Feb 19 2015

Phantom Acupuncture

There are two basic schools of thought when it comes to acupuncture, which is the practice of placing thin needles into alleged acupuncture points in order to have a therapeutic or symptomatic effect. The “traditional” interpretation is that the needles are stimulating a physiological response of some kind at the acupuncture points. Within this school there is a range of opinions as to whether this response is due to a biochemical, neurological, or another known biological response or whether it is due to the still more traditional (but actually less than a century old) belief that the needles are manipulating the life force or Qi.

The other school holds that acupuncture is essentially an elaborate placebo. (Note – this article contains all the references necessary to support my statements below, so I will not repeat them.) Any apparent response is a non-specific response to the attention of the practitioner, expectation, distraction from pain, simple regression to the mean, and other illusory effects.

Each school makes different predictions about the various lines of evidence that can be brought to bear to resolve this question. There have been in total several thousand clinical studies looking at the apparent effects of acupuncture. These have failed to convincingly reject the null hypothesis, meaning that they have not demonstrated a clear biological response to acupuncture for any indication. The better controlled studies consistently show that needle location does not matter (sham acupuncture), and that needle insertion does not matter (placebo acupuncture). You can literally have a non-acupuncturist randomly poke someone with toothpicks and get the same response as the full acupuncture treatment.

The other line of evidence regarding acupuncture are studies that look at physiological responses to having needles poked through the skin. These studies, completely unsurprisingly, show that “stuff happens” when you stick a needle through the skin. There is a local reaction to the trauma, and the brain reacts in a predictable way. I do not think these studies in any way distinguish between the two interpretations of acupuncture. Even if acupuncture is nothing but a placebo, we would still expect these types of responses to sticking needles into tissue.

One way in which these studies might differentiate the two interpretations is if it could be convincingly shown that acupuncture points are real – the body responds in a consistently and functionally different way when acupuncture points are jabbed than when non-acupuncture points are jabbed. However, the evidence does not support this conclusion. In fact the totality of the evidence strongly supports the conclusion that acupuncture points have no basis in reality – they don’t exist.

There is now a new line of evidence that is very interesting, and one that I had not previously considered – phantom acupuncture. A recent study looked at performing acupuncture on a phantom limb. They used a now well-established technique of tricking the brain into incorporating a dummy body part as if it were real. They placed subjects in front of a table so that one of their arms was below the table, with a rubber arm above the table placed in such a way that visually the rubber arm looked like their own arm. They then stroke the rubber arm and the subjects real arm simultaneously. The brain sees and feels the rubber arm being stroked, and this sensory feedback is often enough for the brain to create the sensation of ownership over the rubber arm.

The researchers then placed acupuncture needles into the rubber arm that subjects had incorporated as their own. Obviously there is no possibility of any physiological response from the needle penetrating the rubber arm. I further think it is reasonable to conclude that placing a needle into a rubber arm cannot activate acupuncture points (if they existed) or alter Qi (if it existed). This experiment nicely eliminates local physiological responses and any Qi responses to the needles.

The researchers performed functional MRI scanning (fMRI) on subjects while needles were placed in their phantom rubber limbs. Keep in mind that fMRI research involves collecting lots of data and aggregating it. So the researchers are not looking at brain reactions in real time, just the aggregate brain activity of many subjects over many trials. They then look for statistical associations in the activity.

What they found was the same brain activation that previous studies have found with acupuncture of real limbs.

When the rubber hand was fully incorporated with the real body, acupuncture stimulation to the rubber hand resulted in the experience of the DeQi sensation as well as brain activations in the dorsolateral prefrontal cortex (DLPFC), insula, secondary somatosensory cortex (SII), and medial temporal (MT) visual area. The insular activation was associated with the DeQi sensation from the rubber hand.

If these results hold up, this implies that the brain is simply responding to the expectation and visualization of the needle penetration. Actual needle penetration is unnecessary. The most parsimonious interpretation of this data is that acupuncture is all in the mind. There is no need to hypothesize the existence of Qi, acupuncture points, or a specific physiological mechanism for acupuncture.

There are plenty of studies that show that the perception of pain is easily manipulated by simple things such as distraction. Swearing, distorting body image, and crossing your arms while one of them is pricked will all reduce pain perception. Pain perception is closely tied to attention, and so simple distraction is effective. It’s no surprise, therefore, that the brain responds to phantom stimulation.

At the very least this study demonstrates that all prior studies looking at fMRI responses to acupuncture needle insertion were likely simply showing a non-specific brain response to the expectation and/or visualization of needle insertion, without the need to invoke any specific physiological responses.

Conclusion

The totality of evidence strongly indicates that there is nothing specific to acupuncture. Acupuncture points don’t exist, Qi does not exist, and the elaborate details of acupuncture treatment do not matter. In other words – acupuncture is an elaborate (and unnecessarily so) placebo.

We can now add phantom acupuncture to sham and placebo acupuncture as lines of evidence demonstrating that acupuncture is no more than a placebo. The researchers indicate their desire to take the next step – to see if there is a clinical response to phantom acupuncture. The placebo hypothesis predicts that there should be, at least to some extent, depending on proper blinding (if possible).

What all of this means is that the very concept of acupuncture adds nothing to our understanding of the universe, and biology and medicine specifically. It is a failed concept. We lose nothing by discarding it. Any part of acupuncture that “works” is mere placebo and therefore not specific to acupuncture. Anything specific to acupuncture does not work.

Any non-specific symptomatic benefits to acupuncture (which do not appear to be clinically significant, by the way) can be achieved without sticking needles through the skin (which entails some risk), does not require special training, and does not require an expensive elaborate procedure. Further, persisting in the myth of acupuncture fosters misunderstanding of science, biology, and medicine which has insidiously negative effects.

Acupuncture itself is a phantom phenomenon and should go the way of the ether and N-rays.

194 responses so far

194 Responses to “Phantom Acupuncture”

  1. John Danleyon 19 Feb 2015 at 10:07 am

    I had a feeling the Cenobites were overrated. As Orac calls it, “theatrical placebo.”

  2. tmac57on 19 Feb 2015 at 11:05 am

    So…this is Acupuncture for Dummies? 🙂

  3. edamameon 19 Feb 2015 at 11:07 am

    There is tension between the unqualified assertion that it is all placebo, and the fact that there are actual effects that are real and measurable even in nonhuman subjects.

    Dr Novella claimed, “Any part of acupuncture that “works” is mere placebo and therefore not specific to acupuncture.”

    It is very unlikely to be mere placebo in the mouse models that show pain alleviation with needle insertion (readers might see: ‘Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture’, which was discussed here some time back) Producing placebo effects in mice takes effort.

    On the other hand, Dr Novella you seem to realize it is not mere placebo when you discuss nonspecific benefits. This must be a technical term, as having relief at a particular location where there was pain is pretty specific, no? More specific than simply taking an aspirin, which gives systemic non-localized pain relief. Is a localized injection of lidocaine a nonspecific benefit?

  4. mumadaddon 19 Feb 2015 at 11:32 am

    edemame,

    If the same effects are achieved without needle penetration; or penetration at random points rather than ‘acupuncture points’; or penetration of a dummy arm, then they are non-specific to any part of the acupuncture intervention. Or is Dr N missing something? What other components are specific to acupuncture that could account for the positive effects? What possible mechanism could you propose to rescue acupuncture when removing any component still produces the same results?

    This must be a technical term, as having relief at a particular location where there was pain is pretty specific, no?

    ‘Specific’ refers to clinical effects, not the location of the pain.

  5. jsterritton 19 Feb 2015 at 11:36 am

    “Acupuncture itself is a phantom phenomenon and should go the way of the ether and N-rays.”

    Excellent article. Thanks for concisely presenting the two main “competing” theories of acupuncture, including even a brief history of the practice (i.e., it’s not ancient), and introducing yet another whole category of control to the reader by way of a fascinating study (i.e., adding “phantom” to “sham” and “dummy” controls).

    As we all do, I have a fair number of friends and relatives who use acupuncture. And of course it works well for many for subjective reporting of pain, as expected. I find it frustrating, though, that almost everyone I know who has benefitted from acupuncture insists emphatically on the legitimacy of the mythology of acupuncture. Not only do they reject information that conflicts with this mythology, they resist new information altogether, as if learning about acupuncture on their own (or at all) might be apostasy or might somehow jeopardize the benefit they gain from acupuncture. This superstitious behavior belies the magical thinking involved in acupuncture as therapy, yet none may speak of it. Hand-in-glove with this is the belief by many (in my experience) that their particular practitioner is “really great.” This too belies magical thinking: that acupuncture — with all its ancient wisdom, verity, and rigorous theory — is only as good (i.e., therapeutic) as the person doing it. Obviously, this kind of thinking doesn’t cut it with real medicine: I neither have to believe in antibiotics or like the doctor who gives them to me to have my strep cured.

    Of course, the more credulous a person is, the greater they may benefit from placebo. But that’s a slippery slope my friends slide down all the time: from acupuncture to TCM to chiropractic to craniosacral to homeopathy. All of these “alternative” modalities seem to demand one last — but BIG — obeisance from their supplicants: denigrate/dismiss “western” medicine. This is where I draw the line, because it’s where the “insidiously negative effects” start to snowball as a science-based system of knowledge is replaced with magical thinking, superstition, and pre-scientific fear-based systems of belief, complete with an ecclesiastical order of what are essentially witch doctors. This is where quacks and charlatans exploit the naive and a**hole cults of personality roll back the clock on everything from vaccines to cancer therapy.

    This is why placebo medicine must be demystified and its power taken away from self-appointed experts in magical nonsense.

  6. string pulleron 19 Feb 2015 at 12:00 pm

    A year ago last month I was commuting w/ a work acquaintance to a job. I complained of a cold (which invariably invites all sorts of “advice”) and my co-rider began extolling the virtues of acupuncture. Him: Blah blah blah. Me: “The science shows acupuncture doesn’t work”. Him: “That is false.” Me: “I’ll send you links with all the information”. Him: “No, thank you.” Me: “Well, you brought it up, so don’t blame me for sharing facts with you”.

    Result: an unpleasant couple of hours followed by zero contact since then.

  7. edamameon 19 Feb 2015 at 12:08 pm

    mumadadd I’m not saying placebo isn’t part of the explanation in humans, but based on the rodent behavioral and physiological results (which have been replicated), it is a mistake to say that placebo is the whole story.

    I am not “all in” with acupuncture, but the evidence supports that it can alleviate pain localized to the location of needle insertion. It seems to be due to localized ATP release, as Dr Novella knows and has discussed.

    Because of that, I’m urging caution against the overstatements that it is entirely placebo. The evidence does not support that. People come off as out of synch with the evidence, and having an ax to grind, when they say that.

    Note I would expect that just pricking someone lightly with a toothpick evokes the same adenosine-mediated mechanisms for pain relief. But that wouldn’t imply that needle insertion doesn’t evoke ATP release and the subsequent pain reduction associated with that. It would suggest we need a better control condition for measuring placebo effects.

  8. jsterritton 19 Feb 2015 at 12:08 pm

    ^People are surprisingly thin-skinned about what they consider deeply-held beliefs. This is another telltale sign of how tenuous (and fishy!) these beliefs are. Another example of overreaction to a perceived slight against religiosity. Sorry you lost a pal.

  9. jsterritton 19 Feb 2015 at 12:16 pm

    edamame…

    I take your point. I think you are mistaking Dr Novella’s conclusion that “acupuncture is a phantom phenomenon” for him stating that needles don’t prick. These two things are not at odds with each other and any prick, needling, touch, etc will of course have its physiological effect.

  10. Steven Novellaon 19 Feb 2015 at 12:18 pm

    edamame – The local effects responding to local trauma are not specific to acupuncture. Also, the mouse data is difficult to extrapolate to people – the relative size of the needle being inserted is much larger than an acupuncture needle in a person. Finally, clinical data shows no significant effect compared to placebo.

    So – if there is any local tissue effect from the trauma, it is not specific to acupuncture and it is probably not clinically relevant.

  11. edamameon 19 Feb 2015 at 12:43 pm

    Dr Novella:

    OK that is clear, but even if other things can produce the same effect, that doesn’t mean needle insertion doesn’t produce the effect! The negative spin on the result comes off as clinging to a desired negative result. You can just as easily say it works because it has this known pain-relieving effect, but that you could use other things to get the same effect.

    In terms of control studies, as I mentioned it isn’t clear how many of them evoke the same ATP-mediated mechanism, so they are not all very good controls. Analogy: I don’t say NSAID #1 effects are placebo just because it doesn’t produce significantly different relief than NSAID #2. I would need a better control for placebo effects!

    I see acupuncture as a good place to get our foot in the door with the New Age Hippies who believe anything. Find a point of common ground, and then attack it from that position. “Oh yeah there is evidence that it procudes ATP which has known pain relieving effects. it might provide some relief for localized pain, but so might many other things. Unfortunately there is no evidence that it is useful for cancer, colds, etc.”

    In practice, framing it this way is *much* more effective, is honest, and doesn’t have to turn people off like string puller did when he overstated that it is complete bullshit, full stop. I always make it a point to discuss the results in rodents, to show that I know something about the topic, to form a rapport, before letting out the skeptical side.

    Plus, it is just misleading at best to say that there is zero evidence supporting it, full stop. Or that it is entirely placebo, and this has been demonstrated beyond reasonable scientific doubt. It’s simply false to say these things. Skeptics should be better informed than your average New Age Hippy, and have nuance in our position. Acupuncture is one of the few loci where I can get leverage with these people, and it seems a mistake not to take advantage of it. 🙂

  12. string pulleron 19 Feb 2015 at 1:57 pm

    Well, maybe I’m ignorant of the nuances of the micro-effects of a treatment that in most circles is heralded to cure anything & everything that ails you, but if you can get the same micro-effect of pain relief without breaking the skin and potentially introducing bacteria into the bloodstream or say, puncturing a lung, how useful is a treatment like that? How practical? & how more useful than nothing at all?

  13. Steven Novellaon 19 Feb 2015 at 2:54 pm

    I think definitions are critical. Sticking a needle in a mouses knee is not acupuncture. Sticking needles in anywhere to get a local physiological response is not acupuncture. Just like “electroacupuncture” is not acupuncture.

    The effects of needling are transient and not clinically significant – too small to be noticeable by the usual standards. This smacks of a statistical noise, not a real effect. And – even if we take the maximally generous view that it is real, and explain it with adenosine or whatever, we are still left with evidence that it is clinically insignificant.

  14. carbonUniton 19 Feb 2015 at 2:59 pm

    So when the phantom limb is needled, do the patients think they feel the needle?
    Has anyone tried doing ‘real’ acupuncture with anesthetized limbs? I wonder how those results would differ from the results of the sham forms?

  15. joshguthon 19 Feb 2015 at 3:38 pm

    Let me preface my comment by saying that I agree that there is no “science” behind the placement of the needles or the rebalancing of your Qi. However, the placebo effect can be powerful. I used to suffer from severe seasonal allergies. After acupuncture, I haven’t even taken a single allergy pill in over three years. I don’t believe that it was the acupuncture, but I don’t care if it works, when nothing else did, including medication.

  16. jsterritton 19 Feb 2015 at 3:43 pm

    @edamame

    “Acupuncture is one of the few loci where I can get leverage with these people, and it seems a mistake not to take advantage of it.”

    While I like your “Trojan horse” foot-in-the-door approach to introducing skepticism about acupuncture to a tough audience, I cannot approve of it. Establishing common ground is a great way to begin a discussion and prevent it from becoming a shouting match. Still, citing a single study — in mice no less — as evidence that there is a physiological response to needling and hence an inherent therapeutic value to acupuncture over placebo is misleading. The objection to acupuncture that Dr Novella makes (and I agree with) is that it is not real medicine, only placebo, and that retailing placebo as effective medicine is ethically dubious. Most claims that are made in support of acupuncture as treatment work backwards from reported effect to a guessed-at cause (acupuncture and its mythology). Yours is different only in direction: it is still making a feeble connection between cause and effect (in this case, that release of adenosine associated with tissue damage may explain how acupuncture works). There is little accounting for the behavior of mice in the study [1] I assume you are referring to, and many confounding factors. And while it may be an interesting study, it is always better to look at the whole literature. There is a noticeable trend in acupuncture studies: the more rigorous, blinded, and controlled, the more negative the results. This is telling. In this 2008 review of Cochrane reviews of acupuncture studies [2], Ernst (interestingly a researcher at Exter’s Complementary Medicine dept.) found that of 32 reviews only five showed “positive or tentatively positive” results. Of those five, two were reviews “based on three or less primary studies.” The twenty-five negative reviews were each “based on more than 10 randomized controlled trials (RCTs), including over 1000 patients each.” In 2011, Ernst et al looked at even more systematic reviews with even more dismal results [3]. Our host, Dr Novella, published a similar review with Dr Colquhoun here [4]. The conclusions of these comprehensive reviews are unambiguous: “numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain.” [3]

    By citing a single study of vanishing relevance in support of a physiological, unique-to-acupuncture mechanism of action, you are less likely to introduce skepticism on the subject than to confirm non-scientific belief in the validity of acupuncture as medicine. It’s a cherry pick.

    Again, I am not saying your approach to negotiating with “these people” is a bad idea. I have an abysmal track record of currying anything but ire with my methods. I don’t call anyone out, but when someone asks, “what, don’t you believe acupuncture works?” I always reply: “define works.” 🙂

    ______
    [1] http://www.nature.com/articles/nn.2562.epdf?referrer_access_token=cNNaq57QAMr-CMo_mg4lENRgN0jAjWel9jnR3ZoTv0PBUjVixMSJUhrK4Uxr2HZi5-RzAjIl5KaryhlAWxMJvGlVlVSuhC0P9Kjn0_oohC4%3D
    [2] http://www.jpsmjournal.com/article/S0885-3924(08)00452-1/fulltext
    [3] http://www.ncbi.nlm.nih.gov/pubmed/21440191
    [4] http://journals.lww.com/anesthesia-analgesia/Fulltext/2013/06000/Acupuncture_Is_Theatrical_Placebo.25.aspx#P74

  17. Steven Novellaon 19 Feb 2015 at 4:05 pm

    josh – the problem with anecdotal evidence is you don’t know what would have happened had you not taken the acupuncture.

    I don’t know the details of your history, but what frequently happens with chronic symptoms is that people try multiple different treatments. When the symptoms resolve, they credit whatever they most recently tried, even if it was pure coincidence. Over time their memories alter so that that the narrative of the treatment working is made more impressive – the two events (treatment and recovery) move closer together in memory.

    We know from studies that acupuncture does not work for asthma, we also know the placebo response from acupuncture in asthma is transient and subjective, without objective improvement in actual airway function. Placebo is not that powerful. The human tendency for narrative is probably more powerful.

  18. mumadaddon 19 Feb 2015 at 5:47 pm

    I would love to see some acupuncture vs local massage, or acupuncture vs local stroking with feathers, or acupuncture vs being lightly spanked locally with a ruler trials, seeing as how we’ve already had prodding the skin with cocktail sticks.

    Sticking needles into the skin/prodding the skin with cocktail sticks may well relieve pain, but if all of the above achieve a similar result, what’s the need to pay for a highly skilled acupuncturist?

    Gate control theory: http://brainblogger.com/2014/06/23/gate-control-theory-and-pain-management/

  19. Ori Vandewalleon 19 Feb 2015 at 6:28 pm

    This is slightly off topic, but it seems very odd to me that the sensation of pain is lessened when you’re distracted. Shouldn’t the “point” of pain be to alert you to some negative stimulus, to gain your attention when you’re distracted? Do we have any idea why it would be the case that we’re less likely to notice pain when our attention is elsewhere?

  20. tmac57on 19 Feb 2015 at 8:36 pm

    mumadadd= I think you are on to something…Fifty Meridians of Qi ? Sounds like a hit! 🙂

  21. grabulaon 19 Feb 2015 at 9:59 pm

    @jsterritt

    “All of these “alternative” modalities seem to demand one last — but BIG — obeisance from their supplicants: denigrate/dismiss “western” medicine. ”

    I listen to a handful of ‘alternative thinking’ podcasts to get a handle on the mentality that goes into it. Yesterday I was listenning to a podacast called Inception Radio that had an interview with “Dr.” Susan Shumsky (I put Dr in quotes because I’m not convinced it’s for real) who stated emphatically that “western science” is just barely starting to catch up with ancient eastern medicine. This was in reference to chakras and qi and all that other crap.

  22. jsterritton 19 Feb 2015 at 11:24 pm

    @grabs

    “I listen to a handful of ‘alternative thinking’ podcasts to get a handle on the mentality that goes into it.”

    You’re a better man than I am, Gunga Din.

    An interesting point that Dr Novella tangentially addresses in this post is the “ancient wisdom” fallacy. I recently got into it pretty hot ‘n’ heavy with a great, good friend about acupuncture. He has benefitted from acupuncture for pain stemming from a back/neck injury. Making various and conflicting defensive maneuvers in support of the practice, his redoubt of choice was always the “ancientness” of acupuncture. I consider this a very weak point indeed — wouldn’t something old and pre-scientific necessarily be inferior to something modern and scientific? But still, it does seem to resonate with people. A little exploration reveals just what you’d expect about all of these “ancient” practices and systems, from Leviticus to homeopathy: magical nonsense and fallacy. The story behind acupuncture is particularly colorful, though, since the practice — which is in fact steeped in age and tradition — has only recently been dusted off as the worst kind of grift to run on (first) rural Chinese by a totalitarian leadership unable to deliver on real medicine and (second) as a fad for credulous American hipsters in the 1970s. The rest is history (like acupuncture should be).

    The contemporary claim by sCAMmers that ancient systems are somehow (magically) superior to modern ones is just the kind of flawed syllogism we’re used to discussing here: if the new is bad, the old must be good. It doesn’t have to work, it just has to be alternative.

  23. Paul Parnellon 20 Feb 2015 at 6:12 am

    Well clearly they need to do the phantom limb study with mice…

    I would pay money to see that grant proposal.

  24. BillyJoe7on 20 Feb 2015 at 6:59 am

    josh,

    “the placebo effect can be powerful”

    The placebo effect is weak, unreliable, and transient.

  25. Ur23on 20 Feb 2015 at 7:55 am

    http://www.ncbi.nlm.nih.gov/pubmed/24322588
    http://www.myconsciousbrain.org/acupuncture-triggers-neurotransmitters-in-the-body/

    “Electroacupuncture blocks pain by activating a variety of bioactive chemicals through peripheral, spinal, and supraspinal mechanisms. These include opioids, which desensitize peripheral nociceptors and reduce proinflammatory cytokines peripherally and in the spinal cord, and serotonin and norepinephrine, which decrease spinal N-methyl-D-aspartate receptor subunit GluN1 phosphorylation.”

  26. joshguthon 20 Feb 2015 at 8:44 am

    BillyJoe7 — Let’s agree to disagree regarding the placebo effect. For me, it was not weak, unreliable, and tansient.

    Dr. Novella — You make a good point about the temporal relationship not being proof of cause and effect. I admit that I tried many different things because I was suffering from allergies that would not go away even after seeing an allergist and taking multiple medications, including a steroid. In the end, I have no idea what stopped my allergies, but they have stayed away without the medication that I have been taking for years. I don’t credit my accupuncturist, but I also don’t regret going a couple times.

  27. tmac57on 20 Feb 2015 at 10:43 am

    Ur23- I don’t know if you caught it but Dr. Novella rightly does not consider ‘electroacupuncture’ to be the same thing as acupuncture. He has stated many times that adding the electric current can have a clinical effect, and is not in any way part of the philosophy of what traditional acupuncture theory is claiming.

