Pictured: OHP and HERB picking “evidence-based treatment options”

Do You Believe in Magic?

Do you believe in magic for a back pains fix

How the needles can free her, where ever it pricks

And it’s magic, if the chi is groovy

It makes you feel happy like an old-time movie

I’ll tell you about the magic, and it’ll free your soul

But it’s like trying to tell a CAM ’bout randomized control

If you believe in magic don’t bother to choose

Although subluxation is simply a ruse

Just go and get adjusted on the table

It won’t wipe off the pain no matter how hard you try

Your wallet is empty and you can’t seem to find

How you got there, so just blow your mind

If you believe in magic, come along with me

We’ll CAM until morning paid for by the OHP

And maybe, if the CAM is right

I’ll meet you tomorrow, sort of late at night

And we’ll go dancing, baby, then you’ll see

How the magic’s in the CAM and the CAM’s in me

Yeah, do you believe in magic

Yeah, believe in the magic of a back pains fix

Believe in the magic of CAM

Believe in the magic that can set you free

Oh, talking ’bout magic

Do you believe like I believe… Do you believe in magic

Do you believe like I believe… Do you believe, believer

Do you believe like I believe… Do you believe in magic

The Lovin’ Spoonful. Sort-of.

Maybe not my best lyrics.

More Oregon magic

It continues.

Oregon has a problem with prescription pain pills. Oregon leads the nation in the abuse of such drugs, federal statistics show, with Oregon’s rate of prescription drug abuse 39 percent higher than the national average. Go us.

Why that is, I do not know. As an Infectious Disease doctor I prescribe a narcotic about once a year. There are real problems with the treatment of chronic pain and while I am aware of the issues and the changes over the last 25 years, it does not impact my practice, so my knowledge of the issues is basic.

I am also well aware of the Oregon Health Plan (OHP). The OHP was intended to make health care more available to the working poor, while rationing benefits. They were fairly transparent that resources were fixed and not everything would be covered.

Given limited resources, part of the plan has always included a prioritization of treatments and diagnostics, paying for care that give the most bang for the buck. Not a perfect way to ration care and as is always the case, no good deed goes unpunished.

Another effect of limiting care, according to the Bend Bulletin, may be that:

OHP members who suffer back pain have been left with no choice but to take drugs, and the policy could be contributing to Oregon’s high rate of narcotic abuse

since other interventions to treat back pain are not paid for. Interventions like acupuncture and chiropractic.

New guidelines were recently updated by the Health Evidence Review Board (HERB) and as a result:

The new guidelines open the door to acupuncture, chiropractic, cognitive behavioral therapy, osteopathic manipulation and physical and occupational therapy.

To be picky, the guidelines do not say chiropractic, but “spinal manipulation,” although the codes to be used are those for chiropractic manipulation. And as is so often the case, the title of an organization often does not describe what they actually do. As in the ‘Health Evidence Review’ part. As the local ID expert in my hospital, or for this blog, when I review the evidence, I try to read as much as is possible, not only relying on reviews, but as much of the primary literature as I can. I found that the primary literature is misrepresented by not only reviews, but the authors of the primary literature. This is perhaps particularly true in the SCAM world, as the careful evaluation of a paper will determine.

HERB reviews reviews

As best I can tell, the HERB relied on two reviews, “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline” from the American College of Physicians and the American Pain Society from 2007 and “Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline” from 2007.

That is it. Two reviews, from 2007, from the same journal (from the same issue!). That hardly seems a sufficient basis upon which to make decisions.

The first review notes:

For chronic low back pain, moderately effective nonpharmacologic therapies include acupuncture (114–115)…spinal manipulation (108)

Reference 114 concludes:

For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

And 115:

The quantity and quality of the included trials varied.

CONCLUSIONS: Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.

To add to the mix, the Cochrane review notes:

For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.

Virtually every acupuncture meta-analysis, from the first one in 1980, has some variation of

Various potential sources of bias, including problems with blindness, precluded a conclusive finding although most results apparently favoured acupuncture.

