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Rapid Responses: Rapid Responses published:
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NICE appraisals of specific CAM therapies for specific indications are necessary to promote patient choice and equity of access
- Charlotte Paterson (9 March 2007)
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CAM evaluation by NICE
- Edzard Ernst (9 March 2007)
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And the Loch Ness monster too...
- Bruce G Charlton (10 March 2007)
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Mockery of Evidence Based Medicine
- Sudip Sikdar, Park Road, Waterloo, Liverpool, L22 3XR (11 March 2007)
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Who is qualified to be a CAM expert?
- Michael K McMullen (13 March 2007)
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Saving money
- Jonathan G Bensley (15 March 2007)
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Nobel prize
- Tom Boyles (24 March 2007)
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Honest research
- John M English (30 March 2007)
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evidence-based not fear-based medicine for CM
- Lesley Braun (20 May 2007)
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Charlotte Paterson, Senior Research Fellow Institute of Health & Social Care Research, Peninsula Medical School, Exeter. EX1 2LU
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Dear Editor As so cogently argued by Franck and colleagues(1), excluding complementary and alternative medicine (CAM) from consideration by NICE flies in the face of NHS strategies to reduce health inequalities and increase patient choice. In 1998, there were 22 million visits to complementary therapists in England and 90% of these were purchased privately(2). Colquhoun’s repost, that NICE can’t afford to waste its time evaluating CAM, does not reference either of the recent systematic reviews of the cost effectiveness of CAM(3). Both of these reviews find good evidence for certain therapies in certain conditions, and remind us that NICE would not be evaluating ‘CAM’, any more than it would be evaluating ‘conventional medicine’(4,5). Herman and colleagues’ review of 39 full economic evaluations found that the quality of reporting was comparable to that found by systematic reviews of economic evaluations in conventional medicine. Fourteen exemplary studies indicated that the following CAM therapies may be considered cost- effective compared to usual care for various conditions: acupuncture for people with migraine; manual therapy for people with neck pain; spa therapy for people with Parkinson's disease; self-administered stress management for cancer patients undergoing chemotherapy; pre- and post- operative oral nutritional supplementation for patients undergoing lower gastrointestinal tract surgery; biofeedback for patients with "functional" disorders (eg, irritable bowel syndrome); and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients. Last year, evidence of the cost-effectiveness of acupuncture for chronic low back pain has been added to the list(6). All these interventions are safe and they are popular with patients. Is it relevant to point out that the only thing they don’t do is to transform the NHS budget into pharmaceutical company profits? Dr Charlotte Paterson 1. Franck L, Chantler C, Dixon M. Should NICE evaluate complementary and alternative medicine? BMJ 2007:334:506. 2. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001; 9:2-11. 3. Colquhoun D. Should NICE evaluate complementary and alternative medicine? BMJ 2007:334:507. 4.Canter PH, Coon JT, Ernst E. Cost effectiveness of complementary treatments in the United Kingdom: systematic review. BMJ 2005;331:880-1. 5. Herman PM, Craig BM, Caspi O. Is complementary and alternative medicine (CAM) cost-effective? a systematic review. BMC Complementary and Alternative Medicine 2005;5:11. 6. Wonderling D. Acupuncture in mainstream health care . BMJ 2006;333:611-2 Competing interests: None declared |
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Edzard Ernst, Professor of Complementary Medicine Peninsula Medical School, 25 Victoria Park Road, Exeter, Devon EX2 4NT
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I have argued for years that NICE should evaluate CAM. But I am not as sure as Franck et al (BMJ 10 March 2007) that this would result in a positive verdict. The authors correctly state that there are numerous Cochrane reviews already available. They fail to comment, however, on their results. By far the best evidence exists for herbal remedies. Currently there are 33 Cochrane reviews. Less than a handful of them generate positive conclusions. Franck et al also seem to think that the standard we apply to conventional medicine is effectiveness as “compared with no treatment”. Using this standard, we would almost certainly find that placebo is effective, safe and cheap. Single standard? My foot! Competing interests: None declared |
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Bruce G Charlton, Editor-in-Chief, Medical Hypotheses Newcastle University, UK
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NICE should not only be evaluating complementary and alternative medicines; but also deploying evidence-based methods to tackle such burning questions as the existence of the Loch Ness monster, the theory that astronauts from Mars built the pyramids, and whether Elvis is still alive. In fact, if NICE spent more of their time and resources on this kind of stuff, and left off drugs and procedures, they might do a lot less harm [1]. 1. Charlton BG. The new management of scientific knowledge: a change in direction with profound implications. In: NICE, CHI and the NHS reforms: enabling excellence or imposing control? Edited by A Miles, JR Hampton, B Hurwitz. Aesculapius Medical Press: London, 2000. Pp 13-32. Competing interests: None declared |