  28. Teaseron 20 Feb 2015 at 1:00 pm

    @jsterritt

    Your statement is an appeal to modernity, equivalent to your friends appeal to antiquity:

    ” — wouldn’t something old and pre-scientific necessarily be inferior to something modern and scientific? But still, it does seem to resonate with people.”

    Some dispositions evince an unbounded admiration of antiquity, others eagerly embrace novelty; and but few can preserve the just medium, so as neither to tear up what the ancients have correctly laid down, nor to despise the just innovations of the moderns. But this is very prejudicial to the sciences and philosophy, and, instead of a correct judgment, we have but the factions of the ancients and moderns. Truth is not to be sought in the good fortune of any particular conjuncture of time, which is uncertain, but in the light of nature and experience, which is eternal. Such factions, therefore, are to be abjured, and the understanding must not allow them to hurry it on to assent.” – Francis Bacon

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the human race to our “modern” times.

  29. jsterritton 20 Feb 2015 at 1:19 pm

    Teaser

    You are absolutely right, that sentence is an appeal to modernity. However, if you think it erodes my argument (or in this case, my little story) in any way, you’re crazy. Thanks for stepping up to illustrate cherry-picking and argument from fallacy (aka fallacy fallacy) in classic @Teaser style.

    Thanks for reading!

  30. Teaseron 20 Feb 2015 at 1:57 pm

    @jsterritt

    Now you are jumping to conclusions now about my intent. I am not arguing anything. Just reading and learning.

  31. BillyJoe7on 20 Feb 2015 at 3:58 pm

    josh,

    “BillyJoe7 — Let’s agree to disagree regarding the placebo effect. BillyJoe7 — For me, it was not weak, unreliable, and tansient”

    Firstly, the appeal to “agree to disagree” always sounds like a cop out to me. It means you are unable or unwilling to defend your position against any arguments that might be made against them.

    Secondly, when you say “for me, [the placebo effect] was not weak, unreliable, and tansient”, you are simply jumping to a conclusion about what happened to you. You had allergies. Your allergies stopped. in the interim, you tried acupuncture. You wrongly attributed that change to the placebo effect of acupuncture. This is the logical fallacy called “post hoc ergo propter hoc” or “after this, therefore because of this”.

    Thirdly, I have a counter-example. Throughout the third year of his life, my son had total body eczema. Then suddenly, within the space of a week or two, his eczema completely disappeared. We did nothing (apart from the usual OTC treatments that we’d been using all year). It just spontaneously resolved.

    ” In the end, I have no idea what stopped my allergies, but they have stayed away without the medication that I have been taking for years. I don’t credit my accupuncturist, but I also don’t regret going a couple times”

    Perhaps your allergies just spontaneously resolved. Perhaps the allergen that caused your allergies simply disappeared from your environment.

  32. hammyrexon 20 Feb 2015 at 4:00 pm

    It’s interesting people believe “the effect is placebo” cannot be true simply because there’s a described mechanism of action; those are not mutually exclusive things.

    Especially odd, seeing as many alternative medicine proponents believe scientific reductionism is a fundamentally flawed approach to these questions, yet curiously they are often the ones worshiping mechanism of action as an alternative to good clinical evidence. In the end, they have far more in common with pharmaceutical companies than they like to believe.

  33. BillyJoe7on 20 Feb 2015 at 4:09 pm

    Teaser,

    “We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the human race to our “modern” times”

    Or perhaps we survived despite ancient medicines’ best efforts to wipe us out. (;

  34. Bill Openthalton 20 Feb 2015 at 6:07 pm

    Teaser —

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the human race to our “modern” times.

    So humans need medicine to survive? What nonsense; life thrives without medicine, and so did, and does, humanity. Medicine merely serves the individuals who would have died (a bit) earlier but for the medical intervention.

  35. mumadaddon 20 Feb 2015 at 8:29 pm

    c

  36. mumadaddon 20 Feb 2015 at 8:31 pm

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the beaver race to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the hammerhead shark race to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the helicobacter pylori race to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the blue whale race to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the Cymothoa exigua race to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the Deinococcus radioduransrace to our “modern” times.

    We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the Cupid Stunt race to our “modern” times…

  37. mumadaddon 20 Feb 2015 at 8:33 pm

    If that last comment appears multiple times it’s because of some rule about repetition that I was unaware of…

  38. ccbowerson 20 Feb 2015 at 9:46 pm

    jsterritt brings up the “romanticization of the past” narrative that often bothers me. This manifests in many ways, but appears to be something that resonates with many people. Sometimes it is a reverence for ancient cultures and ‘forgotten wisdom’ that Teaser alluded to. The truth is that many more terrible things happened in the past, but we don’t have access to those terribles. People like to be optimistic about those things, which is OK, but let’s make sure our perspective is accurate. Life in the past was difficult and likely worse by nearly every metric than the average person living today.

    Other times the romanticization is more personal… that your childhood, or the previous generation is better than the current (e.g. the people, music, politics, etc). I think both are driven by an aesthetic appeal of certain narratives that make people feel better about the past and more pessimistic/realistic about the present. It’s harder to deny the things you don’t like when they are close in time and space (i.e. things happening to you now), but it is easier to smooth out the rough edges of the past, as they are more distant.

  39. sonicon 21 Feb 2015 at 12:54 pm

    There are two basic problems with this presentation.

    1- it begins with a false dilemma.
    2- efficacy of acupuncture is being conflated with the existence os ‘Qi’.
    Yet acupuncture not working does not equal ‘no Qi’ and
    acupuncture working does not prove the existence of ‘Qi’.

    While I recognize these two camps exist, I find that in many cases the truth isn’t at the extreme in these cases (acupuncture treats everything/nothing), but rather somewhere in a more moderated position.
    I believe edamame has brought this up as well.

    The existence of ‘Qi’ is an emotionally charged one- if one believes that any acceptance of acupuncture is acceptance of ‘Qi’, then one’s motivation turns to disallowing this thought rather than a clear analysis of the data.
    Further if one thinks rejecting acupuncture is the same as rejecting Qi, then some researchers would be motivated to interpret the results favorably…

    I believe it is this false proxy aspect that causes the false dilemma and reduces the opportunity for reasoned exchange on this topic.

  40. jsterritton 21 Feb 2015 at 2:22 pm

    @sonic

    “If one thinks rejecting acupuncture is the same as rejecting Qi, then some researchers would be motivated to interpret the results favorably…”

    Have you not read the OP or any of the comments?

    This is not a discussion of whether results show that acupuncture works or whether people believe in Qi or not. It is a discussion of yet another science-based nail in the coffin of the myth of acupuncture. You are really too late to change the topic to a discussion of a false false dichotomy of your capricious choosing.

    You bring nothing meaningful to the topic at hand so seek to hijack it altogether. Bad manners.

  41. Willyon 21 Feb 2015 at 7:44 pm

    “We are all standing on the shoulders of ancient medicine as proven by our current existence. The “old and pre-scientific” treatment methods were effective enough (placebo or not) to deliver the human race to our “modern” times”.

    I think someone owes Isaac Newton an apology.

  42. sonicon 22 Feb 2015 at 9:02 am

    jsterritt-
    I’m not sure how confusing two issues enhances the rationality of the discussion.
    In this case the issues being confused carry emotional baggage– confusing these things seems quite contrary to any attempt to have a rational discussion.

    Excuse me if noting this is inappropriate.

  43. arnieon 22 Feb 2015 at 10:21 am

    jsterritt,

    “You(sonic) bring nothing meaningful to the topic at hand so seek to hijack it altogether. Bad manners.”

    I agree with you, but then, as always, he responds with his patented disarming style of manipulation by blaming you for confusing the issues and attempting to keep you hooked in to his own never ending efforts to undermine Steve’s OP by attempting to both divert, and muddy, the waters so he can promote his own irrational and confusing ideology.

    As in the comment I just posted in Steve’s recent “Darwin was not wrong” post, the only way to really end sonic’s inevitable attempts to hijack and confuse Steve’s OPs is to ignore him altogether at, or near, the beginning of his entry in to the discussion. His gentle, disarming, ingratiating writing style, IMO, is an habitual disingenuous effort to camouflage his hostile, manipulative trolling. Of course I could be wrong, but my opinion grows out of following this blog and Sonic’s “contributions” for a long time and evaluating the latter in the light of decades of relevant career experience.

  44. tmac57on 22 Feb 2015 at 11:07 am

    Regarding the idea that modern medicine is “standing on the shoulders of ancient medicine …”, It is more like it is standing on the corpses of a billion dead, bad ideas until systematic and rational observation and experimentation combined with new tools of investigation gave us a boost high enough to see actual results. There are still many out there who would try to topple us from that perch, and wave ancient and rotting red herrings in our faces.

  45. jsterritton 22 Feb 2015 at 11:33 am

    Ancient medicine must have worked, because as we all know humanity has enjoyed today’s levels of robust health and life expectancy for thousands of years. Oh, wait…that’s not right. Scientific medicine stands on the shoulders of only a single lifetime of scientific medicine. And we’re still trying to shrug off the perils of mumbo-jumbo that sCAMmers and witch doctors would kill us with. Ancient mumbo-jumbo.

    “For most of human existence, according to fossil and anthropological data, the average human life expectancy was 35 years. As recently as 1900, American average life expectancy was only 48. Today, advocates of alternative health bemoan the current state of American health, the increasing numbers of obese people, the lack of exercise, the use of medications, the medicalization of childbirth. Yet life expectancy has never been longer, currently 77.7 years in the US.”

    -Amy Tuteur, MD

  46. Lane Simonianon 22 Feb 2015 at 1:22 pm

    Many of the purported positive effects of acupuncture are likely due to its activation of the phosphatidylinositol 3-kinase/Akt pathway. This pathway is neuroprotective in part due to the increased production of glutathione which is a critical antioxidant.

    http://www.ncbi.nlm.nih.gov/pubmed/21770712

    http://link.springer.com/article/10.1007/s11481-014-9550-4

    http://www.hindawi.com/journals/ecam/2014/483294/

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3958908/

    The following article discusses the impact of acupuncture and eugenol in a mouse model of Alzheimer’s disease.

    http://www.ncbi.nlm.nih.gov/pubmed/24024340

    Eugenol like acupuncture is likely neuroprotective because directly (in the case of eugenol) or indirectly via increased glutathione production in the case of acupuncture they increase the scavenging of peroxynitrites which is the critical oxidant in many neurodegenerative diseases.

    http://www.ingentaconnect.com/content/ben/cbc/2006/00000002/00000001/art00005

    http://www.ncbi.nlm.nih.gov/pubmed/15941312

    http://www.ncbi.nlm.nih.gov/pubmed/17237348

    Aromatherapy with eugenol (in rosemary essential oil) has improved cognition related to personal orientation in people with dementia and especially in those with Alzheimer’s disease.

    http://onlinelibrary.wiley.com/doi/10.1111/j.1479-8301.2009.00299.x/full

    Combine this with panax ginseng which contains several peroxynitrite scavengers (ferulic acid, vanillic acid, syringic acid, p-coumaric acid, and maltol) and the results for Alzheimer’s patients are likely to be even better.

    http://www.ncbi.nlm.nih.gov/pubmed/19298205

    http://www.ncbi.nlm.nih.gov/pubmed/22780999

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659550/

    Wouldn’t it be funny if three of the most almost universally “scientifically” despised alternative treatments in the West: acupuncture, aromatherapy, and ginseng turned out to be much more effective than drugs currently being used to treat Alzheimer’s disease and those which have been consistently failing in clinical trials.

  47. BillyJoe7on 22 Feb 2015 at 3:34 pm

    When there are two extremes, I think it is best to sit right in the middle.
    It doesn’t matter if the theory has no basis in fact. It doesn’t matter that clinical trials have failed to reject the null hypothesis. It feels comfortable sitting here in the middle where I can watch the two extremes go to battle and I can feel superior to both.
    And it’s really important for me to say this.

  48. Teaseron 22 Feb 2015 at 9:13 pm

    Sheesh….I go away for a reiki energy healing weekend retreat and come back to find I have been lambasted for pointing out that today’s woo was yesterdays pinnacle of science.

    Leeches anybody? How about a nice blood letting? Cut your limbs off with a bloody saw on a civil war battle field? Quick trepanation to clear the mind?

    I am not romanticizing the past in any way shape or form.

    Good freaking source jsterritt! 🙂
    “Dr. Amy Tuteur has lost two jobs in the past year as guest writer at salon.com and Science Based Medicine. This was apparently because of her attitude and because she was writing about things she knew nothing about. Her accusations against MANA and her presence across the internet are nothing new. ”

    Here is a modicum of science applied to the issue of life expectancy over time.
    http://www.anth.ucsb.edu/faculty/gurven/papers/GurvenKaplan2007pdr.pdf

  49. jsterritton 22 Feb 2015 at 10:32 pm

    Teaser..

    Thanks for the mansplaining and well-poisoning. Anything to say about the substance of my excerpted quote? Or about my point in general?

    Nope?

    Didn’t think so.

    Suck it.

  50. Lane Simonianon 23 Feb 2015 at 11:08 am

    I am always somewhat bemused by the tone and nature of the discussions that take place on various skeptic blogs. Some people get a little agitated when you present evidence contrary to their deeply held beliefs. And one of those deeply held beliefs among many western scientists is that natural products cannot be used to treat any disease.

    Successful human clinical trials pose a particular problem. It is almost always easier to find a hopeful explanation for failure in clinical trials (too small a dose, may have helped a subgroup, does not reach its target, etc.). The most likely explanation is that the drug being tested is ineffective. But when so much is invested in these trials, a number of pharmaceutical companies will keep trying until every possibility has been exhausted.

    But to try to explain away successful results is much more difficult. The usual approach is to say that the trial was poorly designed and run. Then run it better and see what happens.

    It is no more cherry-picking to present positive results than it is cherry-picking to present negative results. And when it comes to various natural treatments you will find many things that don’t work at all, some that will work in mice but not in humans, and a few that will work in humans. This is no different than the results produced by drugs. There is no alternative medicine; there is simply medicine and as most scientists steeped in other traditions know certain plants are part of that medicine.

  51. Bruceon 23 Feb 2015 at 12:14 pm

    Lane:

    “And one of those deeply held beliefs among many western scientists is that natural products cannot be used to treat any disease.”

    I am sure you will find the majority of scientists will admit that “Natural” products (for what I assume your definition of “natural” might be) can treat diseases. In fact, it is the identifying of many of the active ingredients of the “natural” products that have resulted in the vast majority of modern medicine. Medicine is a science and science is based in the observation of nature. All they have done is identify what the active ingredient, ensured what dosage is effective is (taking into account side effects) and taken out all the other crap that could potentially contra-indicate.

    “It is almost always easier to find a hopeful explanation for failure in clinical trials (too small a dose, may have helped a subgroup, does not reach its target, etc.). ”

    It is almost always easier to conduct a study without the proper checks and balances in place.

    Have you been reading the literature on Homeopathy, or perhaps Acupuncture… or maybe reiki? Don’t you find it strange that many (if not all) of the remaining “natural” remedies suffer from this exact problem you are pointing out. The only difference is that they don’t have the same standards of efficacy so do not have to spend so much money in proving they work. I think you are trying to run the Big Pharma gambit here, but you are not really doing it that well.

    “It is no more cherry-picking to present positive results than it is cherry-picking to present negative results.”

    It is cherry picking to present those results that are clearly in the minority of the studies done which are not done as rigorously as the others as representing the definitive conclusion.

    http://en.wikipedia.org/wiki/Cherry_picking_(fallacy)

  52. Lane Simonianon 23 Feb 2015 at 3:25 pm

    I partially agree with you. Most scientists will acknowledge that many of our medicines came from natural products, yet seem dismissive of the idea that any natural product itself can treat a disease. Maybe it is because they feel the concentration is not high enough in the natural product. Maybe, it is a belief that we can alter the natural product in such a way that it will always be more effective than the natural product itself. But in any case, when you mention the concept of an herb, for example, being effective against a particular disease, certain terminology such as quackery, pseudoscience, woo, etc. is quickly applied by many scientists. The idea that no natural product can be used to treat any disease is no more preposterous than the notion that any natural product can be used to treat any disease.

    I have seen six different studies in which herbs have been used to treat Alzheimer’s disease and or another dementia: ranging from open label to double-blinded and randomized: aromatherapy with rosemary, lemon, orange, and lavender essential oil (Jimbo 2009), lemon balm extract (Akhondzadeh, 2003), sage extract (Akhondzadeh, 2003), Korean red ginseng (Heo, 2011), heat processed ginseng (Heo, 2012), and Angelica archangelica along with rice bran (Kimura, 2011). All contain similar compounds (methoxyphenols which are the most effective peroxynitrite scavengers) and all produced similar results. Some may call this cherry-picking, but I call it mounting evidence that certain natural products can be used to treat Alzheimer’s disease. The only thing missing is the will by many to conduct larger experiments and the money for those few who wish to do so.

  53. jsterritton 23 Feb 2015 at 4:37 pm

    @Lane Simonian

    “Some may call this cherry-picking, but I call it mounting evidence that certain natural products can be used to treat Alzheimer’s disease.”

    The former are correct, you are wrong.

    We are familiar with your AD aromatherapy (and other “natural” modality) studies here, because you’ve shared them before. They are of terrible quality. I have previously taken the trouble to read them and comment:

    …said studies are all over the place, are small, clearly exploratory, old, and each is testing a different compound. Two are reports of rat studies. The aromatherapy study is a fishing trip or a joke. No two of these studies support each other in any way that I can make out.

    Now you’re back again, shoehorning into a discussion about acupuncture your twin beliefs that certain “natural” compounds are effective treatment for AD (based on no compelling evidence) and that they are not being pursued because they are “natural.” A single fact answers both: these compounds are not promising. As such, you can advocate for more science, but not in good conscience less regulation. There is no conspiracy against “natural” treatments. Every doc and scientist knows that many effective treatments come “from nature” and that’s where much of today’s R&D is looking for new ones. AD is a particularly active field of study and no rock (or flower or essential oil) is being being left unturned on purpose, as a result of a conspiracy against natural ingredients. While you are correct that many in medicine and science cringe at the term “natural,” it is because that word is almost invariably partnered up with non-medical, non-scientific nonsense.

  54. RickKon 23 Feb 2015 at 7:12 pm

    Isn’t it funny how many people who consider themselves proponents of “natural” health remedies will vigorously defend the practice of sticking dozens of sterilized needles made of engineered stainless steel into all parts of the body, but will vigorously attack the practice of sticking one sterilized needle into a vein in a person’s arm?

    What is natural about acupuncture?

    jsterrit – In the history of consumer products, has any single word allowed more corporations to sell more completely useless products than the word “natural”?

  55. Lane Simonianon 23 Feb 2015 at 11:32 pm

    The connection between acupuncture, aromatherapy (eugenol is a component in several essential oils), and Alzheimer’s disease is the following:

    http://www.ncbi.nlm.nih.gov/pubmed/24024340 (I know–another mouse study).

    You cannot call it cherry picking when every methoxyphenol tested (eugenol, ferulic acid, and syringic acid) has partially reversed Alzheimer’s disease. When similar compounds works again and again only people with closed minds or financial interests will try to ignore their effectiveness.

    Look at the Akhondzadeh studies that were double-blinded and randomized. Tell my why they are junk (and it cannot be you don’t like or believe in the results)?

    Many rocks are being left unturned when it comes to Alzheimer’s disease. Almost all the research is being put in the amyloid and tau basket and very little work is being done with antioxidants. Scientists working with the latter compounds cannot receive adequate funding to conduct clinical trials (I know this because they have told me personally).

    Try to get the Alzheimer’s Association, large research organizations, or pharmaceutical companies in the United States to help fund studies on antioxidants to treat Alzheimer’s disease and see how far you get.
    They are afraid the results will be successful. On the other hand, the huge mass-marketing essential oil companies worry about potential failure.

    Somehow the word natural has become paired with non-scientific. Certainly, the scientific evidence for some claims are not there, but where such evidence does exist the resistance to their use is both unscientific and decidedly unhelpful

  56. Lane Simonianon 24 Feb 2015 at 12:52 am

    I will back away from my comments on motives as it would seem cruel to assume that people are simply motivated by money.

  57. arnieon 24 Feb 2015 at 7:58 am

    Lane S.–“They are afraid the results will be successful.”

    It seems extraordinarily cynical to believe that the Alzheimer’s Association, scientific research organizations, and pharmaceutical companies would truly rather have people become and remain demented rather than to help find ways to mitigate the suffering.

    Really now!! That would be the height of immoral and unethical motivation and conduct by those organizations. I suggest you back up that accusation with some solid evidence, not just hearsay.

  58. Bronze Dogon 24 Feb 2015 at 8:20 am

    @Lane S.: The medical and scientific communities aren’t cartoonishly monolithic, which would be a prerequisite for the usual conspiracy theories about suppressed treatments. Some people go into science and medicine because they want to help people. Some do it for the chance at being the first to discover something. Some do it because either they, their family, or their friends suffer from a condition. Scientists, doctors, and medical researchers are human beings and that entails diverse motives, both good and evil.

    Even then, no matter how good your intentions are, it’s not a good idea to stray from scientific standards. People with good intentions are just as prone to self-deception because they’re still human beings. Scientific methodology is how we guard against self-deception.

  59. Bruceon 24 Feb 2015 at 9:13 am

    I would add that a bigger barrier to dementia research is the lack of research subjects. Sure, there might be hundreds of thousands of people affected, but they are only now being diagnosed correctly (here in Scotland we have targets to INCREASE the prevalence, because it I understood it has been woefully under-diagnosed in the past) and when they are, even if they are willing to take part in studies there are issues around consent and guardianship at the later stages.

    Lane seems to live in a world where there is unlimited money and unlimited research subjects and feels that every avenue needs to be run down with equal vigour and at equal expense. The bare and honest truth is that there is limited resource in more ways than one and decisions have to be made based not only on the results of the studies but the plausibility and effect size. Just quickly looking at some of the studies as a layman I can already see that there are problems with sample size and the controls used in some of those studies linked above. Someone who was willing to put their own money or a significant amount of their time towards a treatment would most likely be a lot more rigorous than I have been…

    To add to what arnie has said, there are multiple charitable and government funded organisations that are researching dementia here in the UK, and to think that ALL of them in cahoots are wilfully ignoring a genuinely promising avenue of research is quite a bold statement.

  60. Lane Simonianon 24 Feb 2015 at 10:36 am

    Some of you missed my previous retraction. It may be that most scientists in the United States consider the use of natural products to treat diseases as pseudoscience. It is no surprise that nearly every trial using natural products to treat Alzheimer’s disease was conducted outside of the United States and that the few people working on natural products to treat Alzheimer’s disease in the United States are facing funding problems.

    Here are two reviews of acupuncture and aromatherapy on cognitive function and behavior respectfully.

    http://link.springer.com/article/10.1007/s11481-014-9550-4

    http://www.ncbi.nlm.nih.gov/pubmed/22433025

    Certainly there are limits to these studies and there are counter studies, but there is a body of evidence that suggests (not proves) that acupuncture in combination with aromatherapy can improve cognitive function and behavior in some patients with dementia.

    I never really buy the limited resources argument. People are making a conscious decision of what to fund and what not to fund and they are choosing to fund (for whatever reason) what has already not worked rather than what has already worked. The Alzheimer’s Association has told me they do not want to give people false hope, but denying real hope may be even worse.

  61. Steven Novellaon 24 Feb 2015 at 10:50 am

    Lane. I think you misunderstand the reason for lack of enthusiasm regarding your hypothesis.

    First – everyone is underfunded these days and complaining that their research is not getting enough priority. So this doesn’t mean much.

