Mike Barr

I will have to catch up on my NATAP reading to see what the latest is on expected availability of this miracle drug (hepmag.com says mid-2013 for the single drug and 2014 for the FDC). And I understand that the initial enthusiasm (100% clinical cures for genotype 1; 75% clinical cures for genotypes 2 & 3, with more recent data on efficacy in genotypes 4-6) has mellowed a bit.

If others out there have beat me to the punch in experimenting, successfully one hopes, with herbology--Chinese, Taiwanese, Tibetan, Ayurvedic or otherwise, please share your experiences.

In the meantime, I will report on 2 or 3 classic formulas (Shu Gan Tang, Chai Hu Shu Gan Tang, Xiao Chai Hu Tang, for starters) that, over the centuries, have proved good for your "gan" (anglicized pinyin for liver in Mandarin): reducing inflammation, slowly (reversing?) fibrosis, encouraging the growth of new hepatocytes.

While personally I prefer the freshly brewed broth-like Chinese herbal potions, this is not terribly practical and eventually a bit costly for chronic administration, there are some reasonably effective tablet and granule products at many of the better herb companies. The Hepatoplex series, as well as Ecliptex and Milk Thistle 80, of Oakland, CA-based Health Concerns, are four tablet forms that come to mind. (Opinions vary on whether or not the recommended dosage is adequate, although the company says that the dosage labeling is based on 150-pound body weight, and one might want to adjust accordingly. Thrice daily dosing is often not practical, so the total daily dose is often divided by two and taken morning and late afternoon or early evening.) Depending on your constitution and individual presentation, there might also be other, less liver specific, formulas that can help you.

Ruth aka "Misha" Cohen, out in SF, most recently at the Cancer Research Institute at the UCSF School of Medicine, has of course been focusing on Chinese medicine and hep C for a good part of the past 20 years or so. Her 2007 Hep C book (and various YouTube type streaming videos) might also be a valuable resource. In addition to the tableted formulas mentioned above, Dr. Cohen in her book recommends Enhance, Clear Heat, and then a variety of more specialized formulas according to  the person's individual constitution and/or symptoms.

Severity of fatigue, muscle aches (myalgia), irritability and nausea were all reported to decrease.

(If  you're curious, the ear points these clinicians used were Shen Men, Thalamus, Lung, Liver "and/or" Sympathetic. Interestingly, they used 32-gauge (0.18 x 25 mm) needles. Retention time: 30-45 minutes. All results were statistically significant, although the nausea change just barely so. Reductions in irritability showed the most impressive decrease, followed by muscle aches (myalgia)).

One wonders if the results might have been even better if the treatments could have been performed more frequently (it appears that folks had only 4 treatments over a period of 6 months), maybe using ear seeds or magnets for home or office stimulation between visits, and if some body points could have been added. (BaiHui and HeGu were employed in an undisclosed number of cases, presumably in accordance with individual pattern presentations.)

Now that genotype-1 infections (which are reported to account for around 90% of hep-C cases in the US) are being eradicated with the new protease inhibitors (in combo, lamentably, with the standby interferon/ribavirin "backbone"), it seems all the more important to find ways to help folks get through the course of treatment.

There does not appear to be much published research on the use of acupuncture--ear or otherwise--to manage the side effects of interferon therapy. And until these promised non-interferon based hep-C therapies (I don't know alot about Gilead's sofosbuvir, but some investment wags think this first "all-oral" combo hep-C regimen could gain an expedited FDA nod some time in the second half of 2013) are made available and time tested, seems we are stuck with at least 6 months of weekly sub-Q interferon injections.

I contacted the author of the paper, an acupuncturist MD at the VA in Portland, OR, to try to find out additional information on her study and any plans for follow-up investigation. She explained their plans for a larger and "cleaner" study in order to tease out the exact contribution of the acupuncture intervention, as well as to better understand the optimal timing of the acupuncture treatment in relation to self-administration of interferon injection.

(Readers might also want to check out the medhelp.org (or other) online community forum for other peoples' experiences. The one I happened onto this morning yielded several helpful first-hand experiences: One person writes that s/he heads to acupuncturist the morning after the previous night's interferon jab, and that it really helps. Of course, not everyone can afford or has the required insurance plan to cover weekly (or, perhaps better: biweekly) visits to an acupuncturist in private practice. But as someone from the Bay Area wrote in, communal or group acupuncture places (officially called "community" acupuncture) offer scaled-down but completely adequate services for a fraction of the cost of a private session. This person was going to a community acupuncture place in Berekley, CA for all of $15 a visit! And don't forget massage. Many folks report that a monthly massage also really helps.

