May 29 2009

The NICE Fiasco

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The National Institute for Health and Clinical Excellence (NICE) is an independent UK organization that provides advice on which treatments and medical practices are likely to promote health. In other words, they comment on what they think is or should be the standard of care. This is a very important function, and the NICE is generally taken seriously.

That is why it was very disturbing to find that in their latest guidelines for low back pain they include recommendations for both spinal manipulation (wihout explicity naming chiropractic) and acupuncture.

The spinal manipulation recommendation is at least semi-reasonable, in that there is some evidence for modest benefit for spinal manipulation for acute uncomplicated low back pain. However there are still problems that derive from the bait and switch tactic employed by many practitioners of spinal manipulation.

David Colquhoun discusses this issue well. Patients may be referred to a chiropractor for uncomplicated low back pain, and then be hit up for treatment of their asthma, or to bring their child in to treat the colic. In fact, to demonstrate this he called a couple of chiropractic offices posing as a patient and they were happy to offer treatment for asthma and colic, and to assess him for whatever else might be ailing him.

Acupuncture is even more of a clear-cut issue – the evidence clearly shows that acupuncture does not work for low back pain.  And the bait and switch also applies – once you are visiting with an acupuncturist you are likely to hear about non-existent life energy and meridians and how acupuncture can cure all sorts of medical problems.

Colquhoun reports that NICE normally does a good job of making science-based recommendations – so what went wrong. I agree with his assessment that three factors likely played a role: infiltration by proponents, political correctness, and the bait and switch. In short, NICE took their eye off the ball and got snookered.

Colquhoun documents the infiltration of NICE by proponents – people who have a financial stake in the recommendations, specifically chiropractors and acupuncturists.  I have seen this happen in universities as well, and it has occurred in the US at almost every level of political and academic regulation. These are the same people, by the way, who scream about the influence of Big Pharma in medicine (sometimes legitimately), but then see no problem with people who’s entire practice is based upon medical acupuncture being in a position to make official recommendations about the evidence for acupuncture.

It is an unfortunate reality that proponents, especially those with a financial stake, tend to have a much higher degree of motivation and persistence to promote their claims than those who do not have a personal stake but may be skeptical of the claims to be vigilant against them.

And so the nonacupuncturists advising the NICE may not be familiar enough with the evidence, they may not really care about or understand the secondary consequences of recommending quackery, and they are easily put off their game by rhetoric about being “open-minded” – rhetoric which CAM proponents have perfected over the years. The bait and switch works, and the most plausible and benign-sounding claims for acupuncture are used to recommend referral to acupuncturists – who will then inflict all manner of pseudoscience on their patients.

Even worse – once they gain the imprimatur of official recognition they will increasing work their way into the system. Eventually they will be their own gate-keepers and regulators. Critics will be dismissed as being closed-minded, as having an ideological axe to grind, as being politically “incorrect.” They will even be sued for libel, as the British Chiropractic Association is doing to silence Simon Singh for daring to say that the BCA makes recommendations that are not evidence-based.

It is still amazing to me how CAM propoenents have successfully created a bizarro world in which to operate – where the usual rules of science, transparency, and criticism are turned on their head. I have been personally told by academics (CAM shruggies who have fallen for the line of BS) that lack of transparency is necessary because proponents fear that otherwise they will be criticized. Think about that sentiment very carefully. In simply wishing to discuss the published evidence about a specific claim I have been accused of being closed-minded and having an agenda. Well, I do have an agenda – it’s called science-based medicine. But that’s not what they meant.

What amazed me most is that otherwise bright and savvy academics and regulators have fallen for the bait and switch. CAM proponents are steadily infiltrating the very organizations that would review and regulate their claims and practices. They are systematically insulating themselves from outside criticism. They are bamboozling the public, and more importantly those whose job it is to know better.

I also personally know many scientists and physicians who are as appalled by all of this as I am, but who simply cannot be bothered to speak out against it. They fear they will become the targets of recrimination. Now they rightly fear they will become the target of law suits. Most wish to simply ignore the issue, hoping it will go away. They express to me that they are glad that I and others are speaking out, because that means they don’t have to.

Well – they are wrong. The evidence is clear. The entire question of science-based medicine vs so-called alternative medicine (CAM) needs a very public and transparent airing. All scientists and professionals need to understand the issues and to speak out.

The NICE episode is just the latest example. It won’t be the last. And the public health will suffer.

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