    Mouse models of things like AD are difficult, and the history of going form mouse to human has not been great. There was a tremendous amount of interest in the oxidative stress model of neurodegenerative disease, and there still is. However, after 20 years it has become clear that the markers of oxidative stress, and their mitigation, does not simply translate into either a diagnostic or therapeutic tool.

    http://www.ncbi.nlm.nih.gov/pubmed/24669288
    http://www.ncbi.nlm.nih.gov/pubmed/24949424

    So far, this has just not panned out clinically. This actually created a scientific mystery – why didn’t they work? It seems that oxidative homeostasis may be a downstream effect, or just a bystander, when it comes to neurological degeneration. Either that or there is another layer of complexity that we have not dug down to yet.

    At the same time there are at least several other promising avenues of research in AD, including protein folding, axonal transport, and others.

    So it is extremely oversimplistic to paint this picture that the true cause of AD has been discovered but is being ignored because of financial interests. It’s just not reality.

  62. Bruceon 24 Feb 2015 at 11:02 am

    “I never really buy the limited resources argument.”

    As it should happen this was posted today on the BBC website:

    http://www.bbc.co.uk/news/health-31586077

    Why would you expect people to direct their limited resources towards something that has a body of evidence behind it that to date only “suggests” an improvement in cognitive function and behaviour in “some” patients with dementia? All this supported by studies you admit have “limits”?

    All scare quotes are direct words you have used. It is all just too fluffy and lacking in real substance.

    You say you retracted, but in the same post you then accuse those same people of denying people real hope… what is their motivation of doing this if it is not money then? Stupidity? Incompetence? They just don’t care? What are they funding that has already not worked? What are they basing their decision to fund? Whether you “buy” it or not, decisions need to be made and implying that those making them are making bad ones really needs a bit more evidence behind it if you want people on this blog to follow you on it.

  63. Steven Novellaon 24 Feb 2015 at 11:03 am

    Regarding those links, it is hard to overstate how unimpressed I am with this research. The first link simply reviews animal studies for mechanism. This is not evidence that acupuncture works for any cognitive impairment. There have in fact only been a few small human trials with inconsistent results -http://www.ncbi.nlm.nih.gov/pubmed/25206464. This is with including chinese studies, that have a documented bias that renders all chinese acupuncture studies suspect.

    Putative mechanisms are wildly speculative. They amount to little more than “stuff happens” when you stick animals with needles, without demonstrating an actual mechanism of a documented clinical effect.

    The second review is likewise unconvincing. The clinical evidence is preliminary, of the sort that is overwhelmingly likely to be a false positive.

    You are operating in the twilight zone of clinical research. We know from history that a much higher threshold of evidence is required before we achieve a reliable conclusion.

  64. Lane Simonianon 24 Feb 2015 at 11:43 am

    Thank you very much for your response, Dr. Novella. Yes, many scientists have complaints about lack of funding for medical research. And you raise some important questions and points regarding the use of antioxidants to treat Alzheimer’s disease.

    The standard hypothesis for Alzheimer’s disease is that oxidative stress is a downstream effect of amyloid production and/or tau tangles. The opposing hypothesis is that oxidative stress is what causes the formation of amyloid (and other misfolded proteins), tau tangles, synaptic dysfunction, and problems in axonal transport.

    http://jpet.aspetjournals.org/content/321/3/823.long

    The two hypotheses are not mutually exclusive, but it appears that oxidative stress is what drives the disease and that amyloid and tau are minor contributors to that stress.

    If that is the case why haven’t most antioxidant treatments been more effective? In the study done by Galasko which showed no benefit and in some cases even some harm done by antioxidants, he may have used the wrong form of Vitamin E (the type that decreases levels of the better antioxidant form) and a less soluble form of alpha lipoic acid. Vitamin C in the presence of hydrogen peroxide (which is present in early to middle Alzheimer’s disesase) is actually a pro-oxidant. Unfortunately, some in the news media misconstrued these result and proclaimed that antioxidants cannot be used to treat Alzheimer’s disease.

    More broadly, are questions of concentration, absorption, metabolism, and chemical structures. The best anti-oxidants for Alzheimer’s disease are methoxyphenols because the methoxy group donates electrons and increases the hydrogen donating capacity of the phenol groups (or in the case of eugenol the phenol and methylene group). The reaction with peroxynitrites is the following: ONOO- +
    2H+ + 2e-=NO2- + H20. Hydrogen donation partially reverses oxidation and water is a de-nitrating agent. However, NO2- combines with hydrogen peroxide to reform peroxynitrites. So if you have a phenolic compound or other antioxidant compound that is not a highly effective peroxynitrite and hydrogen peroxide scavenger, the best you can do is slow down the progression of the disease.

    Each methoxyphenol has its own limitations. Curcumin is not well absorbed into the bloodstream; ferulic acid is not well-absorbed into the fatty tissue of the brain. Each has improved behavior in people with dementia, but each has had only a limited effect on cognition.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665200/

    http://www.ncbi.nlm.nih.gov/pubmed/21272180

    http://www.alzheimersanddementia.com/article/S1552-5260%2810%2901948-5/abstract

    Eugenol even though it is lipophobic can be inhaled easily into the hippocampus, but its actions on the sympathetic nervous system can increase agitation in some people with demenita.

    Panax ginseng on the other hand contains two methoxyphenols (ferulic acid and syringic acid) that seem to improve both cognition and behavior in people with Alzheimer’s disease and these antioxidant compounds are increased at very high heat (steaming over the boiling point).

    http://www.ncbi.nlm.nih.gov/pubmed/22780999

    Aerosolized curcumin, aromatherapy with essential oils high in eugenol, and sun ginseng (processed at high heat) likely at this point at least present the best antioxidant options for treating Alzheimer’s disease and several other forms of dementia.

  65. Lane Simonianon 24 Feb 2015 at 12:13 pm

    @Bruce. To be truthful, I don’t know why the funding is not there for larger-scale clinical trials. How much of it is due to financial interests–I don’t know. Yes, this is much too broad a brush which I brandished in frustration, although I am not sure it can be discounted entirely.

    If I had to pick one word it would be disbelief. If it were two words, I would pick cognitive dissonance. Why someone would not be interested in trials that have produced positive results–however small the size; no matter what the limitations of the trials–is unfortunately beyond me.

  66. Bruceon 24 Feb 2015 at 12:26 pm

    Lane,

    I think you need to respond to Steve’s posts. You might find the reasons for the lack of interest there.

  67. jsterritton 24 Feb 2015 at 1:41 pm

    Lane…

    I think you need to bring your thinking more in line with current and best science rather than inventing implausible reasons to explain why they diverge. It’s clear you believe that the oxidative stress model of AD is correct and warrants more attention and funding than it is getting. In support of your belief you cite only a handful of studies of poor quality, while ignoring the prevailing high-quality research with results like: “all clinical studies conducted to date did not prove a clear beneficial effect of antioxidant treatment in AD patients.” [1]

    Cherry-picking studies as you do is not persuasive. It indicates that you are trying to find evidence to fit your convictions, instead of following the evidence where it leads. This is a red flag. Similarly, your belief that a conspiracy of sorts exists against “natural” treatments for AD doesn’t make a case for the validity of natural therapies or the oxidative stress model — it is a straw man argument. You express “disbelief” and “cognitive dissonance” that others are so unimpressed by the results of the studies you cite. I’ll reiterate that those studies are wholly unimpressive: the results are tenuous and the methods are doubtful. On top of this, you simply have to factor in the preponderance of compelling, higher-quality, repeated studies showing contradictory (i.e. negative) results.

    Questionable results from small, exploratory studies are not the basis on which to make sound decisions. Making funding and development decisions based on such a flimsy pretext will impede — not advance — medical science. Using such a pretext to peddle false hope to sick people is unethical.

    _____
    [1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941783/

  68. RickKon 24 Feb 2015 at 2:56 pm

    Lane,

    Just one little piece of advice when reviewing acupuncture studies.

    If you look through pubmed at studies done at western research centers, on ANY topic, will be a mix of positive and negative results.

    Acupuncture studies published in China are NEVER negative.

    http://www.ncbi.nlm.nih.gov/pubmed/9551280

    You can trust the honesty of a medical system that produces 99% favorable results as much as you can trust the freedom of an election where the incumbent wins 99% of the vote.

  69. RickKon 24 Feb 2015 at 3:02 pm

    Lane said: “Yes, this is much too broad a brush which I brandished in frustration, although I am not sure it can be discounted entirely.”

    Lane, you might want to try this. Mentally take the position that acupuncture is placebo, just like classical homeopathy. Assume for the purpose of this mental exercise that there are literally over a billion people in the world who believe acupuncture works, are quite convinced that it does, and who will respond with the full force of the placebo effect. Assume also that there are thousands of researchers who also assume it is more than placebo, or who very much want to prove it is more than placebo.

    Now, armed with your devil’s advocate-style critical thinking, go find the research that would unequivocally convince you, the hyper-skeptic.

  70. Steven Novellaon 24 Feb 2015 at 4:25 pm

    Lane – it’s not that no one thinks it’s important. It’s that there are limited funds and competing important questions. Existing negative evidence is a barrier to overcome.

    I agree that it is possible that the wrong dose of the wrong antioxidants are being used. But that amounts to special pleading. You can always cry – too little, or wrong version or whatever, when the study is negative.

    But now the burden is on the proponents of the failed hypothesis to do the research and show that they are right.

    I have no dog in this hunt (scientifically). I would love for AD to be treated with vitamins. I lost a grandmother to AD and it is in my family. Plus I really like successfully treating my patients. I was as disappointed as every neurologist when antioxidants didn’t cure all the horrible neurodegenerative diseases we manage.

    But evidence is king, otherwise we’re well-meaning witch doctors.

  71. Lane Simonianon 24 Feb 2015 at 4:52 pm

    So many interesting points and arguments, it is hard to know where to begin. @jsterritt, the pubmed article you cite is quite good. I would say that to a certain extent most Alzheimer’s researchers agree that oxidative stress plays a role in Alzheimer’s disease, where the disagreement lies is in how large a role it plays.

    I agree that mouse studies do not often predict future success in human beings. The article I linked to was interesting to me because it combined acupuncture with eugenol. Acupuncture has been linked to enhancing brain derived neutrotrophic factor (like exercise) and via this growth factor leads to the activation of the phoshphatidyinosiolt 3-kinase/Akt pathway which is neuroprotective (increase blood flow in the brain, neurogenesis in the hippocampus, and maintenance of antioxidant systems). However, this pathway is cut off by the presenilin gene mutation or by peroxynitrites via tyrosine nitration. Eugenol helps reverse tyrosine nitration. Thus it may be possible even likely that acupuncture itself does not increase cognitive function in people with Alzheimer’s disease but in conjunction with eugenol it does. I would like to see how this may work in humans before drawing any conclusions.

    http://www.pubfacts.com/detail/15941312/In-vitro-activity-of-the-essential-oil-of-Cinnamomum-zeylanicum-and-eugenol-in-peroxynitrite-induced

    In regards to the placebo effect, it may in fact have a physiological as well as a psychological basis, especially in regards to the reduction of stress. In any case, it is hard to say when cognition is limited if there is placebo effect at all or if there is it is a highly modified effect.

    Bias on the part of the observer is always a potential problem. I have no proof that the scientists who did the human clinical trials that I have listed doctored any of the results. I will assume otherwise unless someone uncovers proof of this.

    I am an environmental historian not a scientist so this is where I am in disagreement with many of you. A historian collects the evidence to build a story. I did not begin with the oxidative stress theory of Alzheimer’s disease indeed it was one of the last hypotheses for the disease that I came across when I started researching Alzheimer’s disease eleven years ago. So I went backwards from there: what factors caused peroxynitrite formation and did they increase the risk for Alzheimer’s disease, what factors lessened peroxynitrite formation and did they decrease the risk for Alzheimer’s disease, what damage is done to the brain by peroxynitrites, what clinical trials were there if any that used peroxynitrite scavengers to treat Alzheimer’s disease. The fact that the answers to these questions all began to fit into places over several years was not manufacturing evidence to support my position; it was evidence that peroxynitrites play a central role in Alzheimer’s disease. Once you know the oxidants involved (peroxynitrites and to a lesser extent hydrogen peroxide), then you need to find the particular antioxidants that are most effective against these particular oxidants.

    Would I like to see better designed trials with more participants? Certainly, I would. But I can only present the evidence that I have acquired over eleven years. As one person intrigued by the hypothesis told me extraordinary assertions require extraordinary evidence. I don’t have it yet. But the evidence is much deeper and much richer that one might expect, especially if one expects all antioxidants will not work for Alzheimer’s disease.

  72. arnieon 24 Feb 2015 at 5:47 pm

    Lane,
    “But the evidence is much deeper and much richer that one might expect, especially if one expects all antioxidants will not work for Alzheimer’s disease.”

    I hope that the scientists involved in this research did not “expect all antioxidants will not work for AD”. If they did, they have deviated from what they were, or should have, been taught in their training to become a competent scientist. I can’t speak for environmental historians on this issue, but your comment that “I am an environmental historian not a scientist so this is where I am in disagreement with many of you” is intriguing, if ambiguous. Expectations can (but probably doesn’t inevitably) lead to bias in evaluating the research literature.

  73. jsterritton 24 Feb 2015 at 6:47 pm

    Lane…

    I don’t think anyone here accused you of “manufacturing evidence” to support your position.

    To be blunt, you are raking together a small pile of cherry-picked studies and (special) pleading that it will one day measure up to the mountain of negative results from good studies and systematic reviews that inform the current science on the oxidative stress model of AD. It is very unlikely that you will ever discover the “extraordinary evidence” to back your “extraordinary assertions” in this manner. Why do you have your heart set on what appears to be a failed avenue of inquiry (at least at this time, using best practices)? According to keystone tenets of science-based medicine and skepticism, commenters here (and Dr Novella) can only suggest moving on to greener pastures. You seem open-minded and curious. If you are seeking the best understanding of AD science, you might want to jettison your attachment to any one narrative, especially one that doesn’t hold up — sunk costs be damned. Follow the evidence.

  74. Bruceon 25 Feb 2015 at 4:12 am

    Lane, I can see you are heavily invested in your theory (11 years!), and I will leave you with these thoughts:

    “In any case, it is hard to say when cognition is limited if there is placebo effect at all or if there is it is a highly modified effect.” – You are saying you are not sure if it is the placebo effect or not. You are admitting two things here; one is that the effect is small enough that it could be a placebo, and two is that the studies done were not good enough quality to address this.

    so here is a question for you: After 11 years of collecting evidence are you confident enough in this to invest your own money? You are quite happy to berate everyone else for not putting their resources in the right place, but is it something you would be willing to do?

    Honestly, as someone who works with older people and with medical and social professionals of all ilks, if there was something out there that made a noticeable difference to the personal outcomes of the patients they would be all over it. Your continuing blanket statements of possible doctoring or bias is quite astounding. Why do you believe that you, an environmental historian, sees what thousands and thousands of medical professionals, who in many cases have personal links to those affected by dementia, do not?

  75. Lane Simonianon 25 Feb 2015 at 11:08 am

    I have been asked several more questions, so I will try to answer them.

    First of all this is not my hypothesis. Mark A. Smith, one of the founders of the peroxynitrite hypothesis for Alzheimer’s disease, said this about his critics:

    “I have received a lot of stick for my scientific talks where for over a decade I have challenged the amyloid hypothesis. I typically tell the audience that my views are controversial and that I would really appreciate someone pointing out a flaw in my logic or presenting evidence that shows that I am wrong. Neither has ever happened.”

    Further defense for the oxidant hypothesis for Alzheimer’s disease comes in the link provided by jsterritt:

    “The pressure from oxidative stress in the aging brain in combination with a lowered antioxidant defence creates a harmful combination that could disturb functions and damage organelles such as mitochondria. This would eventually lead to loss of synapses and cell death that give rise to the clinical symptoms associated with AD. For these reasons, therapies using antioxidants still hold great promise. However, results so far have been rather disappointing and most studies have failed due to various reasons.”

    There are likely many of the reasons why antioxidant therapies have failed so far (indeed as I and others have said before one can find many reasons for failure–some potentially valid and others not–but it is hard to explain away success). All I have done is pointed out which phenols (methoxyphenols) are most effective at scavenging and partially reversing the damage by peroxynitrites and the positive results from clinical trials using these compounds. I suppose it could be a false positive, placebo effect, dumb luck, coincidence, or some other factor but I highly doubt it.

    As to why most of the medical profession is not aboard with this, see most of the comments above (again maybe it is because I am an environmental historian but I take awhile before I rule things out; so I agree with Arnie that because some antioxidants have failed does not mean every antioxidant will fail; if the same type of compound or treatment approaches fail time after time I rule it out–anti-amyloid approaches for example, but if the same type of compound works over and over again I rule it in–isn’t that how science is suppose to work?).

    Here are some quotes from people who began as skeptics but became “believers”:

    Rollie Hampton, a senior at Cornell University, studying lemon balm for the treatment of Alzheimer’s disease:

    “Before this, I did not realize the potential that plants had [to treat disease]. I realized that many plant-based drugs are adapted to become more potent or to target a specific mechanism,” Hampton said. “That was really cool.”

    East Carolina University recreational therapist David Loy who was part of a program using aromatherapy in memory care facilities:

    “I’m a scientist who believes nothing works without evidence; prove it to me,” he said. “I am working with an aromatherapist who believes everything can be cured through scents. I must admit, I’m becoming a believer, because of some of the data.”

    Benjamin Pearce owner of a group of memory care facilities in New Jersey:

    The lei is one way Pearce delivers aromatherapy to the elderly residents in his 12 New Jersey facilities. He also instructs his staff to spritz lavender on their pillows and mix six drops with their bathwater. Other natural oils, such as citrus blends and rosemary, are added to humidifiers, massaged into patients’ skin or pumped into the air via diffusers. “I’m the most pragmatic person you’ll ever meet, and I am totally sold on aromatherapy,” Pearce says.

    Pat Zinke, operator of a foster care facility for people with Alzheimer’s disease:

    When the weather warms, residents will have the opportunity to go outside for supervised gardening. Currently, Zinke has found that residents respond favorably to aromatherapy with essential oils.

    “I don’t know how, but it’s working,” Zinke said. “I’m amazed. I’m trying to be open minded.”

    Could these people and many others be deluding themselves–possibly. Could the people who believe that aromatherapy is a pseudoscience be deluding themselves–possibly. I have seen it work with my mother, I have seen it work through friends and acquaintances, I have seen it work in care facilities, I have seen it work in clinical trials. Is that enough evidence for me? Yes. Is it enough evidence for others? No.

    So would I put money into these treatments? Yes. I contacted an organization that does these studies a couple of days ago. I recommended aerosolized curcumin, aromatherapy with essential oils high in eugenol, and sun ginseng for Alzheimer’s disease. The doctor asked if I wanted to sponsor a clinical trials and I just laughed but I should have asked how much (I very much doubt I have the money to sponsor a whole trial but may be a portion of it). The point is I should not have to put money into what others should be funding, but if that is the only way to move things forward, I would do it.

  76. tmac57on 25 Feb 2015 at 11:40 am

    Lane- Your anecdotes on aromatherapy are indistinguishable from all of the testimonial tripe that we see on every sketchy alternative medicine/therapy website.
    In other words they stink!

  77. jsterritton 25 Feb 2015 at 1:28 pm

    Lane…

    These infomercial-style testimonials are the worst kind of “evidence” you could provide here. You are making at least two different arguments: one from ignorance (e.g., cherry-picking positive studies, ignoring negative ones) and one from anecdote. In fact, it seems that you are working backwards from anecdote to support your claims about efficacy with cherry-picked trials. You are shifting the burden of proof and claiming an authority from poor/tenuous trials while denying that of gold-standard systematic review papers. You even cherry-pick positive-sounding statements from within negative research papers (Persson et al), ignoring the authors’ primary conclusion that “all clinical studies conducted to date did not prove a clear beneficial effect of antioxidant treatment in AD patients.”

    Holding out hope for treatment advances using the oxidative stress model of AD is one thing; making claims for aromatherapy as medicine is irresponsible. Leaving aside the many troubling aspects of aromatherapy, the scientific literature is bursting with evidence that real antioxidant therapies don’t work. You appear to be claiming that the least plausible of therapies holds the most promise, in inverse relation to the evidence, because of …what? Anecdote? Hope? Sunk costs (e.g., 11 years of research)?

    This is magical thinking and woo. It is the wrong direction to look for treatment/cure. Rather, you will find cults of personality, snake oil peddlers, and charlatans retailing false hope for profit and attention. You will I’m sure find plenty of well-intentioned caregivers and professionals, but nice intentions and wishful thinking are no substitute for science.

  78. arnieon 25 Feb 2015 at 1:35 pm

    Lane,

    I think perhaps your deep belief that anti-oxidants are efficacious in the treatment of AD, and your search for support in that belief, led you to misinterpret my comments as supportive and indicatede by your surprising statement that “…..I agree with Arnie….”. That sense of agreement is a one way street, I’m afraid.

    Perhaps I wasn’t clear, but in writing that I hoped that scientists involved in this research did not “EXPECT that ALL antioxidants did not work”, I was not suggesting that they, or I, should or do expect that SOME might work. Rather, I was addressing the bias-inducing problem of EXPECTATION in doing scientific work and your insinuation that perhaps the research isn’t supporting you because the researchers do not expect antioxidants to work. Do you see the distinction? I think scientists should simply “follow the evidence” wherever it may lead (and I don’t mean the kind of anecdotal stuff you’re now feeding us) and to be very careful not to let their interpretations of the evidence be contaminated by hopes and expectations. Further, the evidence that needs to be followed must be based on far more in depth research projects than anything you, or anyone, has produced so far in support of to the role of anti-oxidants in AD treatment.

    You almost seem to believe that your “environmental historian” training and experience has enabled you to be more qualified to evaluate scientific research, results and conclusions, and priorities for funding than those of us in the medical and scientific disciplines (and “discipline” is an appropriate word in this context). The strength of our hope for an effective treatment for AD might lead us into funding, or doing, research on it, but it must not be allowed to cloud our critical thinking and judgment in evaluating the quality and conclusions of that research. Otherwise, we risk falling prey to the siren song of pseudoscience rather than science and science based medical practice. It seems like something is blocking your understanding of that so far and that “something” led to your belief that we were in agreement.

  79. Lane Simonianon 25 Feb 2015 at 3:31 pm

    I will try to capture your statement more accurately: we should not expect all antioxidants to fail because some antioxidants have failed in clinical trials so far. That they may still fail is a distinct possibility, but we don’t have enough evidence to support that conclusion yet. Do I have it more or less right? My only disagreement with this is that some antioxidants have already succeeded in clinical trials.

    We are not talking about anecdotes. As noted, these are not people trying to sell mass-marketed essential oils for aromatherapy. These are people who work day in and day out with patients with dementia. They could be wrong about their daily observations, but the point was to answer the question if this worked would not all health care professionals be using it. Some are and with good results. You can question their observational abilities or that their desire to see something work gets in their way of an objective analysis. I can neither prove or disprove that. But most people generally don’t invent things out of whole cloth (some do, of course).

    As far as being an environmental historian, it may be an advantage in two ways: you are less likely to prejudge data and you are in part able to see the history of how certain environmental toxins, diets, and plant resources have contributed to illness or contributed to their treatment in the past and present. You are also able to see how certain scientists vociferously rejected the careful research of others (think Rachel Carson and DDT). Some skeptical scientists appear to be working backward: x, y, and z cannot work so when evidence is provided that x, y, and z does work it has to be wrong. Telling the story before you have seen all the evidence is a cardinal sin in history (although again some do), it should be a cardinal sin in science as well.

    I have five lines of evidence in support of the peroxynitrite hypothesis of Alzheimer’s disease:

    All factors that increase peroxynitrite formation (from stress, to certain pesticides, to a diet high in sugar, salt, carbohydrates, and high fructose to corn syrup, to genetic mutations, to certain medications, to certain chronic bacterial and viral infections, to air pollutant, to water pollutants) increase the risk for Alzheimer’s disease.