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Sudip Sikdar, Consultant Psychogeriatrician Mersey Care NHS Trust, Waterloo Day Hospital, Park Road, Waterloo, Liverpool, L22 3XR
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Dear Editor I read Franck and Colquhoun’s debate on NICE and complementary and alternative therapy (CAM) (1) with great interest. Many mental health trusts are beginning to invest money and manpower in these forms of treatment (primarily because of strong lobbing by some professional groups and also because of the belief that soaring drug costs can thus be minimised) without any concrete evidence of either the cost effectiveness or efficacy of CAM in various mental disorders. Yet trusts and PCTs readily restrict use of cholinesterase inhibitors for dementia. Recently, a proposal was put forward to our trust’s drugs and therapeutics committee to allow use of auricular acupuncture in patients with opioid dependence. The proposer presented “strong evidence” of its effectiveness and nearly persuaded the committee. A Cochrane database search(2) with key words “complementary therapy”, “acupuncture” and “aromatherapy”, the most commonly used forms of CAM in the NHS, revealed 38, 55 and 5 hits respectively. Many of these reviews are on use of various types of CAM on patients with mental illness for example, acupuncture for depression(3), schizophrenia(4), smoking cessation(5), cocaine dependence(6); meditation for anxiety(7) and aromatherapy for dementia(8) etc. The protocol for acupuncture for opioid dependence(9) has been awaiting review for the last 5 years! The conclusions for all but one review suggest that there is no evidence to justify using these treatments in the disorders mentioned above. The aromatherapy review which showed beneficial effect was based on individual patient data from one RCT. Yet, CAM is mushrooming in society in general (Indian and Chinese head massage are now regularly provided in shopping centres and barbers’ shops) and NHS urgently needs NICE to evaluate these forms of treatment before the hypocrisy of using “evidence based medicine (EBM)” only mantra is used to axe another drug treatment in a major illness once again. Colquhoun’s arguments that there is no need for NICE to spend their resources in evaluating a treatment modality that is well known to be ineffective doesn’t hold water when the NHS has declared as its core principle to practice EBM only and uses the same argument to rationalise other forms of treatment. References 1. Franck L, Chantler C, Dixon M and Colquhoun D (2007) Should NICE evaluate complementary and alternative medicine? BMJ, 334, 506-507 2. Cochrane Database of Systematic Reviews 2007 Issue 1 3. Smith CA, Hay PPJ. (2004) Acupuncture for depression. Cochrane Database of Systematic Reviews, Issue 3. 4. Rathbone J, Xia J. (2005) Acupuncture for schizophrenia. Cochrane Database of Systematic Reviews, Issue 4. 5. White AR, Rampes H, Campbell JL. (2006) Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews, Issue 1 6. Gates S, Smith LA, Foxcroft DR. (2006) Auricular acupuncture for cocaine dependence. Cochrane Database of Systematic Reviews, Issue 1. 7. Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M. (2006) Meditation therapy for anxiety disorders. Cochrane Database of Systematic Reviews, Issue 1. 8. Thorgrimsen L, Spector A, Wiles A, Orrell M. Aroma therapy for dementia. Cochrane Database of Systematic Reviews 2003, Issue 3. 9. Ying L, Man Jia Zhu, Fan Rong Liang. Acupuncture for opioid dependence. (Protocol) Cochrane Database of Systematic Reviews 2002, Issue 4. Competing interests: None declared |
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Michael K McMullen, Herbalist Stockholm, Sweden 11600
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Much of the talk around CAM therapies is by "experts" who either have limited clinical experience of the field (and there are between 20 and 200 therapies depending on how much you like subdivisions) or have limited research training. My view is that "experts" should be both clinically experienced and trained researchers! This implies that any individual CAM expert can have authority only in a limited area. Perhaps with government funded research scoholarships for university PhDs (where the scale of research funding REFLECTS community usage of CAM therapies) we might get more answers ie EVIDENCE and less never-ending & meandering "less than expert" opinions and discussions. Competing interests: Herbalist and distributer of herbal and nutritional agents in Sweden. Currently involved in post graduate research at the University of Westminster |
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Jonathan G Bensley, Student Monash University, Victoria, Australia