The second reference used by HERB? For acupuncture they state:

For chronic low back pain, both systematic reviews found acupuncture moderately more effective than no treatment or sham treatments for short-term (<6 weeks’ [16] or <3 months’ [17–18] duration) pain relief. Acupuncture was also associated with moderate short-term improvements in functional status compared with no treatment (standardized mean differences, 0.62 [CI, 0.30 to 0.95][16], and 0.63 [CI, 0.19 to 1.08][17–18]), but not compared with sham therapies

As we have noted, if a therapy is no better than sham/placebo

IT DOES NOT WORK.

Sorry.

I yelled.

But sometimes I just get too aggravated by the double standards of SCAM evidence. To continue:

A recent, higher-quality trial not included in the systematic reviews found no differences between acupuncture and sham acupuncture for pain or function (Appendix Table 8) (130).

Evidence of longer-term benefits from acupuncture is mixed. Acupuncture was moderately superior for long-term (>6 weeks’ duration) pain relief compared with sham TENS in 2 trials and compared with no additional treatment in 5 trials, although there were no significant differences compared with sham acupuncture. One higher-quality trial found no differences in pain 1 year after acupuncture therapy compared with provision of a self-care education book (161). A higher-quality trial not included in the systematic reviews found clinically insignificant differences (<5 points on 100-point scales) between acupuncture and no acupuncture for pain and function after 6 months . Another recent, higher-quality trial found acupuncture slightly superior to usual care on Short Form–36 pain scores after 24 months (weighted mean difference, 8 points [CI, 0.7 to 15.3 points]) and for recent use of medications for low back pain (60% vs. 41%), although ODI scores and other outcomes did not differ.

So for acupuncture approval, OHP relied on reviews of meta-analysis, and the primary sources suggest the therapies result in at best short term efficacy, the positive effects likely due to poor methodologies and long term effects that were ‘slightly superior’ or ‘clinically insignificant’.

They evidently did not review the literature to show that acupuncture is a theatrical placebo, has no basis in reality-based medicine and that most positive effects are due to bias in poorly done studies.

…results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies.

Thin gruel indeed to justify the State paying for acupuncture. My tax dollars in action. Or my tax dollars inaction, since they did not do what I would consider due diligence in reviewing the literature.

Same as it ever was.

Chiropractic steps up to the wand

The analysis of chiropractic is equally unimpressive.

Reference 108, a meta-analysis, states:

Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.

CONCLUSIONS:

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

And that chiropractic is no better other therapies:

High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.

The conclusions of the second reference used by HERB are equally tepid about the benefits of chiropractic.

For low back pain of unspecified duration, 1 higher-quality trial (681 patients) found no differences in pain, functional status, or other outcomes between patients randomly assigned to chiropractic versus medical management. The other trial (1334 patients) found spinal manipulation to be slightly superior to usual care for pain and disability (about 5 points on 100-point scales) after 3 months in patients with subacute or chronic low back pain, although effects were not as pronounced after 12 months, and differences on the RDQ did not reach clinical significance (about 1 point). Manipulation and exercise did not significantly differ, and the addition of manipulation to exercise therapy was no better than exercise alone.

Not, as was mentioned in the newspaper, that:

Large, randomized trials have shown that for chronic back pain, acupuncture and chiropractic therapy are equally helpful, said Dr. Richard Deyo, professor of evidence-based medicine at Oregon Health & Science University. He served on a task force that advised the Health Evidence Review Commission. “Different people respond to different things,” he said. “The outcomes tend to be very similar, in the short term at least.”

It is more accurate to say they are equal placebos, doing nothing, since short term improvement is just what one would expect from a placebo that does nothing to the underlying process. I do not think I read the same papers as Dr. Deyo. And if you tend towards the Bayesian approach, it your intervention has no prior plausibility, like acupuncture or chiropractic, then any positive result is likely a false positive.

And should I mention that the deliberate use of placebos are unethical? Naw.