    All factors that decrease peroxynitrite formation (a Mediterranean diet or a diet from India) reduce the risk for Alzheimer’s disease.

    Peroxynitrites directly or indirectly can explain all the symptoms and features of Alzheimer’s disease (amyloid, tau tangles, mitochondrial dysfunction, problems in axonal transport, reduced transport of glucose, reduced blood flow in the brain, reduced neurogenesis, impeded neurotrasmissions, synaptic dysfunction, reduced synthesis of neurotransmitters involved in short-term memory, sleep, mood, social recognition, and alertness, and the death of neurons.

    Clinical trials with methoxyphenols have produced significant improvement. in cognition and behavior in people with dementia and especially those with dementia. The following are the two most effective trials involving steamed ginseng.

    A 24-week randomized open-label study with Korean red ginseng (KRG) showed cognitive benefits in patients with Alzheimer’s disease. To further determine long-term effect of KRG, the subjects were recruited to be followed up to 2 yr. Cognitive function was evaluated every 12 wk using the Alzheimer’s Disease Assessment Scale (ADAS) and the Korean version of the Mini Mental Status Examination (K-MMSE) with the maintaining dose of 4.5 g or 9.0 g KRG per d. At 24 wk, there had been a significant improvement in KRG-treated groups. In the long-term evaluation of the efficacy of KRG after 24 wk, the improved MMSE score remained without significant decline at the 48th and 96th wk. ADAS-cog showed similar findings. Maximum improvement was found around week 24. In conclusion, the effect of KRG on cognitive functions was sustained for 2 yr follow-up, indicating feasible efficacies of long-term follow-up for Alzheimer’s disease.

    Nutr Neurosci. 2012 Jul 9. [Epub ahead of print]
    Heat-processed ginseng enhances the cognitive function in patients with moderately severe Alzheimer’s disease.
    Heo JH, Lee ST, Chu K, Oh MJ, Park HJ, Shim JY, Kim M.
    Abstract
    OBJECTIVES:
    Ginseng has been reported to improve cognitive function in animals and in healthy and cognitively impaired individuals. In this study, we investigated the efficacy of a heat-processed form of ginseng that contains more potent ginsenosides than raw ginseng in the treatment of cognitive impairment in patients with moderately severe Alzheimer’s disease (AD).
    METHODS:
    Forty patients with AD were randomized into one of three different dose groups or the control group as follows: 1.5 g/day (n = 10), 3 g/day (n = 10), and 4.5 g/day (n = 10) groups, or control (n = 10). The Alzheimer’s Disease Assessment Scale (ADAS) and Mini-Mental State Examination (MMSE) were used to assess cognitive function for 24 weeks.
    RESULTS:
    The treatment groups showed significant improvement on the MMSE and ADAS. Patients with higher dose group (4.5 g/day) showed improvements in ADAS cognitive, ADAS non-cognitive, and MMSE score as early as at 12 weeks, which sustained for 24-week follow-up.
    DISCUSSION:
    These results demonstrate the potential efficacy of a heat-processed form of ginseng on cognitive function and behavioral symptoms in patients with moderately severe AD.

    To ascertain the principal active peroxynitrite (ONOO(-)) scavenging components of heat-processed Panax ginseng C.A. Meyer (sun ginseng [SG]), the ONOO(-) scavenging activities of fractions and components of SG were compared. The results demonstrated that the ONOO(-) scavenging ability of SG was due to its ether fraction containing phenolic compounds. High-performance liquid chromatography analysis and ONOO(-) scavenging activity tests of the phenolic acids contained in SG identified vanillic acid, ferulic acid, p-coumaric acid, syringic acid, and maltol as the main active ONOO(-) scavenging components of SG. The ONOO(-) scavenging activities of phenolic acids and maltol were dependent on the degrees of their proton donating ability.

    It is easy to say you don’t like the hypothesis, you don’t like the clinical trials, you don’t like the case studies. But if you consider the totality of the evidence, one would have to be wrong on so many different levels for the hypothesis to be substantially wrong (I keep tweaking and changing it). Like Mark A. Smith, when someone proves me wrong I will move on. I am not here to convince you that you are wrong; I don’t have the irrefutable evidence to do this. Just that the arguments that I am wrong seem to full back on well-worn skeptical terms (woo, pseudoscience, snake oil, etc.) rather than substantial evidence to the contrary (and that certain antioxidants have not worked so far is not substantial evidence to the contrary–that would be like saying because a certain antibiotic did not effectively treat a certain infection that no antibiotic can treat any infection). So I try to cut through the noise, and see what might actually be helpful

  80. jsterritton 25 Feb 2015 at 4:48 pm

    “My only disagreement with this is that some antioxidants have already succeeded in clinical trials.” Citation needed (cherry-picks need not apply).

    “We are not talking about anecdotes. As noted, these are not people trying to sell mass-marketed essential oils for aromatherapy. These are people who work day in and day out with patients with dementia.” These are still anecdotes and an argument from authority.

    “Some are and with good results.” Citation needed (ibid).

    “But most people generally don’t invent things out of whole cloth (some do, of course).” No one is saying that this anecdotal evidence isn’t real and sincerely believed, only that anecdotal evidence is not scientific evidence. The testimonials you provide are merely the subjective reporting of people’s personal experience. These are opinions, not science. When commenters here point out the worthlessness of this type of evidence, citing bias, they are not accusing anyone of fraud. Rather, they are merely trying to explain to you the difference between good evidence (scientific, tested, rigorous, with bias removed) and bad (anecdote).

    “Telling the story before you have seen all the evidence is a cardinal sin in history (although again some do), it should be a cardinal sin in science as well.” There will never be a “final reckoning” — science is always moving forward with the evidence. You are the one who is discounting the preponderance of scientific evidence in favor of your small trove of cherry-picks and anecdotes. In other words, you’re guilty of the sin you describe: insisting on a story without considering the evidence.

    “The arguments that I am wrong seem to fall back on well-worn skeptical terms (woo, pseudoscience, snake oil, etc.) rather than substantial evidence to the contrary.” This is not true. Commenters here have provided links to a number of systematic reviews comprising any number of research studies with negative results [1] [2]. You choose to ignore these and have countered with cherry-picks and anecdotes. The arguments made here have been evidence-based and reasoned. Accusing us of name-calling is poor repayment and doesn’t strengthen your argument one bit.

    “That would be like saying because a certain antibiotic did not effectively treat a certain infection that no antibiotic can treat any infection.” You are committing so many fallacies of reasoning it’s hard to keep track. This “absence of evidence” gambit underscores your overarching argument from ignorance. Nobody here is claiming to know everything, yet that’s where you’re setting the bar for evidence that contradicts your argument.

    As Dr Novella commented above, “evidence is king.” You seem to think that some evidence, regardless of its source, reliableness, methods, etc. is all you need to advance your AD “narrative.” It’s not, because there is a preponderance of better evidence eclipsing yours. I would especially draw your attention, again, to the 2014 Persson review showing negative results in study after study of precisely the compounds you are championing here.

    “So I try to cut through the noise, and see what might actually be helpful.”

    It is arrogant of you to discard the good evidence provided to you here and instead cling protectively to your exercise in confirmation bias and storytelling. You are not Galileo. You are thriving on noise.

    ______
    [1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941783/
    [2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4053273/

  81. Lane Simonianon 25 Feb 2015 at 6:44 pm

    Your evidence is better than my evidence is what you feel it comes down to. I respectfully disagree and hope that the future of Alzheimer’s research will see if oxidants are the main driver of the disease and if a particular antioxidant or combination of antioxidants can be used to effectively treat the disease. Some of the initial evidence is promising but not conclusive.

  82. arnieon 25 Feb 2015 at 6:52 pm

    Lane……no, you still didn’t understand the point that I was making. You seem so profoundly committed to your conviction that anti-oxidants are the antidote to AD symptoms and progression that you have been unable to see the larger point I was making which is applicable to scientific research, in general, namely, that advance “expectations” can subtly bias study design, interpretation, and conclusions. Perhaps even more, “expectations” and pet beliefs can lead naive readers of science research reports, even highly educated historians, to unknowingly allow confirmation bias to lead them into all kinds of errors in logic and reason not only in interpreting what they read on a science subject, but in being vulnerable to thinking that the testimonials and anecdotes they read or hear are events of evidence supporting their deeply clung to biases and wishful thinking.

    I think jsterritt’s challenges and comments to you (and those of others) are attempts to confront you with the same problems in your comments.

  83. Lane Simonianon 25 Feb 2015 at 10:16 pm

    Yes, I understand your point: expectations can influence results, such as all Chinese acupuncture studies show a benefit to acupuncture (in some case that benefit may actually have been there; in other cases not). Time will tell if I am guilty of a conformation bias or if the evidence actually supported the hypothesis.

    My profound disagreement is on two levels: one is that any study or systematic review that supports the use of specific antioxidants in the treatment of Alzheimer is cherry-picking whereas any study or systematic review that reaches the opposite point of view is good science. Second is the labeling of observational studies as merely useless anecdotes. Observation is as much a part of science as experimentation. When a doctor asks a patient their level of pain or where it is hurting or did a medication help or have side effects is the patient’s response an irrelevant anecdote? There is a wonderful book called Medicine and the Reign of Technology where many physicians began to consider patient responses unreliable especially in the wake of new technology.

    What I most object to is the use of labels in the place of persuasive arguments: cherry-picking, woo, pseudoscience, anecdotes, snake oil, etc. This reflect the bias of the author and may or may not have anything to do with objective reality.

    A couple of years ago, I wrote about peroxynitrites on another website. The scientist who responded was uncomfortable with the hypothesis but he asked his colleagues directly working in the field if there was anything to what I was saying. They said to send me to the KEGG pathway for Alzheimer’s disease. Not all of KEGG confirmed my hypothesis but I was grateful to have the parts that did not as well as the parts that did. That’s how science advances, not through the use of pejorative language and red herrings.

    Here is what I would like: evidence that the oxidative damage in Alzheimer’s disease is caused primarily by amyloid or by tau tangles, evidence that amyloid or tau tangles cause some damage other than oxidation, and evidence that the compounds that I have identified do not help people in larger clinical trials. Then I can move on to a better understanding of the disease. Or alternatively, none of those things are true and my job is done.

  84. jsterritton 26 Feb 2015 at 12:40 am

    Lane…

    First, you are constructing a false equivalence between studies of shaky quality, cherry-picked for positive results over years, and the current scientific literature on the oxidative stress model. Second, you are demanding a successful model as an alternative to yours (if not oxidative stress, then plaques). Failures of other models do not make yours successful (they are unrelated; it is a false choice). Third, you are making a straw man argument about being bullied with terms like cherry-picking, woo, pseudoscience, anecdotes, snake oil, etc. No one here (myself included) has used these terms in lieu of a real argument. You have presented us with cherry-picked studies and anecdotal evidence, the hallmarks of pseudoscience (or “woo”). Only a single commenter has used the word “pseudoscience” here (not directed at you), whereas you bring it up a lot. Even if commenters here were mean and bullying, that fact would not strengthen your argument (it would only make us jerks).

    The anecdotes you have provided us with are the “testimonials” in your comment above. No one is saying that the observational studies you cite are anecdotes, only that they are of questionable quality (for a number of reasons) and with equivocal or unimpressive results. What makes them cherry-picks is that you only cite studies with positive results, ignoring the lion’s share of ones with negative results. You do not cite any systematic reviews in support of your argument. If one were to read only your presentation of the science on AD, they would conclude that the oxidative stress model was the bleeding-edge of AD research and that antioxidant therapies — even ones as implausible as aromatherapy — were a veritable panacea. You know this is not the case, so you should not present it as such.

    You should improve your understanding of the scientific method. A doctor asking a patient to report on their health and response to treatment is not an observational study. Only with a statistically significant cohort and a proper control group (i.e., a lot of such reports, carefully controlled for bias) does such reporting have scientific value. Post hoc, subjective, inherently biased “evidence” gathering was replaced by the scientific method precisely to improve medicine, not stymie it.

    Your demands are unreasonable (“here is what I would like”). Some have already been met and others are beyond anyone’s ability. You have refused to accept the current review articles about the inefficacy of antioxidant treatment for AD. You refuse to consider other models unless oxidative stress is ruled out entirely. It’s too bad your mind is so set on “confirming” your “hypothesis” (not scare quotes, just your words). You clearly know a great deal about — and have a great interest in — AD research. In my opinion, that knowledge would be enhanced by adding some healthy skepticism to the mix and following the evidence where it leads.

  85. Lane Simonianon 26 Feb 2015 at 12:45 am

    Peter D. Kramer importantly argues that there is a place for “anecdotes” and “vignettes,” as adjuncts to data, to help doctors make clinical judgments. As a nurse scientist, I applaud this view, but I argue that these anecdotes are data that can be systematically collected and analyzed to help illuminate patients’ experiences.

    Most nurse-scientists conduct quantitative research, including clinical trials, but many of us conduct qualitative research for the distinct purpose of generating data to understand patients’ perspectives and experiences of their illnesses and their treatments. Data comes in a variety of forms and collectively leads to a comprehensive understanding of our patients.

    ELLEN F. OLSHANSKY
    Irvine, Calif., Oct. 19, 2014

    The writer, a nurse, is a professor in the Program in Nursing Science, University of California, Irvine.

    Amen! Can anecdotes always be trusted–no. Can they sometimes add to clinical trial evidence–even some scientists will say yes. If you want, don’t believe the clinical trial results or the observational evidence. But acknowledge your own biases as well as the biases of those who you are criticizing.

  86. Lane Simonianon 26 Feb 2015 at 1:02 am

    Yes, see where it leads.

  87. Bruceon 26 Feb 2015 at 4:20 am

    Lane,

    You really are going through the scientific fallacy playbook:

    First you pre-empt your cherry picked studies by trying to brush all studies with the same brush. All studies are not the same, and the ones you have presented are poor, even you admit this.

    You have then attempted to poison the well with alluding to and then very quickly jumping back from allegations of fraud and scientists only being in it for the profit. You can appear to back away from that as much as you like, but you know full well what you were doing.

    All this littered with a huge dose of JAQing off… and…

    You are now reduced to arguing the power of anecdotes. This is something that has been addressed at length in the following post:

    http://www.sciencebasedmedicine.org/the-role-of-anecdotes-in-science-based-medicine/

    I have had recent experience of this where there were what felt like many anecdotes coming across my and managers desks about a recent work issue. When I looked at the data it turned out there was nothing there more than the usual statistical noise. The anecdotes were simply a few and very small minority or staff who had made some very sketchy assumptions and jumped to some convenient conclusions (for them).

    I really can’t add any more to it than that without repeating myself, the article linked and what others above have said. You should really read through those studies that jsterrit posted, they are pretty comprehensive. In this case, his evidence is very much better than yours and I actually regret saying you should put your own money into it because in all honesty you will be wasting it.

  88. Hosson 26 Feb 2015 at 10:19 am

    Lane
    The evidence you’re using is of poorer quality than the evidence you’re rejecting. You’re not going to convince anyone here into lowering their standards of evidence, which is essentially a large part of what you’re arguing.

    “Don’t f***ing “Jimmie” me, Jules, okay? Don’t f***ing “Jimmie” me. There’s nothing that you’re gonna say that’s gonna make me forget that I love my wife, is there?” (You get +5 Tarantino points if you know the quote off the top of your head.)

    There’s nothing you can say that will make me accept lower quality evidence.

    You could be right though, but the only way to prove it is with data that doesn’t currently exist. Until you have the evidence, there’s nothing that you’re gonna say that’s gonna make me forget that I love my wife.

  89. Lane Simonianon 26 Feb 2015 at 10:35 am

    I will try to get to this somewhat differently. The objection to the systematic reviews in regards to antioxidants in the treatment of Alzheimer’s disease is not with the quality of these reviews but with the antioxidants reviewed. One needs to provide systematic reviews of the antioxidants that have been appeared to be successful to do it right.

    Here are the most recent systematic reviews for aromatherapy and dementia:

    http://www.ncbi.nlm.nih.gov/pubmed/22433025

    http://www.ncbi.nlm.nih.gov/pubmed/24569873

    That the conclusions are inconsistent is not surprising. Aromatherapy with certain essential oil can reduce mild anxiety, but not severe anxiety and certain essential oils can actually increase anxiety. All these reviews on inconsistent and incomplete data always urge larger-scale trials.

    Observational data (and I prefer that term over the trivalizing word anecdotes) is just like any other data–it can be useful or it can be misleading (good link by the way). Scientists like quantitative data and qualitative data is often considered to be always unreliable (or maybe I am just getting a bad sample size on this blog). This from my perspective is both incorrect and unfortunate.

    So when I use the term red herring I don’t necessarily mean that people are trying to deliberately distract from the data at hand. However, one cannot conclude from a systematic reviews of antioxidants that excluded the antioxidants producing positive results that the antioxidants producing positive results were ineffective. Nor when people working in memory care facilities or studies similarly report positive results using these same antioxidants that their evidence cannot be relied upon simply because it was “anecdotal”.

    Of course I make mistakes (like assuming that aromatherapy had only minor side effects or could be used to treat all anxiety) and sometimes I make allegations that are over the top, but for the most part I try to argue fairly and rationally and based on the best evidence that I have before me.

  90. jsterritton 27 Feb 2015 at 12:13 am

    Lane…

    “All relevant randomised controlled trials were considered.” [1]

    This is from the review of the Cochrane database of studies you link to. It is an acceptable review*, showing negative results.

    The Geriatrics and Gerontology review you link to [2] is behind a paywall. Still, its results appear to be equivocal at best. The abstract suggests that the paper has combined the results of 11 RCTs, with mixed results. I cannot comment on the quality of this review, except to note the low impact factor of the journal (in an active field of study– AD — this is unimpressive, but not damning). I wish you would consider that the mechanism of aromatherapy involved in these studies itself speaks against the efficacy of antioxidants (or any novel therapy administered as such) and that RTCs and “observational data” concerning it are red flags for solid science (see here [3]). All you have cited here are scientific papers calling for more study in the familiar cautious language of science. You continue to discount negative results from better quality sources about more plausible (than aromatherapy) antioxidant treatments for AD. Also, you throw all results re dementia and cognitive function in the elderly together in one basket. AD is far more specific than that. Making people feel better is a fine thing, but it is not treatment for disease. I think you are conflating the two.

    You have to stop objecting to terms that are wholly accurate, like “anecdote.” You have provided much anecdotal evidence in this thread and that’s all it is: anecdotal evidence. Please learn to understand the difference between a technical term and “pejorative language.” Also please learn to be less thin-skinned: no one here is against you or seeking to diminish your beliefs out of meanness or enmity. Calling anecdote “qualitative” (vs the cold, statistical “quantitative” data of science) does not make it equal to scientific evidence. You’re just imposing a false equivalence that makes, literally, no sense.

    I have learned a lot about AD from discussion with you here. Thanks. I hope you’ll keep the channels open.

    Your complaint is that the oxidative stress avenue of inquiry has dead-ended. It is not with the commenters here or Dr Novella.

    ____
    [1] http://www.ncbi.nlm.nih.gov/pubmed/24569873
    [2] http://www.ncbi.nlm.nih.gov/pubmed/22433025
    [3] http://www.scientificamerican.com/article/velvet-improves-older-adults-well-b/

    * note: this is not a Cochrane review, it merely draws on the DB

  91. Lane Simonianon 27 Feb 2015 at 1:38 am

    This is good enough for me. I don’t want the oxidative stress avenue of inquiry to be dead-ended until after the best antioxidants have been tested for Alzheimer’s disease and failed.

    I am indeed thin-skinned; it is sometimes hard to distinguish between a disagreement over evidence with a personal attack–I think your evidence is weak versus I think the way you think is ridiculous.

    I seek not absolute agreement or even partial agreement, but just a bit of grudging respect (which is sometimes provided) that there is a slight chance that I might be right.

    I am not sure when or if I will be back here. I should probably get off of In the Pipeline, too. It does little good to post where 95 percent of the people are going to disagree with you on principle. It is better to post where 50 percent of the people agree with you and tell you why and where 50 percent of the people disagree with you and tell you how to expand your field of vision. I have done much better on Alzconnected and the Alzheimer’s Reading Room where a small group of dedicated researchers keep pushing each other to find better answers, not to be stuck in a perpetual argument.

  92. Bruceon 27 Feb 2015 at 4:16 am

    “It is better to post where 50 percent of the people agree with you and tell you why and where 50 percent of the people disagree with you and tell you how to expand your field of vision.”

    You want false balance, and that is something you won’t get here, so it is probably best you find somewhere else.

  93. RickKon 27 Feb 2015 at 6:49 am

    Lane said: “It does little good to post where 95 percent of the people are going to disagree with you on principle. It is better to post where 50 percent of the people agree with you and tell you why and where 50 percent of the people disagree with you and tell you how to expand your field of vision.”

    Well, I prefer the way science works – where lots of competitive colleagues pick your hypothesis apart, vigorously and meticulously informing you where and why you are wrong. Only by weathering and addressing that level of criticism and scrutiny can you find out that your idea is actually right.

    Talking to people who are inclined to agree with you is how we get homeopathic treatments for Ebola, no-touch martial arts masters and people who think Sandy Hook was a hoax. Convincing educated, evidence-based skeptics is how we get Nobel Prizes, smallpox eradication and a global digital communications network for debating the merits of science.

    If you are serious about this topic, and it appears you are, then THIS is exactly the kind of forum you need to convince if you want to actually determine that your ideas have merit. If the only people who agree with you are those who view aromatherapy uncritically, then you’ve achieved nothing real other than introducing another form of placebo theater. And the challenges of AD and dementia need real solutions, not more theater.

  94. mllevy1on 02 Mar 2015 at 1:44 pm

    Check out my blog site entitled Placebo Medicine. It is about how the neuroscience of the placebo effect explains complementary medicine and describes how to correctly integrate complementary into mainstream medicine. http://www.placebomedicine.com/

  95. Bronze Dogon 02 Mar 2015 at 5:12 pm

    @ mllevy1: Do you actually know what we think the placebo effect is, and why we consider it unreliable and unethical to prescribe them?

    1. The placebo effect isn’t any one thing. It includes factors like chance recovery, natural healing, and very importantly, human psychology. That’s why clinical studies compare real treatment versus placebo treatment or current standard of care plus a placebo. The placebo effect is going to happen to both groups which is what makes it possible to isolate the treatment’s actual effect on their health.

    2. Unless you’ve got something like a meta-analysis of placebo vs. no treatment studies to show me, the placebo effect doesn’t have any effect on objective measurements used to determine a person’s health, except possibly stuff related to stress, but that’s only a guess of mine. It’d make more sense and be more respectful of the patient’s autonomy to reduce stress with good bedside manner, relaxation techniques, and counseling than with a placebo.

    3. If sCAM is all about the placebo effect, why do we need to bother integrating it? Sugar pills, saline solution, and so forth are usually much cheaper.

    4. Don’t you find it unethical and paternalistic to routinely deceive patients allegedly for their benefit? Mainstream medicine’s been moving on to patient-centered care, where the patient’s informed decisions are at the heart of the matter. Prescribing placebos is a step backwards.

  96. jsterritton 02 Mar 2015 at 5:31 pm

    @mllevy1 (from his website)

    “Many physicians argue that deception in medicine is unacceptable and I agree but deception is not required for Placebo Medicine to work. It works just as well, and often better, with a fully informed patient.”

    I’m listening…

    “I coined the term “Placebo Medicine” to create a category that is half complementary and half mainstream medicine.”

    You lost me.

  97. ccbowerson 02 Mar 2015 at 7:24 pm

    “deception is not required for Placebo Medicine to work. It works just as well, and often better, with a fully informed patient.”

