance

Practitioner blinding

Question 5

Blinding and acupuncture, how to test sham needles?

Answer 5

Patient and practitioner blinding needed

Question 6

Orthodox explanations for acupuncture effect?

Answer 6

Gate control theory of pain
Opioid release
Placebo effect
Expectation effect for osteoarthritis patients

Question 7

Trialing chiropractic?

Answer 7

Is it possible to blind the patient or practitioner?
Placebo manipulations?
– Comparative treatments, e.g. physiotherapy
– Massage often part of chiropractic assessment

For lower back pain “not possible to confirm or refute” the benefits of chiropractic manipulations over alternative/current treatments…
– Painkillers
– Exercise
– Physiotherapy

Question 8

Simon Singh and the British Chiropractic Association

Answer 8

He stated they promotes chiropractic as a treatment despite lack of evidence to support the claim
Was sued then case dropped after 2 years

Question 9

Cochrane Review of Chiropractic interventions for low-back pain

Answer 9

Combined chiropractic interventions show to slightly improve in pain/disability in short term.
No evidence supporting evidence of a clinically meaningful difference for pain vs other interventions

Question 10

Why do people use CAM?

Answer 10

Health promotion / disease prevention
Exhausted conventional options
Conventional options associated with side effects / risks
No conventional therapy available
Conventional approach emotionally / spiritually bereft
Do they know it’s CAM?

Question 11

How do CMA appear effective?

Answer 11

Some MAY ACTUALLY BE effective
-e.g. Herbal remedies could contain active ingredients

For those with NO plausible scientific explanation or inherent efficacy. For example if..

• Disease-associated: Depends on disease nature so CAM taken when disease is already regressing makes you believe that regression is accredited to CAM
• Patient-focussed: intrinsic beliefs and attitudes of patient
• CAM-based

Question 12

Natural impediments to making valid inferences

Answer 12

Placebo effect

Natural history of disease

Causal inferences

Reluctance to admit when wrong – i.e. cognitive dissonance

Simple optimism
– Internal locus of control. “I think I’m healthy so therefore I am”

Respect for authority

Conspiracy-orientated view of the world – c.f. “What Doctors Don’t Tell You”

Question 13

Ethical issues around CAM:

Does it work?
Is it safe?
How to balance patient choice against the first duty of a doctor:

Answer 13

Does it work?
– It it’s nothing more than a placebo, is that a bad thing?
– Do we need to know how a treatment works?

Is it safe?
– Regulation of practitioners / substances
– Direct vs indirect harm

How to balance patient choice against the first duty of a doctor:
– Make the care of your patients your first concern
– Patient autonomy
– Informed choice

Question 14

The placebo effect is _____, and CAM may accentuate many aspects of it

Answer 14

The placebo effect is multifactorial, and CAM may accentuate many aspects of it

Question 15

The efficacy claims of CAM are ________

Answer 15

The efficacy claims of CAM are testable

Question 16

Even if implausible or ineffective, there are many _____ why a patient may view CAM as working for them

Answer 16

Even if implausible or ineffective, there are many reasons why a patient may view CAM as working for them

Question 17

Should CAM provision or research be funded from public funds:
Should it be researched?
A fair allocation of money?
A fair exploration of choice?

Answer 17

Should it be researched?
– Worthwhile finding active ingredient in herbal meds?
– As worthwhile researching homeopathy?

A fair allocation of money?
– Or a diversion of funds from science-based therapies?

A fair exploration of choice?
– Or weakening commitment to the scientific method?
– Undermining or enhancing public trust?

Question 18

To outline and explain five unethical effects that may arise if the NHS funds homeopathy

Answer 18

1. Delayed in accessing conventional and effective treatments
2. Spending NHS fundings on treatment that has no evidence basis. This is an inefficient way of spending limit funds as patients will then have to use resources later if condition doesn’t resolve and will probably have progressed.
3. Patient deception
4. NHS support of homeopathy weakens patient confidence in system due to lack of evidence base. Risk of double standard as there are unproven medical remedies with clinical reasoning behind them
5. Homeopathy distracts patients from other but effective forms of complimentary medicine by generalising the therapy