Scraped knees and entomophagy

I will mention in passing that I have long been of the opinion that most SCAMs are the equivalent of kissing a child’s boo-boo or apes grooming each other. Chiropractic and acupuncture are touch-based elaborate treatment rituals and much of their perceived beneficial effects could be from:

mounting evidence that more elaborate treatment rituals trigger larger nonspecific effects. The reasons for this remain unclear. In a pilot field study, we investigated the role of psychophysiological changes during a touch-based healing ritual for improvements in subjective well-being….Subjective well-being increased significantly from before to after the ritual. The analysis of psychophysiological changes revealed a significant increase in respiratory rate from baseline to ritual, while skin conductance, heart rate, and heart rate variability did not change. Increases in [skin conductance levels] as well as decreases in respiratory rate from baseline to ritual were significantly associated with improvements in subjective well-being…. Conclusion. Higher sympathetic arousal during a touch-based healing ritual predicted improvements in subjective well-being.

So the state is going to pay for the metaphorical picking and eating of lice.

And this also ignores the question of the state paying for practitioners of magical pseudo-medicines and all the associated useless interventions and beliefs espoused by chiropractors, naturopaths and traditional Chinese medicine practitioners noted at length on this blog.

It hardly seems like a good use of Oregon’s resources, nor a good approach to chronic back pain. It seems that Ben Goldacre’s aphorism is being ignored: Just because there are flaws in aircraft design that doesn’t mean flying carpets exist.

Oregon chooses flying carpets.

They do suggest a possible benefit:

The expense of a broader range of treatments could be offset by a decline in narcotics use

And I hope they do some epidemiologic studies to show benefit of adding pseudo-medicines to OHP, although I am not so sure the cost is worth the lack of benefit.

Credentialing magic

Being credentialed is a necessary pain. I have to document for my hospitals and some insurance companies that I am trained in my specialty and should be competent to practice medicine. It is a lot of paperwork and it has to be kept up to date. I am, however, credentialed in reality-based medicine.

How do you credential someone in a field that is based in pseudo-medicine, divorced from reality, with a panoply of imaginary diseases treated with equally imaginary therapies? Like naturopathy?

As noted by one author who desperately wants to give his difficult patients to naturopaths:

Unfortunately, a number of serious difficulties can be encountered by internal medicine, family medicine, and pediatric physicians who refer patients to, or attempt to comanage patients with, naturopathic physicians.

And:

Yet because of differentials in paradigm and/or clinical experience, naturopaths commonly order laboratory tests that are either unrecognizable or seem inappropriate to internists.

They don’t seem inappropriate, they are inappropriate, but to be expected from an education and training dominated by nonsense. I have discussed at length why naturopathic training is useless for diagnosis and treatment. It is an old joke, but ND really does mean Not a Doctor.

It does not worry my alma mater, Oregon Health Sciences University, who ignores the whole science part of their title so they can credential naturopaths. How they do it is detailed in “A Framework for Credentialing Naturopathic Physicians in Academic Health Centers: Oregon Health and Science University.”

They state:

To maintain consistency with the rigorous standards applied to all credentialed healthcare professionals at the institution, the requirements include postdoctoral training (clinical or research) in an AHC to establish cultural competence and the completion of one year in a residency approved by the Council on Naturopathic Medical Education or two years of direct clinical practice in a hospital accredited by the Joint Commission or the Centers for Medicare and MedicaidServices to establish clinical competence.

But pay no attention to the content of the education. Being extensively trained in pseudo-medicine does not mean the practitioner should be allowed to take care of patients, especially at a University.

So what good is:

• Successful graduation from a 4-year accredited, post-baccalaureate, training program with designation as a Doctor of Naturopathic Medicine
• Successful completion of one year CNME (Council on Naturopathic Medicine Education) accredited residency or evidence of 2 years direct clinical practice in a Joint Commission or CMS accredited hospital or academic medical center
• Post-Doctoral Training for at least 2 years in an Academic Medical Center
• Successful completion of NPLEX (Naturopathic Physicians Licensing Examinations) with a current license as an Oregon Licensed Naturopathic Physician
• Additional Active Clinical Practice for at least 2 years, immediately preceding the request for clinical privileges at OHSU, documentable via reports of specific activities from the locations of practice

When it is all based in nonsense? Playing doctor does not make you a doctor.

OHSU does have far more requirements than most practicing naturopaths have who pretend they can function as primary care physicians.

Pseudo-medicine. Paid for by the state, approved by the University.

And lest you be smug, I bet the same things are happening in your state.