    Placebo effects also occur with medicines that actually have therapeutic effects beyond placebo. Given this, what is the utility of placebo without evidence based therapeutic effects? If there are evidence based treatments available, there is no good justification

  98. The Other John Mcon 02 Mar 2015 at 7:30 pm

    So the doctor will say: “I am going to prescribe you a placebo. Eat these 3 pieces of scrap metal and drink two sips of water, and this sugar pill before bed. You are almost certainly not going to get better, and really this has no real hope of working on any level. But this is a power I’d like to harness for The Good of Humanity.” Something along those lines?

  99. jsterritton 02 Mar 2015 at 7:52 pm

    He thinks he coined the term “placebo medicine.” Adorable.

  100. mllevy1on 02 Mar 2015 at 11:30 pm

    #jsterritt I searched the internet and wiki etc. and did not find the term Placebo Medicine in use.

  101. mllevy1on 02 Mar 2015 at 11:44 pm

    #Bronze Dog No, I don’t know what you think the placebo effect is and apparently you do not know what I think it is. The definition is problematic in this line of research. I am defining it by calling it non-pharmacologic therapy. I know that definition is also problematic but the reason I chose it was because i am trying to group together psychotherapy, hypnosis, the doctor-patient relationship, as well as sugar pills or sham surgery and most forms of alternative medicine. Everything that uses suggestion and interpersonal communication to achieve a medical benefit. I am saying that expectation and suggestion can have an effect on brain function that can have an effect on a limited number of health related things such as pain, nausea, depression and anxiety as well as psycho-somatic complaints. This type of suggestion works just as well with a fully informed patient. There is no need for deception. The science in it is in the how the interpersonal communication and expectancy effect neurotransmitter function.

  102. mllevy1on 02 Mar 2015 at 11:54 pm

    #The Other John Mc What you are describing is the nocebo effect. You are suggesting to the patient that they will not get better. If they are effected by that suggestion then it would not be surprising if they, in fact, did not improve. The idea is that suggestion and expectation can effect brain function resulting in a limited effect on health. You can treat pain and nausea through hypnosis or suggestion but you can’t cure cancer in this way. It has to be something that can be treated by altering neurotransmitters such as opioids which suggestion can do.

  103. mllevy1on 03 Mar 2015 at 12:09 am

    # ccbowers Yes, I agree 100%. What I say repeatedly on my site is that the placebo effect is the way we communicate optimistically with the patient to maximize whatever treatment we are giving. I also state repeatedly that the only things that we know placebo can treat all by itself is pain, nausea, depression, anxiety and OCD and, of course, psychosomatic complaints. Anything else I would use whatever the appropriate treatment is plus I would do and say all the things that suggest a positive outcome. Deception is not necessary. In psychiatry we have found, for example, that cognitive-behavioral psychotherapy works as well as Prozac but they work best when you use both together. And you can show functional brain images of the frontal lobes regaining function equally well with the non-pharmacologic intervention of psychotherapy which I see as simply elaborate suggestion. There is no deception involved.

  104. mllevy1on 03 Mar 2015 at 12:26 am

    #jsterritt # ccbowers #The Other John Mc #Bronze Dog Here is a page from my blog about how I would suggest a family physician integrate complementary medicine into his or her practice. It should better address some of the points that are being made here. http://www.placebomedicine.com/?page_id=2619

  105. The Other John Mcon 03 Mar 2015 at 3:00 am

    You would, quite literally, by definition, be unable to prove Placebos’ effectiveness over Placebo, because you are giving Placebo, which is the same thing as Placebo. I can make you feel better just by doing a simple thing: making you feel better. Circular logic off the rails my friend…

  106. Bruceon 03 Mar 2015 at 3:22 am

    mllevy1,

    You might want to check out Harriet Hall’s recent post on SBM:

    http://www.sciencebasedmedicine.org/placebo-are-you-there/

    It is quite comprehensive.

    And you are wrong in your definition of the nocebo effect. A nocebo is when people apparently feel worse because of some inert treatment or substance. I would have hoped someone who has written a blog post on the placebo effect might know this.

    As for “Placebo Medicine”, the author of this very blog used the term back in 2009:

    http://www.sciencebasedmedicine.org/the-rise-of-placebo-medicine/

  107. Bronze Dogon 03 Mar 2015 at 9:15 am

    I know that definition is also problematic but the reason I chose it was because i am trying to group together psychotherapy, hypnosis, the doctor-patient relationship, as well as sugar pills or sham surgery and most forms of alternative medicine.

    One of these things is not like the others, one of these things just doesn’t belong…

    Everything that uses suggestion and interpersonal communication to achieve a medical benefit. I am saying that expectation and suggestion can have an effect on brain function that can have an effect on a limited number of health related things such as pain, nausea, depression and anxiety as well as psycho-somatic complaints. This type of suggestion works just as well with a fully informed patient.

    Your definition of placebo is at odds with everyone else’s use of it, then. What it amounts to is that you’re lumping legitimate ways of relieving psychological issues that occur alongside physiological issues with quackery as “placebo.” We’re already familiar with people who lump diet and exercise as “alternative medicine” so that they can say alternative medicine is more popular. The problem I’m having is that you seem to be doing this in order to prop up “alternative medicine” as an equal alternative when it isn’t.

    There is no need for deception. The science in it is in the how the interpersonal communication and expectancy effect neurotransmitter function.

    Unless you’re trying to help them that way with “alternative medicine,” which makes false claims (hence it’s quackery euphemistically branded as “alternative”). Telling falsehoods to the patient to manipulate their reaction is deception.

  108. mllevy1on 03 Mar 2015 at 11:37 am

    # Bruce If Steven used the term back in 2009 that is likely where I picked it up and forgot where I got it from. I am a huge Novella follower. He…he… In regards to the definition of nocebo, you say, “people apparently feel worse because of some inert treatment or substance.” That is correct but if you mean to imply that an inert substance caused a behavior to occur without going through the brain then I must object. The mechanism that a nocebo uses to effect behavior has to do with suggestion and expectation causing the brain to communicate through neurotransmitters to the body to throw up or experience pain or what ever. You can give someone a sugar pill or just make a verbal suggestion and tell them it will make them throw up and cause a serotonin mediated emesis reaction to occur. The nocebo effect like the placebo effect is mediated through non-pharmacologic suggestion causing real changes in brain function.

  109. mllevy1on 03 Mar 2015 at 11:55 am

    # Bronze Dog I am most definitely not trying to prop up “alternative medicine” as an equal alternative and I am in no way suggesting to tell falsehoods to a patient to manipulate their reaction. I am very clear throughout all my writing that what I am trying to do is find the common thread that is the real causal agent in these seemingly disparate non-pharmacologic interventions. The causal agent in my opinion has to do with suggestion and expectation. To me, psychotherapy is an elaborate use of suggestion and expectation and so is hypnosis and so are placebo and nocebo effects (I specifically exclude all the placebo effects that have to do with regression to the mean or natural course of illness etc. and focus on studies that demonstrate brain changes due to suggestion and that is why the definition is difficult and something I am still struggling with.) I am no big supporter of alternative medicine and I have major issues with how the trillion dollar per year alternative industry is using it. I would like to communicate with folks who like alternative stuff and get them to do it in a more reasonable way but I am not saying that because you can treat pain with a placebo then the brain is some mystical thing that can heal anything. This mechanism we are talking about where suggestion causes the brain to produce chemicals that alter bodily function is what is interesting to me. If you can help me to solve my definition problem so that I am only talking about that and not the other things that cause mis-perception placebo effects I would be most appreciative.

  110. mllevy1on 03 Mar 2015 at 11:58 am

    # Bronze Dog Here is Harriet Hall’s review of my on-line book entitled Placebo Medicine: “Dr. Levy’s book is packed with good information about placebos and about treatments that have no benefit beyond the placebo effect. His light, entertaining style makes it accessible to all and a pleasure to read. I am particularly intrigued by his proposal for incorporating placebo treatments into mainstream medicine.”
    Harriet Hall, MD The SkepDoc, SkepDoc, Science-Based Medicine

    Here is James Randi’s review of that book: “A fine job. So good, that I will even steal material from it for my forthcoming book, A Magician in the Laboratory.”
    James Randi, The James Randi Educational Foundation

    Here is the link to this book: http://www.placebomedicine.com/?page_id=612

  111. mllevy1on 03 Mar 2015 at 12:32 pm

    By the way, I have no control over all the alternative medicine ads on my site. Does anyone know how to reduce them?

  112. mllevy1on 03 Mar 2015 at 12:37 pm

    And if anyone really wants to know what I am thinking on the subject of complementary vs mainstream medicine you can read this piece entitled “The Debate.” http://www.placebomedicine.com/?page_id=2077

  113. Bronze Dogon 03 Mar 2015 at 1:07 pm

    I would like to communicate with folks who like alternative stuff and get them to do it in a more reasonable way but I am not saying that because you can treat pain with a placebo then the brain is some mystical thing that can heal anything.

    Then it would have made more sense to me to talk about integrating mainstream medicine into “alternative medicine,” rather than vice versa. Talking about integrating “alternative medicine” into mainstream medicine is usually a false compromise offered by quacks and their supporters to appease skeptics and appear generous when they’re really asking us to ignore the longer term implications of apparently giving a stamp of approval to quackery and humoring the false dichotomy of there being two major categories of medicine.

  114. jsterritton 03 Mar 2015 at 1:55 pm

    @mllevy1

    “For example, a family doctor might see a person who has Type II diabetes. The patient is prescribed Metformin® to help control their blood sugar but the doctor knows that how and what this patient eats and how this patient exercises and what kind of relationships this patient has will influence the long range outcome of this patient’s health. Therefore, the doctor sends the patient to a nutritionist, psychologist, exercise physiologist, massage therapist and to a homeopath. The reason the homeopath was including is because the patient indicated a positive association with this type of therapy in the past.”

    Are you claiming nutrition, exercise, talk therapy, massage, and homeopathy as “complementary” modalities? They are not. Four of these are standard of care and one is magical nonsense. The homeopath the patient is sent to will necessarily deceive the patient with the myth that homeopathy is effective medicine. The notion that CAM practitioners somehow inherently have good patient relations is a common trope heard from CAM proponents who would like the “people skills” of naturopaths and other quacks to rival actual medical training. And anyway, why would we want “mainstream” doctors learning from practitioners who reject real medicine in favor of magical nonsense and who are by definition either credulous and uneducated about healthcare or are lying to their patients outright? I think a patient should run screaming from any doctor who sends them to a homeopath for treatment of diabetes (or at all).

    I understand that you are describing an ideal situation and a special breed of “gold-star” CAM practitioner — ones who won’t deceive their patients, undermine real care, peddle false hope or magic bullets, and will work conscientiously with the coordinating doctor. But where will you find such a unicorn? CAM modalities are often tangled up with unscientific belief systems. Others are predicated on mistrust of evidence-based medicine itself. Many are simply scams.

    To exploit what little merit there might be in placebo medicine depends on taking it out of the hands of witch-doctors and returning the (dubious and scant) power of placebo to real doctors. This necessarily means divorcing CAM practices from their unscientific belief systems. With nonsense like homeopathy there is no baby, only bathwater. Best to throw it out altogether (I assure you no one will notice; health outcomes will be entirely unaffected).

  115. Hosson 03 Mar 2015 at 5:40 pm

    This is interesting seeing someone trying really hard to rationalize fraud.

  116. Bruceon 03 Mar 2015 at 5:54 pm

    I am more interested in those review quotes he has on his site, by James Randi and Harriet Hall… Is there any way of verifying them?

  117. RickKon 03 Mar 2015 at 6:50 pm

    Dr. Levy,

    1) You can’t recommend homeopathy or Reiki or any number of forms of placebo theater without fully informing the patient that “this treatment medical no benefit beyond the psychological influence it has on you – it is no different than psychotherapy”. Anything less, and you have not fully informed the patient.

    2) The more you blur he lines between science and just-making-stuff-up, the more you erode any standards for medicine and open the door to whatever sells (not whatever works). Look around you – how much of our economy is based on selling people stuff they don’t need? I’d like to think that medicine is striving for a higher standard.

    3) You open the door to MASSIVE amounts of harm. By legitimizing placebo theater vendors, you give them the ability to market such wonders as chelation for autism, applied kinesiology for anaphylactic peanut allergy (what someone recommended for my daughter’s treatment), or homeopathic prophylaxis for malaria and Ebola.

    4) Where does it end? You’re sending them to a homeopath today, tomorrow to a warlock, and next week to that guy down the street who wears a silver suit and has a saucer-shaped office. Are you and every other medical professional able to know where to draw the line between beneficial and absurd? Is legitimizing the absurd really in the best interests of the patient?

    How many other facets of life do we want to take the attitude: “work with whatever the person believes rather than telling and teaching them the truth”? Physics? History? Ecology? Engine maintenance?

    Finally, my trust in doctors would be seriously eroded if I learned they are being directed to make decisions on which patients will be told Santa is real and which won’t. I think you have an obligation to treat me and every other adult patient as an adult. What you’re suggesting in these comments sounds disturbingly paternalistic. And if your doctor won’t tell you the truth, who will?

    I will look for your book based on Dr. Hall’s comments on sciencebasedmedicine and will keep an open mind, but on the surface I see your position as deeply dangerous to the continued advancement of truly effective medicine.

  118. jsterritton 03 Mar 2015 at 7:18 pm

    Bruce…

    Read Harriet Hall’s review.[1] She has great fun entertaining Levy’s premise about “incorporating placebo medicine into mainstream medicine,” but certainly doesn’t lend those ideas credence. It’s a review, not a debate, and Hall never really gets into plausibility. She plays around with Levy’s ideas about identifying particularly susceptible-to-placebo-response patients who might benefit for non-specific symptoms like pain or nausea in a completely mumbo-jumbo-free application of placebo modalities. Hall seems to pine for a time when old fashioned country doctorin’ included the occasional well-intentioned sugar pill. This is what Levy is selling.

    [1] http://www.sciencebasedmedicine.org/incorporating-placebos-into-mainstream-medicine/

  119. RickKon 03 Mar 2015 at 9:29 pm

    The first sentence of my earlier post should have read ” … this treatment has no medical benefit beyond…”

    Fat fingers on a mini iPad. Apologies.

  120. tmac57on 04 Mar 2015 at 9:41 am

    I don’t worry too much about the idea that a placebo might give temporary relief for some types of pain.
    What concerns me greatly, is the widespread idea that placebos have ‘very powerful’ effects, to the point that they are credited with healing serious, life threatening diseases such as cancer.
    This is all part of the mind-body healing idea, where what you have to do is have a positive attitude along with your doctor’s positive attitude, and it will cause your body to rid itself of tumors. Basically, the ideas behind ‘The Secret’, are being leveraged to support the idea that placebos are part and parcel of the mind’s powerful ability to heal the body, and any failure of that are all down to the patient’s poor attitude and inability to ‘just’ get better already!

  121. Bronze Dogon 04 Mar 2015 at 11:00 am

    Worth mentioning: A lot of “positive thinking” fads end up causing a great deal of anxiety in their patients from being constantly vigilant against “negative” thoughts, separating themselves from friends and family for fear of their “negative” influence, and putting up forced smiles lest they invoke the wrath of their quack and fellow patients for having a less than fantastic day.

  122. jsterritton 04 Mar 2015 at 12:44 pm

    In fairness to Levy, he claims to be concerned with bad CAM practices, too. I think he sees “mainstream” medicine as the best hope to stem the tide of dangerous BS that many CAM practices use, like false hope, magic bullets, dangerous practices, and lies. By creating only a small supporting role for CAM in patient care — under the coordinating auspices of real doctors — “mainstream” medicine can control the script and monitor the scrupulousness (and benefits, if any) of the CAM treatment. Maybe Levy will return to address this with his own words, but I read him as seeking to minimize CAM, make CAM transparent, and have CAM subsumed entirely into “mainstream” (or “real”) medicine. This would be preferable to the wild west of scammers and charlatans, cults of personality, actual cults, and magical nonsense preying on the uninformed and credulous without any oversight to speak of.

    However, it is a slippery slope. I am suspicious of “ecumenical” types who seek advantage by pretending there is some middle ground between real medicine and CAM. Usually, such docs are seeking to appeal to patients with the authority of real medicine combined with people-pleasing/appeasing “open-mindedness” about whatever crazy nonsense is in vogue at the moment. Levy tries to set himself apart from these, but he’s still skating on thin ice.

  123. mllevy1on 04 Mar 2015 at 1:42 pm

    # jsterritt # Bronze Dog # RickK # Bruce # tmac57 # Hoss # The Other John Mc Great discussion. I agree with most of what everyone is saying here. The parts I disagree with are mostly accusations that I am saying things that I am not saying. So, just to be clear, no deception is ever OK, deception is not necessary for the placebo effect to work and no study has every demonstrated that it is, there is no paternalism here since I am not advocating lying about anything ever, I AM intentionally being overly optimistic about a utopia world and don’t really think most alternative practitioners will buy into this but I can still talk about it, several of the quotes you guys posted caused me to cringe when I read them and I am trying to find them so I can edit them but thanks for pointing them out, I am just now launching this site and need all the criticism I can get so keep it coming, I DO NOT THINK PLACEBOS CURE EVERYTHING!!!!!! and I frequently say that the only thing they treat by themselves are not illnesses but compensatory brain mechanisms mediated by neurotransmitters such as pain, nausea, depression and OCD, I am not promoting a simplistic “positive thinking fad” this is about a number of interpersonal communication techniques that are designed to manipulate the human brain to produce a compensatory response, when I send a patient to a Homeopath I fully inform the patient that there is no medicine in the water and it is all about getting your brain to produce an opioid to treat your pain by the power of suggestion and implying to the patient that if they cooperate with the Homeopath then it will work, and, finally, I totally agree with the statement that I am trying to take the placebo effect out of the hands of witch doctors and put it in the hands of real family doctors. Also, # jsterritt’s last comment accurately stated what I am trying do extremely well and I support every word including the potential slippery slope stuff.

  124. mllevy1on 04 Mar 2015 at 1:51 pm

    # jsterritt # Bronze Dog # RickK # Bruce # tmac57 # Hoss # The Other John Mc and I did not fake the reviews…he…he. Also, I am currently writing a book called Placebo Psychiatry and you can watch it grow as I write it and if anyone wants to make comments or suggestions as I go it would be greatly appreciated. I can tell by the comments here that this is a group that would be very helpful to me as I continue to write. http://www.placebomedicine.com/?page_id=768

  125. mllevy1on 04 Mar 2015 at 1:59 pm

    # jsterritt # Bronze Dog # RickK # Bruce # tmac57 # Hoss # The Other John Mc Here is one additional point. There are a number of things that exist in both the complementary world and in the mainstream world such as nutrition, exercise, talk therapy, massage, etc. As a psychiatrist I have worked with many of these professionals. They are often torn between the lure of alternative approaches and mainstream medicine. Even a lot of MDs are. I am trying to make some rules so you don’t have to be teetering on the fence. I want to say, “You can do the alternative stuff as long as it is within these parameters that I am setting.” Hope that made more sense.

  126. BillyJoe7on 04 Mar 2015 at 3:14 pm

    Firstly, if you want to take placebo out of the hands of witch doctors and into the hands of doctors you won’t achieve that by encouraging doctors to send their patients to witch doctors.

    Secondly, the onus is on you to provide evidence that fulling informing patients about the placebo nature of the treatment you are referring them for does not diminish, if not destroy, the effect.

    Thirdly, you need to show that the placebo effect is not weak, unreliable, and transient. Otherwise you are wasting your time with that book. You are over-rating the placebo effect.

  127. mllevy1on 04 Mar 2015 at 4:11 pm

    # BillyJoe7 Firstly, I said, “send to witch doctors,” pejoratively. I am clearly saying that if you want to do alternative medicine you need to abide by these rules and a real MD or DO needs to oversee what you are doing. You can find the rules here: http://www.placebomedicine.com/?page_id=2619

    Secondly, I was already thinking about writing an article to specifically address the issue of deception based on what everyone is saying here. There is a lot of evidence to support my position but I need more space than this comment box to make the case. Give me about a week or so.

    Thirdly, it depends on what you are treating. Are you treating a real illness or disease or are you trying to trigger a compensatory brain mechanism. For example, if you are treating a staph infection or a stomach cancer then the placebo effect can be extremely week but if you are treating arthritic knee pain the placebo effect can be very strong. Also, if you separate out mis-perception placebo effects from suggestion mediated placebo effects and only focus on the later then you can see a much stronger effect.

  128. jsterritton 04 Mar 2015 at 5:11 pm

    Mllevy1…

    I recommend making your rules clearer. Are you advising that the coordinating MD educate the patient about homeopathy being an unsophisticated, unscientific system of insane beliefs, and that any response to such treatment would be purely well-understood placebo response (or coincidence), but that the homeopath her/himself still rattle their bones about the law of similars, etc? It is also unclear why you would send a person with a metabolic disease to a homeopath. This appears to contradict what you say about using placebo medicine for symptoms like idiopathic pain and nausea. (You really could not have used a worse example than homeopathy.)

    Also, massage, talk therapy, nutrition, exercise, etc are not “things that exist in both the complementary world and in the mainstream world.” They are absolutely standard of care in “mainstream” medicine. If anything, CAM proponents like to hijack these from real medicine and claim them as their own, because it is safe and effective treatment that actually works and they have nothing else. Claiming diet and exercise as CAM is lying. Selling such as novel CAM therapy is stealing. CAM proponents encourage this myth in the same way they encourage the myth that CAM practitioners have better patient relationships than “mainstream” doctors. This is a common fallacy about naturopaths and such: that they “spend more time” and “listen” to patients. This is another base lie implying that real doctors are unfeeling, don’t care, don’t listen, and can’t be bothered to help. It’s nothing less than CAM proponents/practitioners lying about the practices and integrity of their competitors (real docs) to increase their own stock. I think these two CAM talking-points highlight a pattern by CAM proponents of stealing and lying — or at least being comfortable with same done in their interests.

    The most benign CAMs have nothing of value to offer; the worst are dangerous. In between there is sometimes a weak and illusory placebo response in some patients. If all CAM has to offer is the substandard, fuzzy promise of placebo response brought to you by liars and thieves, shouldn’t they be cut out of the process altogether? (/end dramatic language:))

    None of which is to say that there isn’t some merit in placebo medicine. However, to be practiced ethically it simply doesn’t admit including the magical nonsense, false hope, and false advertising practices that are CAM.

    I look forward to your revised and clearer rules. You’re right that this will be good forum to share your ideas. It is encouraging that you are open to the strong-minded criticism you will encounter here.

  129. mllevy1on 04 Mar 2015 at 11:48 pm

    # jsterritt don’t mind the harsh language at all as I prefer real criticism and not the kind that people who are afraid to hurt my feelings give.

    I agree with most of what you say. In regards to the rules, you can find them on this page. If you have any useful suggestions for improving them I would be all ears. http://www.placebomedicine.com/?page_id=2619

    I am not suggesting that there is any elaborate explanation necessary. You simply say, “Homeopathy has no proven benefit beyond that of placebo but it is a really good placebo and placebos are proven effective treatments. The story line that a homeopath will tell you concerning residual essence in the water after it is repeatedly diluted may not be factually accurate but if you allow yourself to follow the direction and want it to work it can trigger compensatory brain mechanisms through the power of suggestion. This has worked for many people and I believe it can work for you.” That’s it.

    My experience with people who do all those therapies such as massage etc, is that many of them are open to alternative BS and many of them are overt alternative BSers. I would like for them to have clear boundaries.