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I've got a much better idea than wasting money searching for "evidence" on natural therapies. Why not give the money to the urgently needed drugs that NICE has rejected? NICE recommended against Temozolomide and Carmustine implants, despite the low budgetary costs. NICE is also set to recommend against Erlotinib for non-small cell lung cancer, again despite the low budgetary impact. Also recommended against was Fludarabine for CLL, again which would have minimal budgetary impact. And even more amazingly, NICE recommended against Pemetrexed, despite it being the only approved agent for mesothelioma and suggested trying other drugs not approved for the indication. NICE seems lately to be guided by what's trendy and in the media, rather than what's needed. One only need look at the rather rapid approval of Trastuzumab, which will come at a very high cost. If only glioma, NSSLC, CLL and mesothelioma had such great public relations agents working for it... Why not spend the money NICE costs on real medicines, not alternative medicines with practically no evidence for their use. Competing interests: I am a student at Monash University, however the views expressed are my own. |
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Tom Boyles, DTM&H student Liverpool
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I would like to argue that the distinction between complimentary, alternative and conventional medicine is arbitrary and should be removed. Put simply there are therpies that work, those that do not work and those that do harm. So called complimentary or alternative therapies should go through the same process as all other medicines to gain acceptance and if there is enough evidence to trigger a NICE appraisal then so be it. The counter arguement is often that there is no incentive to research therapies that have no patent value. I would argue that the Nobel prize committee would look very favourably on anyone who could prove that medicine diluted until there were no active molecules left could have an impact on health when compared to placebo. Competing interests: None declared |
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John M English, Retired SP1 1JF
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How sure are we that “evidence-based medicine” is as accurately dispassionate as it ought to be? I pick out 4 articles from the recent “Generalist.” One on physiotherapy, and one on long-term antibiotics for childhood UTI, (an issue alive 20 years ago when I was still a GP, and apparently (surprisingly) unresolved even now.) The conclusions? “More research needs to be done.” In other words, it isn’t proven and we don’t really know. Similar articles on NLP and a reference to homeopathy draw similar conclusions, but they aren’t expressed the same way: “The case for them is not proven.” In other words, it doesn’t work, don’t use it!Could that be because they are unorthodox, and unpopular for being so? Is there a difference between these pairs of cases? Prof Ernst, as Chair of Complementary Medicine at Exeter, has contributed hugely to this attitude. He has written many articles concluding that this or that complementary therapy is unproven, with a negative attitude towards it. Research in any of these disciplines is very difficult to carry out, especially with todays strict measures. This could be expanded at length. I would have expected the holder of that Chair to be sympathetic to these problems, and to work with those in the field to find ways round them. No doubt he will dispute this conclusion, but I don’t think he has done so, certainly not adequately. Sometimes he cites his own work, and such other as agrees with it, and ignores work that reaches more positive conclusions. It is surely standard practice to find something to criticise about any piece of research you happen not to like. Have we not seen this many times, in conventional medicine too? The evidence for or against (say) homeopathy ( area I know best) is indeed equivocal. I would contend that it has not been possible to design studies that distort neither the subject nor the methodolgy. I’ll happily defend this assertion. Competing interests: Long term interest in homeopathic medicine; some research experience in this field |
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Lesley Braun, Research Fellow and Lecturer Monash and RMIT Universities, Australia
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Evidence based clinical practice promotes the integration of patient reported, clinician observed and research derived evidence. In practice this is modified by patient preferences and individual circumstances to avoid the 'cookbook' approach. Considering the enormous public use and interest in complementary therapies, it is essential that both community and hospital based clinicians discuss their use of CM with patients and be familiar with the evidence in order to screen for potential unsafe use (such as drug interactions) and actively prescribe treatments which are supported by evidence. Sadly, this is rarely the case. The literature is peppered with research articles and editorials indicating that medical practitioners in most Western countries do not have formal education about CM and are not aware of the evidence of its efficacy or safety, have limited personal experience of its effects and do not routinely ask patients about use thereby missing out on receiving patient feedback. Self-directed learning such as a rudimentary search through the Cochrane reviews is merely a starting point and not an end point towards understanding this enormous field with its great diversity. So, this begs the question of how could it be reasonably expected for a busy clinician to have an informed opinion about CM ? Let use hope that true 'experts' in the various fields of CM are utilised in research development, peer-review processes, higher education and advisory committees so that evidence-based and not fear-based medicine can be practiced. Competing interests: None declared |
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