I haven't seen any $15 price points in NYC (more like $40, $45, $55), but there are a handful of group/community acupucture places in metro NYC: Manhattan Community Acupuncture (UWS), New York Community Acupuncture (West 36th Street),  Harlem Village, Olo, City Acupuncture, Bae (Williamsburg) and Third Root (Ditmas Park). (I have first-hand experience with only Olo Acupuncture (West 23rd Street, between Sixth and Seventh), City Acupuncture (Fulton Street) and Third Root (on the Q and M trains! And I once studied with the woman who started NYCA); the others I found through a search engine.) I am told that City Acupuncture is  soon to open a second location across the Hudson in Hoboken or Jersey City. Anyway, there seem to be more community acu places in the Garden than Empire state at the moment. Stay tuned...)

Housing Works, with Positive Health Project centers in East New York, downtown Brooklyn, West 13th Street and East 9th Street in Manhattan, offers an acupuncture option to its HIV+ clients ("every Tuesday and Thursday from 1pm-5pm") but to my knowledge is not currently offering acupuncture services to their HCV+ folks. (Please correct me if I am wrong!)

Of course, for hep-C infected folks who are not ready (or willing) to take the peg-interferon/ribavirin-PI plunge or waiting for easier-to-take, better tolerated drug combos and are concerned about their liver health, there are quite a few good herbal formulas out there reported to support healthy hepatocyte regeneration, prevent further liver damage and reduce the risk of fibrosis. (This would apply equally to HBV-infected folks who are not on suppressive antiviral therapy.) More on that in a future post though! In the meantime, I would love to see some of the HCV service centers in the city begin to offer this ear acu option to their clients. Feel free to contact me with questions and ideas: mbarr@pacificcollege.edu

Still looking into this, but here's the scoop... first published in PNAS and then picked up and reported by Ira Flatow for NPR's Science Friday yesterday:

The editors are Bradly P. Jacobs (MD, MPH) and Katherine Gundling (MD) of the, respectively, Bay area Institute for Healthy Aging at Cavallo Point (oh my god, sign me up for a weekend here ASAP) and the Department of Medicine at UCSF. Nearly two dozen other contributors hail from highly regarded medical centers such as Johns Hopkins, Mayo, Penn, UCLA, Exeter and National Jewish (University of Colorado at Denver).

After a brief introduction of definitions, criteria and clinical approach, Part II of the book is ingeniously broken down into 12 therapeutic categories (beware, this is an auto-loading .pdf)--gastrointestinal health, cancer, asthma, women's health, men's health, depression, for example--and then the CAM literature summarized, reviewed, discussed within each of these chapters. While I have not been able to access the full text online (although they do offer a Sample Chapter on General Medicine (beware, this is an auto-loading .pdf), the ACP website does freely publish a list of the studies/references for each of the 12 chapters. It can be accessed here.

The chapters of greatest interest to the Poz community are likely to be the ones on Women's Health, Men's Health, and HIV. I will work on summarizing these over the next week. Since so many of my friends (or even family) have been affected by mood disorders (not to mention substance abuse--both prescription and more illicit substances), I would also like to closely examine the chapters on Depression and Drug Interactions.

This looks to be a fun project for a spectacular, if somewhat sedate, summer sabbatical in one of the under appreciated Rust Belt states. I think what I will do is look at each of the clinical areas that might be of interest to Poz readers and then try to do a quick and dirty bullet point summary of what modalities they looked at and then which ones met their criteria for safety and effectiveness.

On second thought, the most efficient method to breeze through all 458 pages might be to look at only those modalities where the Magnitude of Effect was Moderate (other choices were Small or None) and where the final Clinical Recommendation is either Weak in Favor or Strong in Favor--and I will note that below.

General Medicine
Anxiety
Strong in Favor: Relaxation training
Weak in Favor: Acupuncture

Common Cold
Weak in Favor: Echinacea purpurea extract (300 mg TID) (prevention & shorten duration)

(NB: I recently discovered that there are something like nine (and three commonly encountered) species of Echinacea. Echinacea purpurea is the one generally regarded as staving off the first signs of a cold or other URI (and even UTI?). It can also, so the story goes, be used topically for poorly healing wounds. Echinacea pallida is the variety used for influenze-type infections. The Mosby book from where I took this information noted that over half and possibly as much as 90% of the Echinacea sold in the U.S. up until 1991 was actually Missouri snakeroot (Parthenium integrifolium). So know your sources!)