    When you say there is nothing of benefit I have to point out that it is a trillion dollar per year industry and it has existed for all of recorded history minus the past 100 years and people sure seem to benefit in some way. In my opinion, it has to do with how our brains evolved to do social behavior and maintain homeostasis and react to fear and love and rejection and acceptance. I can cause adrenaline to increase in your brain by simply typing “Fuck you!!!” and I am not even in the same place or the same time as you are. Human interaction can cause brain-behavior effects without pharmacologic intervention. These effects can have limited therapeutic effect for things like pain and nausea.

    I totally agree that a physician can not engage in any deception or magical non-sense what so ever and I would never suggest otherwise.

    I really appreciate this discussion and look forward to more help if you desire to keep communicating. Most of my friends and even fellow physicians are drawn by the lure of CAM and can’t seem to give me much helpful feedback.

    http://www.placebomedicine.com/?page_id=2698

  130. mllevy1on 04 Mar 2015 at 11:52 pm

    # BillyJoe7 OK, here is a rough draft of my deception article. See what you think: http://www.placebomedicine.com/?page_id=2698

  131. Bruceon 05 Mar 2015 at 3:44 am

    mllevy1,

    I apologise for stating that you might be lying with your references. That was unfair of me.

    I have been following the conversation with interest from there and I have one question regarding:

    “You can do the alternative stuff as long as it is within these parameters that I am setting.”

    Even with clear rules that we all agree on and in a perfect world where the issues being highlighted by jsterrit, BJ7, Rickk and Bronze Dog have been addressed, do you really think CAM will succumb to something like this? Do you think sCAMers will work within these rules? How will this be policed? I fear that CAM is such a big industry it would recoil quite violently at rules being imposed on it as there have been precious little to date.

    The first hurdle would be getting them to admit that their treatments are no better than placebos…

  132. BillyJoe7on 05 Mar 2015 at 7:41 am

    Morgan,

    “OK, here is a rough draft of my deception article. See what you think: http://www.placebomedicine.com/?page_id=2698

    Some quotes from your draft and my responses:

    “there was a study on IBS”

    By you own admission, that study was flawed by researcher bias, recruitment bias, non-blinding, and absent controls. In other words, it was fatally flawed. That study cannot tell you anything.
    Therefore, you should delete the first four paragraphs from your article.

    “Placebos DO work”

    So what if placebos DO work…if the effect is weak, unreliable, and transient?

    “The question…is, “How or why do they work.” ”

    But, if the placebo effect is weak, unreliable, and transient, that question is not even relevant.
    Before doing anything else, you need to establish the placebo effect is worth harnessing.
    I don’t think you have done that.

    “It turns out that they do work by [deception]…but there have been numerous studies demonstrating that they can also work through a real brain mechanism”

    Fine, but…

    “non-pharmacologic intervention mediated through suggestion and expectancy can trigger compensatory brain responses mediated by neurotransmitters”

    Instead of creating “suggestion and expectancy” around treatments that have been shown to have no effects beyond placebo (ie useless treatments), why not use treatments that have been shown to work over and above placebo effects (ie useful treatements). The former is, at most, a neutral-win situation, whereas the latter is a win-win situation. In fact, the former is more likely to be a lose-win situation if the CAM practitioner doesn’t abide by your rules. And you can almost guarantee that they won’t. So you have a choice is between a lose-win and win-win situation…what are you going to choose?

    “Functional brain imaging reveals that the neural pathways involved are similar between subjects who receive these non-pharmacologic therapies and subjects who receive exogenous opioids, antihistamines, serotonin and norepinephrine for these same conditions”

    But if the non-pharmacologic therapies are so much less effective than exogenous opioids, antihistamines, serotonin and norepinephrine, so what?

    “The key point is that suggestion and expectancy are the active ingredients that trigger the brain response”

    The key point is that mediators of “suggestion and expectancy” such as homoeopathy and acupuncture have no effect beyond placebo. The treatments themselves are useless. And if, as expected, the homoeopaths and acupuncturists don’t abide by your rules, the total result is likely to be negative, especially if they also promote harmful treatments, advise against proven effective treatments such as vaccination, and promote an pseudoscientific, non-scientific, or anti-scientific mindset in their/your patients.

  133. BillyJoe7on 05 Mar 2015 at 8:24 am

    In short, you need to:

    – establish that the placebo effect Is worth harnessing.
    – explain why the placebo effect is worth harnessing via otherwise useless treatments.
    – demonstrate that practitioners using useless treatments will follow your rules.

  134. mllevy1on 06 Mar 2015 at 12:02 pm

    # Bruce Appreciate your apology and just let me state, since you don’t know me, that I make zero money off CAM. My interest is in the brain science of how non-pharmacologic interventions can effect brain function.

    Agree with everything you say. My response is to say, “No, I do not believe that sCAMers will do this but I am not interested in those individuals.” The ones I want to reach are the reasonable people who are kind of in the middle like my niece. She is not an MD but is a massage therapist. She is drawn by the lure of CAM and often asks me questions and is usually unsure of what to think. I want people like her to have some guidance and some parameters that are kind of hard and reliable and easy to follow. Does that make sense?

    An interesting thing is that I am saying there is some benefit from CAM but the way it works is unknown to anyone who does CAM. Maybe if some of them knew how and for what it actually was effective they could change their narrative and not be bold face lying.

    Thanks for your comments.

  135. mllevy1on 06 Mar 2015 at 12:45 pm

    # BillyJoe7 Wow! Great responses. Thanks.

    The fact that a study is flawed does not mean it is wrong. That criticism is a logical fallacy. For example, the original study that found Salicylic acid to be effective was very flawed but it was not wrong.

    The reason they did this IBS study backwards makes sense. They were thinking, “OK, lets do everything we can to maximize the suggestion and expectation and then be totally honest and see if the placebo effect works under those conditions.” So, the issues is, “Were they being totally honest?” The answer to that question is what makes this study alive or dead and it is very reasonable thing to debate.

    Your main critique is to ask the question, “How potent is the suggestion, expectation and actual changes in brain function mediated placebo response?” Great question! This was my initial question also. To study it better I generalized the definition to include all things that were non-pharmacologic ways of changing brain function. Now I could look at hypnosis and psychotherapy and not just placebo studies. As a psychiatrist who has training in cognitive-behavioral psychotherapy and whose wife is a PhD who specializes in that I was very aware of the research that demonstrated this type of talking therapy is as effective as medication. This finding has now been replicated many times and the functional brain images are astounding. Same systems, same pathways, same neurotransmitters improve with non-pharmacologic therapy. The science is in the communication, not in the pill, and the non-pharmacologic approach is as a effective as the pharmacologic approach. I think this gives good insight into the question of how potent can a placebo be.

    Your final point is my favorite point and I absolutely agree with you and I state it repeatedly all over my site. It works best when you do both pharm and non-pharm together. However, there are a small number of specific but general things that placebo alone can treat pretty well such as pain, nausea, depression, OCD and psychosomatic complaints and placebo certainly has less side effects. And for these few things there is a lot of literature demonstrating robust placebo effects. The placebo effects you get in Cancer trials tend to be much smaller and mostly misperception type placebo effects.

    OK, here is a huge and confusing point. Why do we need a totally BS story line to be involved in the treatment? I say we don’t. I am also a trained hypnotherapist and I can tell you that hypnotherapy works best with a fully informed patient who wants to do it and practice can make them better at doing it. The direction that you ask them to follow could be anything. The active ingredients are the suggestions and expectations and rituals. You tell the patient to relax and let yourself follow my instruction. Why can’t we explain to a patient that Homeopathy has no scientific merit but if you relax and allow yourself to follow the instruction you can get your brain to produce opioids that will lessen your pain from IBS. I can do this with roughly 80% of people using hypnosis.

    What do you think?

  136. mumadaddon 06 Mar 2015 at 6:46 pm

    mllevy1,

    Like Bruce I’ve been following this conversation with interest. I find it fascinating and will defer to those with better knowledge of the subject matter to tackle the main topic, but I couldn’t resist this:

    The fact that a study is flawed does not mean it is wrong. That criticism is a logical fallacy. For example, the original study that found Salicylic acid to be effective was very flawed but it was not wrong.

    What logical fallacy do you think that is?

    The fact that flawed methodology occasionally throws up an answer that later gets validated by better science doesn’t excuse drawing conclusions that are unjustified by the evidence available at the time.

  137. RickKon 06 Mar 2015 at 8:52 pm

    Dr. Levy,

    Do you think the Homeopathic Pharmacopoeia of the United States contains any real knowledge or is it all just theater to make the placebos more convincing? Should Pfizer or Merck be able to market sugar pills and make completely false claims about the pills so that doctors may use them for placebo medicine? Curious of your thoughts on these issues.

  138. jsterritton 07 Mar 2015 at 12:01 am

    Kaptchuk et al made a number of errors in constructing their study. Those errors don’t necessarily negate the results, which are only suggestive/equivocal all on their own. The study isn’t fatally flawed by its design shortcomings and mllevy1 is within his rights to call BJ7’s argument a fallacy of composition. That said, I do not envy Dr Levy the task of making his case for placebo medicine with the research papers in his armory. Most are small, exploratory, and have flaws like the ones in the IBS study. Looking through the papers Dr Levy has cited here and on his website, there appears to be an overarching problem that is more than a semantic distinction: specifically, what constitutes a placebo. The IBS study looks like a normal drug trial, except that the treatment arm received a “persuasive rationale” instead of meds and the control arm received no treatment. The “persuasive rationale” consisted of sugar pills and instruction that such pills “have been shown in rigorous clinical testing to produce significant mind-body self-healing processes.” This “rationale” was present even in the advertisements recruiting study participants. Critics contend that this language itself is psychological trickery (and that the ads resulted in participants self-selected to respond positively to same). In other words, critics claim that the “open placebo” design was not truly open and “deception-free,” because it relied on psychological mechanisms to elicit a placebo response and cheerleader effects: namely, suggestion and conditioning.

    Dr Levy seems to have a very expanded definition of what he considers a placebo. On his website he cites a limited number of studies that he interprets as demonstrating a powerful placebo response in subjects for pain, nausea, anxiety, OCD, and depression. While the studies regarding pain are straight-forward enough (almost any form of suggestion can elicit a physiological response in placebo responders that is probably identical to medication effects), the others are unconvincing. The OCD study [1] is not about placebo response, but rather tests efficacy of intensive cognitive behavioral therapy. Similarly, the Leuchter et al study [2] of placebo treatment for depression makes basic mistakes. The authors attribute all positive results in the placebo responder group to placebo, discounting entirely that all subjects in the drug trial received regular supportive psychotherapy. In this study, QEEG maps showed a physiological response in placebo responders almost opposite that of medication responders. The authors incorrectly imply a causal link exists between placebo and this response where there is merely a correlation reflecting the prefrontal activity of depressed subjects as they improve absent pharmacological effects. In other words, the authors attribute all positive results in the placebo group to placebo treatment. This is the same thing that has confounded researchers for decades: whenever you control for a treatment arm in a drug trial using placebo you are likely to see ~30% of subjects who respond in the placebo group. The reasons for this are increasingly well-understood and researchers are trying to correct for the psychological reasons, coincidence, and bias in placebo-controlled studies.

    Dr Levy takes the opposite approach, lumping legit medical interventions like psychotherapy and CBT into the placebo category with needles and sugar pills. Working backwards from results (people feeling better), Dr Levy doesn’t seem to be troubled with patients seeking placebo medicine from CAM practitioners. I think that the overlap underscores that the health benefits from placebo response belong only in the realm of science-based medicine. After all, that’s where these effects are coming from. Being dishonest about the cause of placebo effects (e.g., needling) is as bad as claiming a bogus explanation for them (e.g., balancing/restoring “qi”).

    ________
    [1] https://huehueteotl.wordpress.com/2008/01/22/rapid-effects-of-intensive-therapy-seen-patients-with-obsessive-compulsive-disorder-ocd/
    [2] http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.159.1.122

  139. BillyJoe7on 07 Mar 2015 at 7:59 am

    Morgan,

    “The fact that a study is flawed does not mean it is wrong”

    Firstly, I did not say the study was flawed, I said it was fatally flawed
    Secondly, I did not say it was wrong, I said nothing could be concluded from it.
    My assessment that the study was fatally flawed was based on your summary:

    “This study was done by people who support CAM (complementary and alternative medicine) and was funded by NCCAM (National Center for Complementary and Alternative Medicine) and the advertisement to enlist subjects said it was a “mind-body” study. Suffice it to say, there was tons of bias. Also, the study was intentionally done backwards. It was totally open-label with no control group”

    Nothing can be concluded from an open label study with no control group. It is fatally flawed. I have not read the study, so I can’t comment on jsterritt’s take on it, I only comment of your summary of the study. I assume that, if the study was open label with no control group, jsterritt would agree that nothing could be concluded from it (jsterritt, am I wrong?).

    “[cognitive behaviour] therapy is as effective as medication”

    I hope I got that right.
    If so, are you saying that CBT is a placebo treatment?

    “I absolutely agree with you…It works best when you do both pharm and non-pharm together. However, there are a small number of specific but general things that placebo alone can treat pretty well such as pain, nausea, depression, OCD and psychosomatic complaints and placebo certainly has less side effects”

    Are you saying that placebo is as good as placebo + pharmaceutical in these situations?
    If I have a fractured leg, is a placebo going to suffice?
    Or are we talking only about pain that is largely psychosomatic. I can see how a psychological treatment could effectively treat psychosomatic pain. But I find it difficult to understand how a sugar pill could do likewise unless a psychological sweetener comes with it. But, then, why the sugar pill? Unless you can show that psychological sweetener + sugar pill is better than psychological sweetener. If so, where is this study. I’m not saying it doesn’t exist, I’m saying you haven’t shown one yet.

    “They were thinking, “OK, lets do everything we can to maximize the suggestion and expectation and then be totally honest and see if the placebo effect works under those conditions.” So, the issues is, “Were they being totally honest?” ”

    It would seem to me that to “maximize the suggestion and expectation”, you would have to be “dishonest”. Perhaps you can show me in your own words how it could be done. Paint me a scenario where you use acupuncture or homoeopathy to treat pain where you “maximize the suggestion and expectation” without being “deceptive”. That’s the first part.
    The second part is to find a methodologically sound trial that shows that placebo + psychology is better than psychology alone.

    “Why do we need a totally BS story line to be involved in the treatment? I say we don’t. I am also a trained hypnotherapist and I can tell you that hypnotherapy works best with a fully informed patient who wants to do it and practice can make them better at doing it. The direction that you ask them to follow could be anything. The active ingredients are the suggestions and expectations and rituals. You tell the patient to relax and let yourself follow my instruction”

    Here you are talking about hypnotherapy alone but here…

    “Why can’t we explain to a patient that homeopathy has no scientific merit but if you relax and allow yourself to follow the instruction you can get your brain to produce opioids that will lessen your pain from IBS.”

    …you are talking about hypnotherapy + homoeopathy.
    But why add in the homoeopathy if, as you say…

    “I can do this with roughly 80% of people using hypnosis”

    Does adding a placebo get you above the 80%?
    If so, have you got a clinical trial that demonstrates this?
    If not, why bv||$#!+ around with placebos?

  140. BillyJoe7on 07 Mar 2015 at 8:10 am

    jsterritt,

    “mllevy1 is within his rights to call BJ7′s argument a fallacy of composition”

    Your take: “the control arm received no treatment”
    Morgan’s take: “no control group”

    I was commenting on the trial as summarised by Morgan in his link.

  141. jsterritton 07 Mar 2015 at 11:46 am

    BJ7…

    You should read the study, if only to see a textbook example of the shortcuts you have to take with design and the spin you have to engage in to make your results look more than equivocal in a NCCAM pilot study where you desperately want to show positive CAM results. Still, it’s not a fatally flawed study. It tests a treatment arm (sugar pill & persuasive rationale) vs control arm (no treatment). Both groups received equal face time with medical staff, but necessarily there was no blinding. The researchers are forthcoming about how they recruited for people primed to be placebo responders. The only really goofy thing researchers did was title their paper “Placebo Without Deception” when they weren’t even honest about what a placebo is. They took a bunch of credulous people with an illness characterized by rollercoaster reporting of waning/waxing symptoms and told the treatment arm that they were being given powerful medicine that, even though it was an “open-label” sugar pill, would potentiate a “mind-body healing process.” Deception was clearly used, in the form of suggestion and conditioning techniques. Still, using subjective self-reporting criteria the placebo group had only marginally improved outcomes than the no-treatment group. This was a disappointing fishing expedition for the researchers who clearly wished to catch more fish with their open-label bait than their fishing buddy who used no bait at all. The results may not even qualify as statistically significant because of the sample size. Small fry, indeed.

  142. BillyJoe7on 07 Mar 2015 at 2:38 pm

    jsterritt,

    I will read it when I get a chance, probably some time this weekend.

    I didn’t realise it was a pilot study. In that case the only thing it could possibly say is whether a proper clinical trial is worth doing. Maybe it does that, but I wonder what they would consider a proper clinical trial.

    Also, your description of the IBS trial makes me think that I have come across this study before – especially your description of the recruitment procedure and what they told the participants about placebos. If you’re going to recruit participants by describing it as a study about the “mind-body healing process”, you’re going to attract a disproportionate number of participants who believe in a “mind-body healing process”. Those participants would already be primed by their past history. Even if you were not subsequently “deceitful” (in quotes because they may not be deliberately deceitful) about telling them about the nature of a placebo, a sizeable percentage of these primed individuals would be unlikely to be able to completely tear themselves away from their prior ideas about placebos as magical, wonderful, side-effect free treatments. And, if you were “deceitful” about the nature of placebos, then your trial wouldn’t be about what you say it is about – the use of placebos without deception.

  143. jsterritton 07 Mar 2015 at 3:37 pm

    @BJ7

    “If you were “deceitful” about the nature of placebos, then your trial wouldn’t be about what you say it is.”

    ^This is exactly right.

  144. BillyJoe7on 08 Mar 2015 at 6:18 am

    There seem to be many problems with this trial:

    – It was a pilot study.
    Pilot studies involve a small number of participants over a short period of time. The small number of participants means that, despite random allocation, known and unknown variables are likely to have significantly affected the results. The short duration of the trial means that it is possible that the effect was transient. As such, the only conclusion they can come to is to suggest whether or not it would be worthwhile to perform a large clinical trial. In other words, they simply could not rely on this study to inform them about whether or not placebo without deception works.

    – There was recruitment bias.
    Participants were recruited using advertisements that said this would be a trial of “mind-body medicine”. This would have tended to disproportionately attract participants who believe, or are interested in, so called “mind-body medicine”. These participants would be more likely to be to report that they felt better if they were allocated to the placebo arm and to report that they felt no better if they were allocated to the no-treatment arm, irrespective of whether they actually felt better or not.

    – There was likely to be reporting bias.
    This is always a problem with open label clinical trials, especially those using subjective, as opposed to objective, assessments. Even without recruitment bias, participants tend to want to please the researchers, especially if there was empathetic engagement by the researchers as occurred in this pilot study. As a result of wanting to please the kind and attentive researchers, participants are likely to report improvement if they are allocated to placebo arm and to report no improvement if they are allocated to non-treatment arm.
    Also, even without recruitment bias and reporting bias, participants in the no treatment arm would tend to report that they felt no better. After all, they have been explicitely told that they will receive no treatment and are actually given no treatment – so why would they feel any better!

    – The trial was “deceptive” about placebos.
    Participants were told that placebos have “powerful mind-body effects”. This is false. The evidence is that the placebo effect is weak, unreliable, transient, and really only applicable to a small range of illnesses characterised by symptoms with a large psychological component. IBS is known to have a large psychological component, with symptoms increasing under stressful conditions and improving in a relaxed environment. Also, the idea that placebos have “powerful mind-body effects” was reinforced by telling the participants that they must strictly adhere to the twice daily treatment regimen.

    – The effect size was small.
    The effect size was falsely reported as being about 60%. In fact, 60% reported that they had improved on a dicotomous yes/no scale, not that they had improved 60%. Big difference. In another measure used, the QOL measure, the no treatment arm reported no improvement (4 on a scale of 7) and the placebo arm reported slight improvement (5 on a scale of 7). On the 100 point GIS measure, the improvement was 5.0 points for the placebo arm and 3.9 points for the no treatment arm. On the 500 point SSS measure, the placebo arm improved from an average of about 300 to 392 (30%), and the no treatment arm from about 300 to 346 (15%).
    Even without considering the problems listed above, this was a pretty small effect.

  145. BillyJoe7on 12 Mar 2015 at 7:19 am

    Seems our friend Morgan Levy wasn’t serious after all.

  146. mllevy1on 12 Mar 2015 at 9:04 pm

    # mumadadd “argumentum ad logicam” is the name of the kind of logical fallacy that occurs when your premise is in part or in whole fallacious so you conclude that the conclusion is wrong. In reality, you can use a fallacious premise and still draw an accurate conclusion.

    In this case, they are saying the study is “fatally” flawed so you can not draw any conclusions from it. (they corrected what they were saying a bit.)

    My point was that the conclusions in this study are somewhat justified (not nearly to the point that all the press this study got suggests) if there was no deception. If there was deception then I agree the conclusions were not justified.

    I went on to make the argument that there was no deception.

  147. mllevy1on 12 Mar 2015 at 9:15 pm

    # RickK I do not think that the Homeopathic Pharmacopoeia of the United States contains any real knowledge. The science in what the Homeopath is doing has nothing to do with the story that is being told. The story about the “essence in the water” is just made up. Doctors should never knowingly lie to a patient.

    The aspect of the placebo effect or of Homeopathic medicine that can effect a person’s physiology is non-pharmacologic. The active ingredient is the communication between the practitioner and the patient. It is all about how the practitioner conveys to the patient that he or she thinks the treatment will work and about the expectations of the patient.

    In this was it is similar to hypnosis or psychotherapy.

    If you understand how this mechanism of action works and the few things it can treat such as pain, nausea, depression, OCD and psychosomatic complaints then you can honestly convey this information and honestly tell the patient that you think this will work.

  148. mllevy1on 12 Mar 2015 at 9:45 pm

    # jsterritt I generally think you are understanding what I am saying and I agree with your comments. One point I will address is your comments about Dr. Leuchter’s study. He was actually a mentor of mine at UCLA and I have discussed this study with him personally. Our perspective is that of brain-behavior neuroscientists. It is our understanding that non-pharmacologic interventions can trigger real brain changes that effect behavior and is mediated by neurotransmitters.

    The supportive psychotherapy and the placebos are the same to us. They are both examples of non-pharmacologic intervention. They both use suggestion and expectation as the curative agents. In this study he accurately concludes that patient expectation was the key element of the placebo effect. That is interesting to us because of the brain-behavior correlation you can see on functional imaging.

    An important point is that we are not saying, as so many do, that placebo’s cure everything. The kind of placebo effect we are talking about here that works with neurotransmitter related compensatory brain mechanisms does not work with real diseases except as a additional therapy to improve general health. For example, your statement about a usual 30% response rate is not true. The response rate varies a lot depending on whether you are studying something like pain or depression which are neurotransmitter related compensatory brain functions verses a real disease process such as a bacterial infection or cancer. It is often the case in cancer research or infection research that you get a huge difference between and effective treatment and a placebo and placebo response rates are often 2% or 5% or something. In depression research the placebo effect is often 50%, 60% or something like that and the medication effect is often with 2-5% of the placebo effect.

  149. mllevy1on 12 Mar 2015 at 9:56 pm

    # BillyJoe7 The IBS study was an unusual study because it was intentionally done backwards. The only thing they were interested in was, “Can we elicit a placebo response without deception and with full suggestion?”

    There was a lot of bogus news articles that claimed way more than what you could say from this study. My point was that there was really no deception. Someone argued that since placebos don’t work then saying that they do is deception but I countered by saying placebos do work or we would not be having this conversation and that the issue is how or why do they work.

    In regards to CBT, what I am trying to advocate is the idea that all non-pharmacologic therapy works through suggestion and expectation. The story lines and rationalizations on why they work are just made up BS. Interestingly, if you study all non-pharm therapies, and I include most of CAM, you will find a wide range of BS stories but a common theme in regards to how the communication is happening between provider and patient. It is the social communication that triggers the effect.

  150. mllevy1on 12 Mar 2015 at 10:00 pm

    Sorry I was unavailable for a few days. I don’t have a lap top and had to be away from home on an urgent matter. But I really am enjoying that my writing has received such enthusiastic discussion as I just recently began to promote this site. It does still need a lot of work. The comments here are the best I have had. Thanks to everyone.

  151. BillyJoe7on 13 Mar 2015 at 7:36 am

    Morgan,

    “Someone argued that since placebos don’t work then saying that they do is deception”

    I can’t remember anyone saying that placebos don’t work.
    In any case, I’m not responsible for what someone else said.
    What I said is that the placebo effect is weak, unreliable, transient, and limited in scope.
    If what I say is true, then the statement in the study made to the participants that the placebo effect is “powerful” is deceptive, and that this deception was reinforced by telling patients to comply strictly with the twice daily treatment.

    “My point was that there was really no deception”

    The problem is that you still haven’t backed up that statement.
    You need evidence that the placebo effect is “powerful”, otherwise they were deceptive in characterising it as such.

    “The IBS study was an unusual study because it was intentionally done backwards. The only thing they were interested in was, “Can we elicit a placebo response without deception and with full suggestion?” ”

    Because the study was so flawed (see my previous post), they can’t even conclude that there was a placebo effect, let alone that it was achieved without deception.

    “but I countered by saying placebos do work or we would not be having this conversation and that the issue is how or why do they work”

    The issues for me are:

    – Is the placebo effect powerful enough to be worth harnessing?
    My understanding is that it is weak, unreliable, transient and limited in scope.
    – If so, can it be done without deception.
    My assessment is that your flawed study failed to provide evidence even of a placebo effect let alone a placebo effect without deception.
    – Should doctors be harnessing the placebo effect through CAM, or through real medicine and through legitimate psychological modalities such as CBT?
    My opinion is that, if there is a placebo effect to be harnessed then at least harness it through legitimate science-based treatments. There’s too much risk with CAM and CAM practitioners. I think you are living in cloud cuckoo land if you believe you can get CAM practitioners to follow your rules.

    “In regards to CBT, what I am trying to advocate is the idea that all non-pharmacologic therapy works through suggestion and expectation. It is the social communication that triggers the effect”

    So why not use science based non-pharmacological therapy instead of CAM.
    Drop the BS homoeopathy and just do the CBT.

  152. Karl Withakayon 13 Mar 2015 at 12:40 pm

    “- Is the placebo effect powerful enough to be worth harnessing?
    My understanding is that it is weak, unreliable, transient and limited in scope.”

    This is my take exactly.

  153. tmac57on 13 Mar 2015 at 4:46 pm

    Sometimes my front car tire appears to be low on air when it is not, and that makes me worry a bit if I don’t have an air gauge available to check the pressure. And someone coming along with a fake or empty portable pressure tank might stop and say “I’ll fix you right up my friend”, and then pretends to air up the tire (making a subtle psssssss sound for effect ;),and oh yeah, charges me a few bucks to boot), and I probably would feel more at ease, and satisfied that my ‘problem’ was cured.
    But sometimes the tire really IS a bit low, and if it’s not too bad, the above ruse might also ease my mind (for a while at least).
    It might also make me feel a bit better when the tire is getting dangerously low, and convince me that I can get at least a little further down the road before I have to get it fixed. Some handling will be compromised, and now I’m in danger of damaging the low tire…but I feel better anyway.
    Now take the case where the tire is only slightly low, and the phony tank ruse is used to ease my mind, but this time there is a nail in the tire that’s causing the leak. And it just happened, so the rate of leakage is significant but not apparent yet but really needs immediate attention. Maybe a placebo in this case might not be such a good idea, and might be forestalling real action for a real problem.
    Just a thought.

  154. mllevy1on 13 Mar 2015 at 9:01 pm

    # BillyJoe7 Yes, my preference would be to use science based non-pharmacological therapy instead of CAM but if I thought that would ever happen then I would be, as you say, “living in cloud cuckoo land.” lol Incidentally, I do not think that CAM practitioners would follow my rules in a million years. I am what you might call a theoretical neuroscientist. lol

    In regards to the question of potency of the placebo effect, this is really the issue I would like to discuss. Let me try to make the case that the placebo effect can be much more potent than you had previously thought.

    The placebo effect is a number of things as we have discussed. As I have said, the only thing that interests me is how it works through suggestion and expectation to effect a change in neurotransmitter function that can cause a bodily effect such as reduced pain, nausea, depression or OCD.

    I am a psychiatrist and very familiar with depression clinical trials. I can show you literally thousands of studies that are placebo controlled double blind in which the placebo effect successfully treated 40, 50, 60% of patients in the study. In almost all of these studies the anti-depression medication was found to treat 2,5,10% more patients than the placebo and this is often not statistically significant. (The drug companies don’t publish the negative studies.) To me, this is a powerful placebo effect.

    On the other hand, studies that are testing antibiotics for treatment of a bacterial infection often show extremely weak placebo effects. Something like 2% or 5% while the effective drugs treat 80% or 90%. Huge effect size in these studies.

    So, why the difference in placebo effect size?

    In my opinion, non-pharmacological intervention can only treat things that are neurotransmitter mediated compensatory brain effects. They do not treat bacterial infections. The placebo effect in an antibiotic trial is almost entirely due to things like regression to the mean or misdiagnosis or unseen exposure to other active agents or whatever. The placebo effect in a depression study is much more likely due to an effect on serotonin or norepinephrine production in the brain that is the result of suggestion and expectation. Depression is a condition in which there is a low level of these neurotransmitters in the forebrain. Upon treatment with either CBT or Prozac the forebrain regains normal neurotransmitter function and we can see this on functional brain images such as PET, SPECT, fMRI and QEEG.

    The same thing can be demonstrated with pain and nausea and OCD and with a number of conditions whose etiology is related to psycho-somatic stuff like IBS, or fybromyalgia.

    In fact, here is an argument from another angle. You can think of psychosomatic illness as a nocebo effect. In other words, these individuals have experienced non-pharmacologic suggestion and expectation that says they should have more pain, nausea, depression, bowel problems or muscle cramps and they do. These individuals are greatly helped by placebo medicine and the effect can be dramatic.

    OK, I have many additional arguments but I will stop here and allow you to provide some feedback.

  155. mllevy1on 13 Mar 2015 at 9:03 pm

    # Karl Withakay see my response to BillyJoe above.

  156. mllevy1on 13 Mar 2015 at 9:12 pm

    # tmac57 I am not suggesting that anyone see only a CAM practitioner. I repeatedly say that you should go to a real MD or DO and only ever go to a CAM practitioner at the referral from a real doctor. As a real doctor, we know that 25% of the patients I see are seeing me for entirely psychosomatic conditions and that they will continue to return if I don’t hold their hand and give them positive suggestion. Maybe this is inappropriate to say but these patients are annoying to me. I wish I could send them to a CAM provider after I have made sure they don’t have any real illness. Also, as I have said before, you can do this without any deception. If you have selected the patients properly and your positive suggestion is honest and genuine they can still have a good outcome.

  157. BillyJoe7on 14 Mar 2015 at 1:47 am

    Morgan,

    “Yes, my preference would be to use science based non-pharmacological therapy instead of CAM but if I thought that would ever happen then I would be, as you say, “living in cloud cuckoo land.””

    I don’t mean send them to a CAM practitioner who uses CBT.
    I mean don’t send them to a CAM practitioner (period) – send then to a psychologist who uses CBT.

    “Incidentally, I do not think that CAM practitioners would follow my rules in a million years”

    So, what is your point then?
    If you are saying that doctors should send their patients to a homoeopath who follows your rules so that they can get the placebo effect without the BS but you don’t think any homoeopath would follow your rules in a million years, then what is your point?

    “The placebo effect in an antibiotic trial is almost entirely due to things like regression to the mean”

    The placebo arm of a clinical trial does not measure “the placebo effect”. The improvement seen in the placebo arm of a clinical trial includes things like recruitment bias, selection bias, researcher degrees of freedom, reporting bias, researcher bias, the effects of incomplete/absent blinding, hawthorn effect, and regression to the mean. And, finally, it also incudes “the placebo effect”. It is only this last factor – the actual placebo effect – that we are interested in. You have to separate that out from all the other factors that cause the improvement seen in the placebo arm of a clinical trial. I have not seen you do this. But this is exactly what you need to do to make your case that “the placebo effect” is powerful.

    “the only thing that interests me is how it works through suggestion and expectation”

    Which is the improvement seen in the placebo arm of a clinical trial minus all the factors I listed above that contributre to this improvement apart from “the placebo effect”.
    You need to separate out this effect and make your case that this is a powerful effect.

    “I can show you literally thousands of studies that are placebo controlled double blind in which the placebo effect successfully treated 40, 50, 60% of patients in the study…To me, this is a powerful placebo effect”

    Firstly, if 60% of patients improved but the average improvement was only 5-10%, I would not call this a powerful effect.
    Secondly, we are not talking here about “the placebo effect”. We are talking about all those factors mentioned above, only one of which is “the placebo effect”.
    Thirdly, amongst those thousands of studies, show us your best example. Better still, show us a systematic review of these thousands of studies.

    “On the other hand, studies that are testing antibiotics for treatment of a bacterial infection often show extremely weak placebo effects. Something like 2% or 5%”

    Again 2-5% is the improvement seen in the placebo arm of the clincal trial. Once you subtract all those factors listed above, the actual effect of “the placebo effect” will be much lower. In fact, if you subtract out the effects of the patients’ immune systems, I suspect the residual effect attributable to “the placebo effect” would be close to zero.

    “The placebo effect in a depression study is much more likely due to an effect on serotonin or norepinephrine production in the brain that is the result of suggestion and expectation”

    To avoid confusion, we need to agree on two terms: “the improvement seen in the placebo arm of a clincal trial” and “the placebo effect”. We are interested in the second term. You need to provide evidence that “the placebo effect” pulled out of all the other factors that produce “the improvement seen in the placebo arm of a clincal trial” is actually powerful.
    And that’s only the first step.

    “You can think of psychosomatic illness as a nocebo effect. In other words, these individuals have experienced non-pharmacologic suggestion and expectation that says they should have more pain, nausea, depression, bowel problems or muscle cramps and they do. These individuals are greatly helped by placebo medicine and the effect can be dramatic”

    I’m suggesting that you should use psychological treatments such as CBT, not placebo medicine such as homoeopathy. And you have yet to show us a single clinical trial – let alone a systematic review – that demonstrates that the effect is powerful or dramatic.

  158. goldmund52on 14 Mar 2015 at 12:12 pm

    Morgan Levy, I thought the article on your website entitled The Debate was very interesting. I find the evolutionary psychology perspective on the human condition to be very informative. If we consider that the societal role of “physician” descended from and branched off of the societal role of “magician/shaman/healer” only very recently in the evolutionary time frame it is no wonder that the latter category persists. It’s the default mode. Call it the Persistence of Magical Thinking. (The same perspective applies to the branching of science and religion.) There must have been a group survival advantage to having a tribal magician—knew when to poke a sharp stick in an abscess, had a fund of knowledge about poisonous plants—the repository of transmissible cultural knowledge.

    I remember a lecturer in the first week of medical school stating that greater than 50% of chief complaints in a primary care office have psycho-somato-social overlay. The response of us medical students was something like, “bummer, we’re here to learn science-based medicine not to practice generic primate care-taking behavior.” Medical school tends to make MD’s anti-magic to the point that MD/patient interactions can have a nocebo effect, as some of the pro-CAM comments here demonstrate. I believe there is merit to your idea of MD’s/DO’s focusing more on patients’ need for them to be healer as well as scientist. IMO the way forward is to teach this topic more explicitly in medical schools, the typical way we make progress. The very best physicians already know and practice this way. However, the ethical foundation of science-based medicine is: first do no harm. IMHO the harm caused by CAM practitioners who are philosophically anti-science is far too great to justify an attempt to include them in a conventional medial practice just because they know how to invoke non-specific effects, even if we can identify the neurotransmitters that mediate these effects.

    (Just as an aside, I didn’t read all your blogposts but for me another informative perspective on the patient-healer interaction is attachment theory.)

  159. mllevy1on 16 Mar 2015 at 12:29 am

    # goldmund52 that was exactly what I thought when they told us as first year medical students that half the people who see a family doctor have psycho-somatic complaints.

  160. mllevy1on 16 Mar 2015 at 1:06 am

    # BillyJoe7 CAM practitioners do not uses CBT and I never suggested sending a patient to a CAM practitioner to get CBT.

    My suggestion is to have an MD or DO evaluate a patient and then send selected patients to a CAM provider. The MD or DO works closely with the CAM provider who follows the rules I outlined. You tell the patient the truth that the story line the CAM provider will present is made up but the interaction can elicit a placebo effect that I think you would have a good chance of responding to if you allow yourself to really follow the direction of the CAM provider.

    You want to know what is my point if I think CAM providers won’t follow my rules and that inspired me to say, “I am a theoretical neuroscientist.” I am still amused by having said that and thank you for inspiring it. I am trying to figure out what would be a way to do things in a perfect world.

    There is a bit of confusion in regards to the definition of a placebo effect. The real definition includes all those things you mentioned plus the thing I am interested in. I am the one suggesting that we split those other things off. My point comparing a depression clinical trial to an antibiotic clinical trial is that I think that in a depression clinical trial there is a large suggestion and expectation mediated effect whereas in an antibiotic clinical trial the suggestion and expectation mediated effect is small to non-existent. In other words, the suggestion and expectation effect only works for neurotransmitter mediated compensatory brain responses such as pain and depression and does not work for real diseases like a staph infection.

    You said, “Firstly, if 60% of patients improved but the average improvement was only 5-10%.” I did not say that. What I said was that in most depression clinical trials the medication is barely better than the placebo and is often not even statistically significant. A routine depression clinical trial will find that placebo successfully treated something like 53% of patients and Prozac successfully treated 57% of patients. I never said the word “average.” I said the medicine is often only 2% or 5% better than placebo. Then I concluded that to me a 40, 50 or 60% effect size for the placebo is pretty potent.

  161. BillyJoe7on 16 Mar 2015 at 8:09 am

    Morgan,

    “My suggestion is to have an MD or DO evaluate a patient and then send selected patients to a CAM provider. The MD or DO works closely with the CAM provider who follows the rules I outlined”

    But you are on record as stating that the chances of getting a CAM provider to follow your rules would be about 1 in a million. So, I ask again, in that case what is the point in having this discussion. If you can’t get CAM providers to follow you rules – and you admit you can’t – then the discussion is over. Do not refer to a CAM provider. Period.

    “You tell the patient the truth that the story line the CAM provider will present is made up but the interaction can elicit a placebo effect that I think you would have a good chance of responding to if you allow yourself to really follow the direction of the CAM provider”

    Again, what is the point in continuing this discussion if CAM providers won’t follow your rules.

    “You want to know what is my point if I think CAM providers won’t follow my rules and that inspired me to say, “I am a theoretical neuroscientist.” I am still amused by having said that and thank you for inspiring it. I am trying to figure out what would be a way to do things in a perfect world”

    Let’s just say that I am not amused in the slightest.
    And I’m not interested in a perfect world. I’m not interested in theory divorced from practice.
    I’m interested in the real world.

    “There is a bit of confusion in regards to the definition of a placebo effect. The real definition includes all those things you mentioned plus the thing I am interested in.”

    Perhaps I should clear up the confusion:
    The placebo arm of a clinical trial simply refers to the participants that are given the placebo pill. The effect you see in the placebo arm of a clincal trial includes all those biases I mentioned PLUS “the placebo effect”.

    “I am the one suggesting that we split those other things off”

    Yes, you are interested in “the placebo effect”, not those biases, I understand that.
    The problem is that it is very difficult to split off the effect of these biases, especially “reporting bias”, and especially when the trial assesses only subjective symptoms, and especially when there is no blinding as is necessarily the case with trials of “the placebo effect” such as your IBS trial.

    “My point comparing a depression clinical trial to an antibiotic clinical trial is that I think that in a depression clinical trial there is a large suggestion and expectation mediated effect whereas in an antibiotic clinical trial the suggestion and expectation mediated effect is small to non-existent. In other words, the suggestion and expectation effect only works for neurotransmitter mediated compensatory brain responses such as pain and depression and does not work for real diseases like a staph infection”

    My point is that even with subjective symtoms such as depression, anxiety, pain, and nausea, “the placebo effect” is weak, unreliable, and transient. And you have yet to provide a link to a trial or, better still, a systematic review of trials of the placebo effect (placebo v no treatment) that show otherwise. Certainly your IBS trial doesn’t cut it as I demonstrated a few days ago.

    “You said, “Firstly, if 60% of patients improved but the average improvement was only 5-10%.” I did not say that”

    No, I said that.
    What I’m trying to point out is that linking to a clinical trail that concludes that 60% of patients improved does not prove that the placebo effect is powerful. You would need to know by how much on average they improved. If, on average, they improved only 5% then you would have to conclude that the placebo effect is weak. A 5% improvement is unlikely to be clinically significant. For example, in the IBS trial you linked to, while those not given placebo did not improve at all (4 on a scale of 7), the placebo group improved only “slightly” (5 on a scale of 7). If I remember correctly 60% of the placebo group improved, but the point is that, on average, they improved only “slightly”. You could hardly call that a powerful placebo effect.

    “What I said was that in most depression clinical trials the medication is barely better than the placebo and is often not even statistically significant.”

    What that means is that anti-depression medication is pretty useless in the patients enlisted in the trial. In fact, anti-depressant medication is effective only in severe depression. So, unless the patients in those trials were severely depressed, that result would not be very surprising.

    “A routine depression clinical trial will find that placebo successfully treated something like 53% of patients and Prozac successfully treated 57% of patients. I never said the word “average.” I said the medicine is often only 2% or 5% better than placebo. Then I concluded that to me a 40, 50 or 60% effect size for the placebo is pretty potent”

    The effect size is not 40, 50 or 60%.
    That’s the percentage of subjects in the placebo arm of the trial who improved.
    The effect size is the average percent improvement, not the percent who improved.
    To repeat again, in the only trial you have referenced so far, the percent who improved was 60%, but the effect size was “slight” improvement. That is not a powerful effect by anyone’s standard.

    ————————————–

    Here is what you still need to do:
    – Show that “the placebo effect” is powerful.
    – Show that CAM providers can be convinced to follow your rules.

    It seems to me you have still to demonstrate the first and you’ve given up on the second.
    Where to from here?

  162. BillyJoe7on 16 Mar 2015 at 8:16 am

    goldmund,

    “There must have been a group survival advantage to having a tribal magician”

    Group survival?
    Also, not everything you see is there because of “survival advantage”, so your “must” is misplaced. Was there a survival advantage in doing calculus or was it just a side-effect of brain’s that survived due to characteristics unrelated to doing calculus?

  163. BillyJoe7on 16 Mar 2015 at 8:17 am

    ..sorry, misplaced apostrophe ):

  164. goldmund52on 16 Mar 2015 at 9:43 am

    BilleyJoe7. The human brain is strongly hard wired for pattern recognition. The survival advantage of this is obvious—red sky in morning…—, but it leads to people believing in “luck, destiny, god, free will, jinxes, essences, karma, ESP” (from Matthew Hutson), ie magical thinking. It is an evolutionarily adapted trait, not an epiphenomenon. It’s only because of the recent discovery of statistically valid causal inference that we can even discriminate these categories to some extent. It is why smart, loving, caring, well-intentioned people can believe silly things. Plus, none of us can totally escape magical thinking. This is why–The first principle is that you must not fool yourself, Feynman.

    Group survival. Whether natural selection occurs at the group level is an interesting ongoing topic in evolutionary psychology. The attraction of the theory of group selection is that it may explain strong reciprocity. Strong reciprocity refers to social behavior that has a net economic cost to the individual actor, while either rewarding or punishing other members of the social group according to group behavioral norms. The term for this beneficial group behavior is cooperation. See Bowles and Gintis, A Cooperative Species.

  165. Bill Openthalton 16 Mar 2015 at 12:56 pm

    goldmund52 —

    It’s not so much group selection (there is no reason to assume groups are evolutionary entities) as selection on individual traits that result in group behaviour. In other words, we can assume cooperative behaviour to be a successful strategy “for an individual”, and hence to be selected on. We cannot treat the presence (or not) of a shaman in a group in the same way — because the group is not selected, its members are. Shamans are probably a side effect of two features of the human race: results-oriented reasoning and social hierarchy.

  166. BillyJoe7on 17 Mar 2015 at 7:06 am

    goldmund,

    I was just making the point that it is not the case that every feature must have a survival advantage.

    “Whether natural selection occurs at the group level is an interesting ongoing topic in evolution…”

    Its been a fringe idea for about three decades, with still almost no evidence that it has played any role in evolution. The two main arguments is that group selection, in almost all cases, reduces to gene level selection; and group selection is too slow compared with gene level selection, the result being that it never gets to do anything.

  167. mllevy1on 17 Mar 2015 at 12:54 pm

    # BillyJoe7 I disagree with your suggestion that we can’t talk about what could work even if in today’s world it appears unlikely. Staunch CAMers may be oblivious but a lot of reasonable people in the middle who currently don’t know what to think could be persuaded.

    Totally agree with your comments on the difficulty of figuring out which kinds of placebo effects are at play.

    I don’t understand your reluctance to accept what most depression clinical trials have found for the past 60 years. This is not something that is in dispute. OK, here is a reference: http://jama.jamanetwork.com/article.aspx?articleid=185157 Look at the graph in fig. 2. Even at the severe level of depression the effect size is not astounding.

    Your point about how much the improvement was on placebo in this IBS study is a good point. However, I am not talking about this IBS study. I am talking about depression clinical trials in general. In most of these trials the medication effect and the placebo effect are not hugely different and often not statistically significantly different. Similarly, CBT results are usually equal to or slightly inferior to medication.

    You are correct that I worded it poorly in regards to effect size. What I was trying to talk about was the difference between placebo and medication. Most studies show results for percent of pts improved and for degree of improvement on some scale and I was sort of combining that. Most studies when they report that 60% improve they have some minimal amount of improvement that they consider improved so you can usually talk about it the way I was talking about it in general terms but this has been a controversial issue. OK, so you want to see actual effect size for placebo. Here are some references:

    http://dm.education.wisc.edu/tminami/intellcont/wampold_etal_jcp_2005-1.pdf

    http://bjp.rcpsych.org/content/178/3/192

    http://www.sciencebasedmedicine.org/antidepressants-and-effect-size/

  168. goldmund52on 17 Mar 2015 at 10:14 pm

    Bill Openthalt. You say “there is no reason to assume groups are evolutionary entities.” Well, that’s a pretty definitive statement. Sounds like you looked at both side of the issue and made up your mind. No problem.

    Billy Joel7. You say “It’s been a fringe idea for about three decades, with still almost no evidence that it has played any role in evolution.” Sounds like you examined the research and found “almost no evidence.” No problem. I do think it is accurate to say that group selection is the minority opinion, if that’s your criterion.

    In my view this is one of those times that I’m-not-sure is a safer bet than I-am-right. It’s a very interesting topic that is still actively researched and discussed by scientists. One of the fun things about this topic is that two of my favorite authors, Steven Pinker and Herbert Gintis, have square off with competing essays in 2012. Anyone interested could Google– Pinker Gintis group selection. The nature of human cooperation is a very important subject vis-à-vis the topic of evidence based public policy, which happily makes this side discussion somewhat relevant to the larger themes of this blog.