Diabetes
Diabetic Neuropathy

Herpes Virus Infections
Genital Herpes
Weak in Favor: L-Lysine Monohydrochloride (3g QD) (prevention but NOT shorten duration)

(In vitro studies suggest that arginine-rich environments are critical for herpes virus function and growth (Klyachkin and colleagues, Virology, 2008; Griffith and colleagues, Chemotherapy, 1981). Foods containing more arginine than lysine include whole wheat, oats, chocolate, peanuts, walnuts, orange juice, and blueberries.)

(Migraine) Headaches
Strong in Favor: Biofeedback, CBT, stress mgt, relaxation training (migraine recurrence)
Strong in Favor: Acupuncture (for migraine recurrence)
Weak in Favor: Buterbur extract (liquid-carbon dioxide PA free) (migraine recurrence)

Recurrent UTIs
Strong in Favor: Cranberry supplement & juice (400 mg BID, 11% quinic acid or 8 03 unsweetened juice TID) "Avoid cranberry juice cocktails as they contain minimal fruit content"

Gastrointestinal Health
(Non-ulcer) Dyspepsia
Strong in Favor: Peppermint oil combined with caraway oil
Weak in Favor: Artichoke leaf (2 x 320 mg TDS)

H. Pylori infection/eradication
Strong in Favor: Probiotics (dose varied from 0.2-1g/day) "Reduced AB-related diarrhea"

IBS
Weak in Favor: Tong Xie Yao Fang (Chinese Herbal Formula)
Weak in Favor: Hypnotherapy

IBS Pain
Strong in Favor: Peppermint extract/Peppermint + Caraway ("1-2 capsules TID")
Weak in Favor: STW 5, STW 5-II

IBS Constipation
Weak in Favor: Fiber, Padma-Lax (Tibetan Formula) (1-2 capsules/day)

Diarrhea (adult & child)
Strong in Favor: Probiotics

Diarrhea (in children)
Weak in Favor: Carob bean juice; Apple pectin-chamomile extract

Rotavirus diarrhea (in children)
Weak in Favor: Tormentil root extract (3 drops TID)

Nausea/Vomiting/Motion Sickness
Weak in Favor: Ginger

Nausea/Vomiting (Pregnancy Induced)
Weak in Favor: Ginger

Nausea/Vomiting (Post-Operative)
Strong in Favor: Acupuncture stimulation of Pericardium 6; Ginger (0.3-1g/day)
Weak in Favor: Acupuncture

Nausea/Vomiting (Chemotherapy Induced)
Weak in Favor: Acupuncture stimulation of Pericardium 6

Ulcerative Colitis (acute)
Weak in Favor: Fish oil

Ulcerative Colitis (maintenance)
Weak in Favor: Probiotics

Pouchitis (inflammation of the ileal pouch)
Weak in Favor: Probiotics

Acute GI Pain
Weak in Favor: Acupuncture

Pre-Operative Anxiety
Weak in Favor: Acupuncture

Post-Op Pain
Weak in Favor: Acupuncture

Liver Disease
Chronic HBV
Promising herbs for HBV clearance: Phyllanthus, (not in the Asian cannon) Sophorae (Ku Shen); Jian Pi Wen Shen (a Japanese herbal formula)

GI Cancers
(Nothing in their analyses, up to April 2008)

Musculoskeletal
Low Back Pain (Acute)
Weak in Favor: Spinal manipulation

Low Back Pain (Chronic)
Weak in Favor: Acupuncture, yoga
(Devil´s Claw (50-100mg/day), although Confidence of Estimate of Effectiveness got a C grade, was noted to "Appear to be effective compared to placebo.")

Neck Pain (Acute or Chronic)
Weak in Favor: Spinal manipulation, electrotherapy (low level laser therapy)

Osteoarthritis of the Knee
Weak in Favor: Acupuncture, Glusoamine/Chondroitin (500mg/400mg TID) (the latter "for people with moderate-severe disease")

("Controversy regarding whether glucosamine sulfate preparation (Rotta Pharmaceuticals) is superior to other preparations, including glucosamine hydrochloride.")