  169. BillyJoe7on 18 Mar 2015 at 6:38 am

    goldmund,

    I’m sure that “I’m not sure” is not a safer bet because the evidence is all one sided.
    Sure some scientists are still actively researching this but, as I said, they are on the fringe.

    Anyway, we’re way off-topic.

  170. Bill Openthalton 18 Mar 2015 at 8:33 am

    goldmund52 —

    Then give me reasons why groups would be evolutionary entities. The first problem you have is that ‘group’ covers so many diverse aggregations of humans it is almost impossible to meaningfully compare two groups. Second, unlike groups of cooperating cells forming an organism with the ability to reproduce itself, groups of humans do not form identifiable organisms, and have no discernible reproductive ability. One of the basic tenets of evolution is the increase of the successful vectors in the next generation — but human groups do not reproduce, they merely exist for a while.

    You said:

    There must have been a group survival advantage to having a tribal magician—knew when to poke a sharp stick in an abscess, had a fund of knowledge about poisonous plants—the repository of transmissible cultural knowledge.

    Which I would rephrase as “Organisms with social skills that allow building social structures with enough production capacity to allow specialisatiion, and minds that can transfer information between generations will be evolutionary more successful than organisms only capable of organising in small groups of generalists with less developed intergenerational skills.”

    In other words — humans are more successful than chimpanzees.

    Within the human race, certain societies are more successful than others, for a number of years. Successful societies attract new members, and less successful societies disappear. The momentary success of a society (measured in the number of individuals it consists of) can also be its demise if its members deplete the available resources. Absent reproduction, what would one use as a measure of the success of a group? Its persistence through the centuries, or the total number of individuals an outside observer would consider part of that group?

    Multilevel selection makes more sense — if a trait reduces individual fitness but allows better cooperation and/or more effectiveness within a group, the end result might be favourable for the individuals of a social species. For example, humans specialise, and a specialist taken alone is less able to survive than a generalist (most brain surgeons cannot farm), but cooperating specialists will usually out-compete cooperating generalists. Another example would be monogamy — it reduces the ability of the strongest to reproduce but results in better cooperation between males, leading to more reproductive success for humans in monogamous societies, and hence selection of the monogamy trait. But this only works because humans are social animals.

  171. mllevy1on 19 Mar 2015 at 12:31 pm

    To everyone.

    Here is a link to a new essay I posted at Placebomedicine.com entitled “Deception and Placebo- My personal opinion.” http://www.placebomedicine.com/?page_id=2732

    This essay was inspired by this conversation we are having on this thread.

  172. jsterritton 19 Mar 2015 at 1:12 pm

    Dr Levy…

    Would you please provide citation(s) for the following statement:

    “This is such a powerful effect that it has actually been used to perform open-heart surgery with only hypnosis for anesthesia.”

    This sets my BS detector off in a big way — alarms are ringing! I doubt any surgeon anywhere would have performed this surgery as described as it’s simply unethical. Moreover, wouldn’t we have heard about it? I can’t find anything but the usual puff stories about hypnosis used as adjunct to anesthesia. Making exaggerated claims for the effectiveness of hypnosis is not a good way to win over skeptics, especially if you’re going use those claims in support of CAM modalities.

  173. mumadaddon 19 Mar 2015 at 1:32 pm

    jsterritt,

    I think I’ve heard that one before, actually read it in Bad Science by Ben Goldacre. Great book but the chapter on placebo effects was alarming. IIRC, this supposedly took place in China. I may be misremembering, but it definitely rings a bell.

  174. Hosson 19 Mar 2015 at 4:43 pm

    I still can’t get around telling a patient that a treatment is not effective, but if they just follow the treatment, then it will work. Why recommend the treatment at all? Because sometimes some people feel better?

    Maybe I’m missing something.

    Why recommend a patient for homeopathy when just telling them to get exercise might be the best choice, or to relax more and play more video games, or anything where I’m not giving my money to(what the doctor just describe as a) liar? Comparable free treatments to “placebo medicine” seems like a much better choice. You get the same “benefit” but without giving your money to charlatans.

  175. mllevy1on 19 Mar 2015 at 6:56 pm

    # jsterritt I learned this 30 years ago when I was much less of a skeptic and have just always believed it was true. I will try to find a reference. The way I was told it was used was to a patient who was going to die without open heart surgery but could not tolerate the anesthesia. They trained him over several weeks and he was able to achieve a good enough state of trance that they could successfully perform the procedure. I have considerable experience putting people in trance states and I believe that this could be done but obviously only if there is no other way. OK, I will look really hard for a reference and get back to you.

  176. mllevy1on 19 Mar 2015 at 8:09 pm

    # jsterritt OK, here are the best review articles I could find so far. Still searching for an example of cardiac surgery but it is not looking good. lol These articles confirm my opinion that hypnosis works for pain and can help with surgical procedures and one references cardiac procedures but could not really confirm it.

    http://hc.rediris.es/pub/bscw.cgi/d4420346/Montgomery-Effectiveness_adjunctive_hypnosis_surgical_patients.pdf

    http://hc.rediris.es/pub/bscw.cgi/d5000072/Wobst-Hypnosis_surgery.pdf

    http://orbi.ulg.ac.be/bitstream/2268/26639/1/332.pdf

  177. mllevy1on 19 Mar 2015 at 8:58 pm

    # jsterritt I am pretty sure this is the reference from 1959. http://jama.jamanetwork.com/article.aspx?articleid=326808

    So, my statement may have been embellished but not entirely made up. I would guess that someone embellished it to me when they were teaching me hypnotherapy 30 years ago. My general point that hypnosis can work for pain and surgery is still probably accurate but obviously not for the sole anesthesia when breaking the sternum. I would like to think that I would not believe that if I heard it for the first time today. I guess that it is easy to forget to be skeptical when it is something you have believed for a long time. Lesson learned. Thanks.

  178. BillyJoe7on 20 Mar 2015 at 7:34 am

    Morgan,

    Sadly, after waiting with bated breath for three days, I am completely underwhelmed.

    “This essay was inspired by this conversation we are having on this thread”

    I can see nothing of this conversation we are having on this thread incorporated into that essay.
    Here is what I see:

    1) Morgan Levy claims that the placebo effect is powerful and can be harnessed without deception.
    2) Posters here ask for evidence
    3) Morgan Levy completely ignores calls for evidence and simply repeats his claim that the placebo effect is powerful and can be harnessed without deception.

    “So, my statement may have been embellished but not entirely made up”

    At the very least, it reduces the placebo effect from powerful to weak, directly contradicting your claim and youir reason to be.

    “I would guess that someone embellished it to me when they were teaching me hypnotherapy 30 years ago”

    I find it incredible that you presume to write authoritatively on the placebo effect (to the extent of recommending that doctors send their patients to a homoeopath) and, in doing so, rely on what you maybe remember what somone maybe told you maybe thirty years ago.

    “This is such a powerful effect that it has actually been used to perform open-heart surgery with only hypnosis for anesthesia…. I am pretty sure this is the reference from 1959: http://jama.jamanetwork.com/article.aspx?articleid=326808

    A quote from the abstract:

    The first six all received diphenhydramine, thiamylal, alphaprodine, either pentobarbital or secobarbital, and either succinylcholine or hexylcaine. The seventh required only thiamylal, succinylcholine, and hexylcaine. The eighth, a woman aged 42, underwent mitral commisurotomy after receiving only hexylcaine topically for endotracheal intubation and 30 mg. of succinylcholine intravenously for muscular relaxation

    I hope this does not require further comment.

    BTW, I think you mis-remembered even more than you thought. I’m pretty sure the example of open heart surgery was in relation to acupuncture, not hypnotherapy.
    Here’s is a link which gives the background and also debunks that myth:

    http://www.dcscience.net/2013/05/30/acupuncture-is-a-theatrical-placebo-the-end-of-a-myth/

    Stories circulated that patients in China had open heart surgery using only acupuncture…Simon Singh (author of Fermat’s Last Theorem) discovered that the patient had been given a combination of three very powerful sedatives (midazolam, droperidol, fentanyl) and large volumes of local anaesthetic injected into the chest. The acupuncture needles were purely cosmetic.

  179. Hosson 20 Mar 2015 at 9:44 am

    In Scrubs episode 503(My Day at the Races), Turk preforms an appendectomy on a woman under hypnosis instead of anesthesia. She starts screaming midway through surgery, and Kelso calls it a success.

  180. mllevy1on 21 Mar 2015 at 4:27 pm

    # BillyJoe7 My deepest apologies for the heart surgery statement. It is not something I normally ever say just something that was in the back of my head for a long time and slipped out. In my partial defense, the essay was not one of my usual well researched essays. It was a personal experience and opinion piece that I wrote “off the cuff” without review prior to posting and for you guys to look at and give feedback. You caught something that should be deleted and it was. Thanks for catching it. The point I was trying to make was that placebo works for pain and can help with surgery related pain.

    I also want to make certain that you understand that I am not saying that placebo is always powerful and can treat everything in anybody. I am saying that, like most treatments, it can be relatively powerful in selected patients, for selected conditions and if administered correctly. For example, if you are treating pain or depression in a suggestible patient with a strong placebo (acupuncture, hypnosis or psychotherapy) and administer it with the right suggestion you can achieve a more potent placebo effect.

    # BillyJoe7 said “Here is what you still need to do:
    – Show that “the placebo effect” is powerful.
    – Show that CAM providers can be convinced to follow your rules.”

    Potency
    In regards to potency, there are several factors that need to be taken into account. First, “What are we trying to treat?” Second, “Are we talking about suggestion/expectation mediated placebo or are we talking about misperception mediated placebo?” Third, “What type of placebo are we talking about as there is a range of potency depending on variables related to the placebo itself such as size, color, needles, communication etc.” and Fourth, “What individual is getting the treatment as there is a range of suggestibility among humans with something like 20% being highly suggestible and 20% not very suggestible and 60% somewhere in the middle.”

    The recent meta-analysis I provided earlier is pretty good evidence that the placebo effect is potent when treating DEPRESSION with a general patient population and a relatively weak placebo in the form of sugar pills. http://jama.jamanetwork.com/article.aspx?articleid=185157 Did you look at table 2?

    Here is a study involving placebo in PAIN management: http://stm.sciencemag.org/content/3/70/70ra14.abstract Here is an article by Steven Novella critiquing it. http://www.sciencebasedmedicine.org/placebo-effect-for-pain/ I read this several years ago and it is part of what shaped my opinion.

    CAM
    Those making money off CAM or preaching about CAM on television or whatever are not people that I am likely to reach. My interest is in reaching more sensible individuals who do things like massage therapy or psychotherapy or hypnotherapy as there are many in these fields that are tempted by CAM but do not have enough personal knowledge to know what is real or not. If they could have some simple guidelines it would seem to me that it would be a good thing.

  181. BillyJoe7on 22 Mar 2015 at 1:25 am

    Morgan,

    “http://jama.jamanetwork.com/article.aspx?articleid=185157”

    This is not a test of the placebo effect.
    The hypothesis being tested is that ADM is useful for severe depression but not mild or moderate depression. So they tested ADM against placebo in patients with depression ranging from mild through moderate to severe. They found that ADM is not better than placebo for mild and moderate depression but better than placebo for severe depression, thereby providing evidence for their hypothesis.
    The trial was not setup to test the effectiveness of placebo in the treatment of depression and cannot be used in support of that hypothesis. For that you would need a “no treatment” group.

    “http://stm.sciencemag.org/content/3/70/70ra14”

    It’s impossible to assess a paper based only on an abstract.
    But, I accept that if the placebo effect can be useful for acute pain. If a patient has severe acute pain, he will need an analgesic. The placebo effect of his doctor calmly reassuring him that his pain will be relieved by the analgesic might also assist in relieving his pain. In less severe pain, the placebo effect of calm reassurance that it is temporary may be all that is required. No need for a CAM practitioner in these scenarios.
    Chronic pain is another matter. There is very little evidence that placebo in chronic pain is anything other than weak, unreliable, and transient.

    Regarding CAM practitioners:

    Am I correct in assuming you have backed away from your claim that homoeopaths can be of assistance in the administration of placebo? You did not include them in your above list of CAM providers. Of course you have yet to come up with evidence of any clinical situations where any type of CAM provider would be useful.

  182. mllevy1on 24 Mar 2015 at 6:05 pm

    I am not suggesting that it is a test of the placebo effect. I am suggesting that it is one piece of evidence that the placebo effect might be have some degree of potency.

    Here is a perfect study to get to the issue of whether or not placebo works for chronic pain, assuming that you agree with the numerous studies in the past 15 years that have demonstrated acupuncture to be a placebo. This study lasted 9 months and compared acupuncture to placebo defined as routine management without acupuncture and to sham acupuncture. The conclusion is that acupuncture is better than placebo. My conclusion is that placebo has more potency than no treatment.

  183. mllevy1on 24 Mar 2015 at 6:06 pm

    # BillyJoe7 I am not suggesting that it is a test of the placebo effect. I am suggesting that it is one piece of evidence that the placebo effect might be have some degree of potency.

    Here is a perfect study to get to the issue of whether or not placebo works for chronic pain, assuming that you agree with the numerous studies in the past 15 years that have demonstrated acupuncture to be a placebo. This study lasted 9 months and compared acupuncture to placebo defined as routine management without acupuncture and to sham acupuncture. The conclusion is that acupuncture is better than placebo. My conclusion is that placebo has more potency than no treatment. http://www.ncbi.nlm.nih.gov/pubmed/11932074

  184. BillyJoe7on 25 Mar 2015 at 7:42 am

    Morgan,

    I feel like I’m sinking rubber ducks.

    “I am not suggesting that it is a test of the placebo effect. I am suggesting that it is one piece of evidence that the placebo effect might be have some degree of potency”

    You’re supposed to be supplying evidence that the placebo effect is powerful.
    Instead, you supply a link to the results of a clinical trial that you concede is not even testing the placebo effect and claim not that the placebo effect is powerful but that the placebo effect might have some degree of potency.

    http://www.ncbi.nlm.nih.gov/pubmed/11932074
    The conclusion is that acupuncture is better than placebo. My conclusion is that placebo has more potency than no treatment”

    Firstly, your link goes only to the abstract. As I said previously, it is impossible to assess a clinical trial from the abstract. You need the full paper to assess the trial for methodological errors and to see whether the effects are clinically significant, not just statistically significant.
    Secondly, they say acupuncture is better than placebo (sham acupuncture) on only one of the comparisons they tested for (did they adjust for mutivariate analysis?). They also say acupuncture is better than no treatment (what they call the “control”).
    Thirdly, what does “better” mean? Is it like the the IBS trial where placebo caused slight improvement (of doubtful clinical significance). We don’t know because the abstract doesn’t tell us.
    Fourthly, your conclusion that placebo has more potency than no treatment does not fulfil your mission to show that the placebo effect is powerful
    Fifthly, even if we were to grant you the result of this clinical trial, you still have not proven your claim. You cannot prove your claim by cherry picking single trials that seem (wrongly so far) to support it. What you really need are systematic reviews.

    So, in summary, you have yet to show…
    – that the placebo effect is powerful
    – that the placebo effect can be harnessed without deception
    – that CAM providers will follow your rules.

  185. mllevy1on 25 Mar 2015 at 8:17 pm

    # BillyJoe7

    To me, a 40% placebo effect in an antidepressant clinical trial is a powerful effect considering it is a sugar pill. Here is a full study (they are sometimes hard to find on-line and I agree it is a pain to sign up for something you don’t want) on pain that shows what I think is a powerful effect. http://www.jneurosci.org/content/19/1/484.full.pdf What I mean by “powerful” is an effect that is likely endogenous opioid mediated and not just misdirection placebo. What would be a “powerful” effect to you?

    Here is a 2004 review article that covers most of the topics we are discussing pretty well. http://www.jneurosci.org/content/25/45/10390.short

    The assertion that the placebo effect can be harnessed without deception is my opinion based on my experience with suggestion. I know that when you are doing hypnosis and using suggestion it actually works better with a fully informed patient who voluntarily follows your instruction. I think this is a general rule with suggestion and I think that non-pharmacologic interventions mostly work through suggestion and expectancy. I think the IBS study suggests that this idea is correct.

    Not trying to prove that CAM providers will follow my rules. I am merely suggesting some rules that would make sense to follow.

  186. mllevy1on 26 Mar 2015 at 12:59 pm

    # BillyJoe7 Your comments on this thread have led me to the conclusion that the issues of deception and potency should be much more prominent part of my website. I plan to have two articles on each of these topics that are well researched and referenced. Your comments have given me an idea of how I will craft these articles. Give me a few weeks to accomplish this task. Then, I would love for you to read them and provide feedback. Perhaps, you could give me an email where I can notify you when they are ready to read. Would that be OK with you?

  187. BillyJoe7on 26 Mar 2015 at 4:27 pm

    Morgan,

    “http://www.jneurosci.org/content/19/1/484.full.pdf ”

    Excerpt from “Billy in the bathtub”:

    “To his great amusement, Billy noticed that, whenever he pushed the rubber duck under the water, it bounced right back up again”

    In the context of this discussion…
    You previously presented a clinical trial testing the effect of placebo on acute pain.
    I responded by acknowledging that placebo might be effective in acute pain but that a doctor would not send such a patient off to see a homoeopath, he would give his patient a strong analgesic (active treatment) and reassure his patient that the strong analgesic will relieve his pain (placebo effect).
    Instead of responding to that, you simply present another clinical trial testing the effect of placebo on acute pain.
    We are not progressing.

    Excerpt from “Billy and the wild goose chase”

    “Billy realised that instead of chasing the geese all over the place, things worked out better if he just kept chasing the same goose until it died of exhaustion”

    I will read your link because it sounds interesting, but I won’t be commenting on it here because it is irrelevant to this discussion as I’ve indicated above.

    “Not trying to prove that CAM providers will follow my rules”

    Then you have not proven your case.
    All THREE conditons must be satisfied before you can reasonably suggest that doctors send their patients to a homoeopath.
    You can let me know via this blog when your articles are ready – maybe Dr Novella will let you write a guest article!

  188. mllevy1on 27 Mar 2015 at 8:09 pm

    All of your comments have been lengthy and involved multiple issues. We are getting these issues entangled. It would be better if we were talking face to face as this thread has limitations when the conversation gets complex.

    You seem to think that “My case” is to prove that patients should be sent to Homeopaths but that is not my main point at all. That idea was used to illustrate a point about deception not being needed such that you could send a patient to a homeopath and tell them it was placebo and it would still work. It was a theoretical argument.

    I provided a second clinical trial because you said that you needed better evidence of the “potency” of the placebo. It was not in response to the referral to a CAM provider issue.

    I understand that you abhor the idea of referral to a CAM provider, and reasonably so. My suggestion of doing this with some rules and guidelines in order to take advantage of the placebo effect requires explanation which I did give repeatedly so I don’t know why you accused me of not responding on this issue.

    In regards to the issue of deception you kept saying, “Show me more evidence.” I am trying but it is hard sometimes to find full articles and to find measures that are clearly indicative of potency. I would rather just write an actual researched article and have you review it.

    The issues of deception and potency are great issues that I did not focus on when creating my website but that you made me realize are important to talk about. Also, I would love it if threads like this one could be on my site under articles I have written. I think it would make my site look better.

    One point of procedure is that I don’t understand how you get notified when I write on this thread. Do you? If so, how can I get notified when you write on it?

  189. BillyJoe7on 28 Mar 2015 at 5:58 am

    Morgan,

    Sorry for playing the devil’s advocate.

    “In regards to the issue of deception you kept saying, “Show me more evidence.” I am trying but it is hard sometimes to find full articles and to find measures that are clearly indicative of potency”

    This is exactly my problem – the lack of evidence.
    What I don’t understand is why you don’t see it as a problem.
    There must be clear evidence that the placebo effect can be harnessed without deception, otherwise doctors are not ethically able to use or refer for placebo treatment, and your suggestion that they do so will fall on deaf ears.

    “My suggestion of doing this with some rules and guidelines in order to take advantage of the placebo effect requires explanation which I did give repeatedly so I don’t know why you accused me of not responding on this issue”

    I don’t have a problem with your actual rules.
    My problem is that CAM providers won’t follow your rules. You said as much yourself (a one in a million chance if I’m quoting your correctly). And, if that is the case, your suggestion that doctors refer to CAM providers just doesn’t make sense.

    “I provided a second clinical trial because you said that you needed better evidence of the “potency” of the placebo. It was not in response to the referral to a CAM provider issue”

    I understand that.
    My point was that that clinical trial was about the effectiveness of placebo for acute pain (twenty minutes of ischaemic pain in a forearm by applying a tournique and having the subjects exercise their forearm muscles) and that doctors would treat acute pain with a strong analgesic (active treatment) and reassuring the patient that this strong analgesic will relieve his pain (placebo effect). Acute pain is not a scenario where doctors would think of referring to a CAM provider.

    “It was a theoretical argument”

    I’m not sure many doctors would be interested in a theoretical argument. They are more interested in practical advice. I think you need to describe details of practical situations where you would recommend they make use of the placebo effect. And, in order to convince them to do so, you will need evidence that the placebo effect is powerful, evidence that it can be harnesssed without deception by CAM providers who will follow the rules. If any one of these four aspects falls down, you don’t have a case

    What I’m trying to suggest to you is that you have a lot of work to do before your suggestion will have any traction with science-based medical practitioners.

  190. tmac57on 28 Mar 2015 at 10:25 am

    Maybe Morgan’s (subtextural) aim is to let the CAM providers do the unethical work of deceiving the patients, and allow the science based medicine providers do their job with clean hands?

  191. BillyJoe7on 28 Mar 2015 at 2:56 pm

    Well, I suppose you are not really deceiving patients if you have no idea how BS your treatment is, but Morgan is right, they’re not going to be following any rules laid down by science-based practitioners.

  192. mllevy1on 30 Mar 2015 at 8:25 pm

    # BillyJoe7 Based on my experience with suggestion/expectancy I think you could tell a patient, “The homeopath is just making up a story about the water but if you allow yourself to follow his suggestion you will likely experience a placebo effect that will reduce your pain and if the WAY you say this to the patient is genuine and conveys the message that you believe it will work and if the patient is selected appropriately then it will work. (no deception)

    placebo is only one piece of the argument I am making

    In this chapter of my book Placebo Medicine there is a research article in which I lay out this case. http://www.placebomedicine.com/?page_id=937

    What I plan on doing now is making a new article that focuses more on the issues of size of effect and deception.

  193. mllevy1on 31 Mar 2015 at 1:22 pm

    # BillyJoe7 We are sort of speaking past each other in the respect that you are speaking only about the placebo effect and I am speaking about all non-pharmacological intervention. Remember, I am saying that suggestion/expectation and conditioning are the active ingredient in all forms of non-pharmacological intervention. For example, do you think that the numerous studies that demonstrate a potent effect for CBT (and many other psychotherapies) for depression and OCD, hypnosis for pain, or acupuncture for pain, as well as the many sociological studies demonstrating that things like a good long term marital relationship or membership in a religion or stable financial situation etc are correlated with better health and longevity which are all included in my definition of non-pharmacologic intervention fail to demonstrate any sort of potency of effect? The idea being that your brain is programmed to maintain homeostasis in your body and has a limited ability to produce neurotransmitters and hormones in response to bodily insult in order to re-establish homeostasis and that these compensatory effects can be triggered by social communication that is non-pharmacologic.

  194. SkinnerBoxon 02 Jun 2015 at 9:59 am

    Interesting, but you don’t need a nonsense imaging technique like fMRI to tell you this! Let prior plausibility be your guide for esoteric matters

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