Lateral Epicondyle Pain (aka Tennis Elbow)
Carpal Tunnel Syndrome
Fibromyalgia

Obesity

Coronary Health
Primary and secondary CVD
Strong in Favor: Marine sources of omega-3 fatty acids (1g/d for secondary prevention; 1g twice a week for primary prevention)
Weak in Favor: Plant-derived sources of omega-3 fatty acids (1.5-3g/day)

CVD
Weak in Favor: Soy protein (50g)
Weak in Favor: Lignans (flaxseed) (25-50g)

Stable angina
Weak in Favor: L-carnitine (2g daily)

Secondary prevention
Strong in Favor: Ornish diet
Strong in Favor: Mediterranean diet
Weak in Favor: Transcendental meditation (in some places now called Vedic meditation)
Weak in Favor: Yoga

Primary prevention
Strong in Favor: Mediterranean diet
Weak in Favor: Ornish diet
Weak in Favor: Transcendental meditation (in some places now called Vedic meditation)
Weak in Favor: Yoga

Cancer
Chemotherapy and surgery induced nausea and vomiting
Strong in Favor: Behavioral interventions
Weak in Favor: Acupuncture

Pain
Weak in Favor: Acupuncture

Insomnia
Weak in Favor: Mind-body therapies

HIV
Progression of HIV disease
Weak in Favor: Multi-vitamin and multi-mineral

High triglycerides (usually a side-effect of medications)
Strong in Favor: Omega-3 fatty acids (3g/day)

Depression (relatively common side-effect of efavirenz (Sustiva/Stochrin/Atripla))
Weak in Favor: SAMe (200-800 mg/day)

High cholesterol (usually a side-effect of protease inhibitor type medications)
(Nothing in their analyses, up to April 2008)

Neuropathy (more often than not a side-effect of nucleoside analogue, especially stavudine (Zerit)  but also didanosine (Videx), medications)
No recommendation: Acetyl-L-carnitine (1500 mg BID) ("Case series showed large benefit")
No recommendation: Acupuncture ("Conflicting results")

Women's Health
PMS
Weak in Favor: High fiber/low fat diet
Weak in Favor: Calcium (1200mg/day)
Weak in Favor: Vitamin B6 (50mg/day)

Dysmenorrhea
Strong in Favor: Transcutaneous nerve stimuation

(Chinese herbal medicine received a grade of "moderate" for Magnitude of Effect but "Unclear" under Safety category and thus "No Recommendation" could be made. Note adds: "Dozens of RCTs have been conducted showing moderate to large effects, however study quality is poor.")

Endometriosis
Uterine Fibroids

Infertility
Weak in Favor: Acupuncture

Menopausal Symptoms: Hot Flashes
Weak in Favor: Paced breath work

Osteoporosis
Strong in Favor: Calcium (1200mg/day) "Preferrable to combine with 800 IU vitamin D"
Strong in Favor: Vitamin D (800 IU/day)
Weak in Favor: Tai Chi (5 times/week)

Incontinence (Urinary)
Strong in Favor: Pelvic floor muscle training (regimens vary)
Weak in Favor: Behavioral training (regimens vary)

Men's Health
Androgen Deficiency
Strong in Favor: Testosterone (50-400mg IM; or 5-10g topical)

(I packed up the book for return before I could copy down a couple sentences on DHEA. From what I remember, the authors of that chapter were explaining that DHEA is converted into androstenedione (and possibly also androstenediol) before it can be made into estrogen and/or testosterone. An unidentified expert argues that, "Because DHEA must first be converted to androstenedione and then to testosterone in men, it has two chances to "aromatize" into estrogen--estrone from androstenedione, and estradiol from testosterone. As such, it is possible that supplementation with DHEA could increase estrogen levels more than testosterone levels in men." Here I would argue for the importance of imperical evidence :) --although recommended daily dosages (as well as dosing time: a.m vs. p.s.) are kind of all over the map. From purely personal experience, baby doses (10-12 mg/d, but only 2-3 times/week) seem more effective than these 50mg (the Martina et al., Clin. Endocrinol, 2006 study in "elderly males") and 300mg (the Alhaj et al., Psychopharmacology, 2006 memory and mood study in "health young men") daily doses from the "literature." I will try to figure out a way to get one more glimpse of those pages in the ACP CAM book.)

(This from Wikipedia: In March 2009, a bill was introduced in the U.S. Senate (S. 641) that attempts to classify DHEA as a controlled substance under the category of anabolic steroids. The sponsor is Charles Grassley (R-IA). The cosponsors are Richard Durbin (D-IL), and John McCain (R-AZ).^[46] This bill was referred to the Senate Judiciary Committee. In December 2007, Charles Grassley introduced the "S. 2470: Dehydroepiandrosterone Abuse Reduction Act of 2007," in an attempt to amend the Controlled Substances Act to make "unlawful for any person to knowingly selling, causing another to sell, or conspiring to sell a product containing dehydroepiandrosterone to an individual under the age of 18 years, including any such sale using the Internet," without a prescription. Only civil (non-criminal) penalties are provided. The bill was read twice and referred to the Senate Judiciary Committee where it died. (In Canada, a prescription is required to buy DHEA.))

Athletic Fitness
Weak in Favor: Creatine (2-5g daily)

Sexual Performance
Premature ejaculation
Strong in Favor: Squeeze technique

Erectile dysfunction
Strong in Favor: Phosphodiesterase-5 inhibitors (but only where decreased circulation is the underlying cause)
Weak in Favor: Carnitine (500-1000mg TID) (May be combined with a PDE-5 inhibitor.)
(L-Arginine (2-3g daily) is marketed as the "natural Viagra," but there is very limited evidence that it works--and should be used with caution in post-MI patients. Doses higher than 2-3g/day increase gastrin production in the stomach and may cause GI upset and aggravation of GERD or peptic ulcers. Arginine also "feeds" herpes virus replication.)

A double-blind controlled trial suggested that Yohimbe (derived from the bark of a West African tree) combined with L-Arginine, both taken at 6g daily, was effective for ED. This high a dose in post-MI men >60 years, however, may increase the risk of death. Yohimbe itself has safety concerns, and some experts recommend against using it because of risks of known side effects such as dizziness, anxiety, nausea, hypotension, abdominal pain, fatigue and hallucinations. In customary doses, however, it is generally well tolerated and appears to have "infrequent but serious adverse events and/or interaction safety concerns." "Given the very limited evidence for effectiveness [and] the ... potential safety concerns, it is premature to recommend Yohimbe for ED."

Benign Prostate Hypertrophy (BPH)
Weak in Favor: Saw palmetto (160mg BID)
Weak in Favor: Nettle root (stand alone or in combination with saw palmetto and pygeum)

Over 10 RCTs have shown that saw palmetto reduces nighttime urination, improves urinary flow and quality of life in men with BPH compared with placebo. There have been negative trials too, including a recent carefully designed study of 225 men that failed to show saw palmetto superior to placebo (Bent and colleagues, NEJM, 2006). Saw palmetto showed little to no toxicity in these controlled trials and is considered safe as a food substance.

Other herbs recommended for BPH include nettle root, pumpkin seed extract, and pygeum. Nettle root is a popular treatment in Europe for BPH. It is not as well studied as saw palmetto; there is moderate evidence to support a weak recommendation of nettle root for the treatment of BPH. Pumpkin seed extract or oil is also a popular treatment for BPH in Europe, and is on Germany's Commission E. Randomized, placebo-controlled studies have been limited to evaluating this therapy in combination with saw palmetto. There is limited evidence to support a weak recommendation for using pumpkin seed in combination with saw palmetto  to treat BPH--and insufficient data to make a recommendation for its use as monotherapy. Pygeum is a tree native to central and southern Africa. Its bark has been used since ancient times to treat urinary problems. Today, pygeum is used to treat BPH. Many poorly designed placebo-controlled clinic trials have suggest an efficacy similar to saw palmetto. There is limited evidence to support a weak recommendation for pygeum in combination with saw palmetto for the treatment of BPH. It appears safe for both short- and long-term use, and there are infrequent, not serious adverse events or interactions.

Prostate cancer
Weak in Favor: Lycopene (4-8mg/day) "Dietary lycopene may be more effective"

Prostate cancer is the most common cancer in men. Recent evidence suggests that virtually all men will get prostate cancer if they live long enough. There are two types of prostate cancer: an aggressive type, which occurs in younger men and has the risk of metastases and death; and an indolent type, which occurs in old age and usually does not cause death.

A number of dietary interventions are being studied by the National Cancer Institute and the National Center for Complementary and Alternative Medicine to prevent prostate cancer. These include: selenium, vitamins D and E, lycopene (a carotenoid like beta-carotene found in high levels in tomatoes and pink grapefruit), phytoestrogens, flavonoids, and green tea polyphenols. PC-SPES is a formulation of eight natural products (seven herbs and one mushroom) and was released in 1996 as a treatment for prostate cancer.

Although the overall safety of vitamin E is being questioned, there are some data to suggest that vitamin E may help prevent prostate cancer. An epidemiological case-controlled study at John Hopkins showed decreased mortality from prostate cancer for both vitamin E and selenium--but only when gamma-tocopherol was included. This highlights the importance of recommending MIXED tocopherols as the preferred form of vitamin E and not just alpha-tocopherol. A large NIH study of vitamin E for the prevention of prostate cancer showed negative overall results but a positive effect for gamma-tocopherol in reducing prostate disease (Wright and colleagues, 2007). Because ingestion of supplemental vitamin E has been associated with an increase in overall mortality at doses of 400 IU or higher, its safety is in question. Finally, patients with Type 2 diabetes should not take supplemental vitamin E in doses of 400 IU or higher due to increased risks.

Lycopene is a carotenoid like beta-carotene that is found in high levels in tomatoes and pink grapefruit. Lycopene appears to exhibit about twice the antioxidant activity of beta-carotene and may be helpful for preventing cancer. In one observational study, ingesting a diet high in tomato products reduced cancer incidence by 50% in men and women, with fewer GI cancers along with a reduction in prostate cancer (Franceschi and colleagues, Int J Cancer, 1994). A 4-year observational study of 47,894 men showed that a diet rich in lycopene greatly reduced prostate cancer incidence (Giovannucci and colleagues, J Natl Cancer Inst, 1995). Lycopene appears in reasonably high levels in the human prostate, and there is evidence that lycopene might slow DNA synthesis in prostate cells, which could lower risk of prostate cancer. [That said, ] there is [still very limited evidence to support a weak recommendation for lycopene for the prevention of prostate cancer. Dietary and supplemental lycopene is [nevertheless] considered relatively safe with infrequent, not serious adverse events or interactions.

Pilot studies suggested that PC-SPES may decrease PSA levels in prostate cancer patients; however, subsequent chemical analysis of batches sold over the counter showed that this product was adulterated with diethylstilbestrol (DES) as wellas as indomethacin and warfarin. Additional trials have shown PC-SPES to reduce PSA levels, but it may be that the effect was due to the DES and not the natural produces. Although these studies revealed promising results, there are significant safety concerns due to adulteration of the product.

While long-term controlled trials of CAM therapies to prevent or treat prostate cancer are lacking, there are observational studies that indicate lower rates among patients taking some of these supplements.

Longevity
Strong in Favor: Caloric restriction (daily low calories or intermittent fasting)

Depression
Major depressive disorder
Strong in Favor: Aerobic exercise (walking, running, swimming), 20-60 minutes 2-5x/week
Strong in Favor: SAMe (600-800mg BID)

Weak in Favor: Yoga breathing and/or poses; progressive muscle relaxation (as adjunct); autogenic training (as adjunct)
Weak in Favor: Phototherapy (exposure to bright light)
Weak in Favor: Folate (0.4-1mg/day) (as adjunct)
Weak in Favor: Saffron (30 mg QD)

Only one in five doctors refuse to let drug reps into their offices during office hours. I am proud to count my (new) doc-- all the way back to the late 1990s-- as one of them.

Of course the flip side of this stat is that a full 80% embrace the intrusion. The betrayal of patient confidentiality may well be the chief reason the Don't Tread On Me minority Just Say No to swarmy pill pushers in the office, but a sincere desire to draw a clear line between what is in the best interest of any given patient vs. what is in the best interest of a drug outfit and its hot new drug may also enter into the equation. We can only hope that this trend catches on.

I came across this statistic in the Duff Wilson piece on the front page of today's NYT Business section. It's kind of a great article. I am happy to learn that I wasn't missing anything by not having Epocrates on my phone.

The article is kind of all over the place--with perhaps an undue amount of ink devoted to the mysteries of the placebo effect--but there are some juicy bits here and there and more than a few (unreferenced) factoids that, at least to my mind, merit chasing down.

Among them:

Ornish argues that a focus on diet, exercise and stress reduction (I would only include managing one's response to stresses) can do a better job of preventing, slowing and even reversing heart disease than most drugs and surgical procedures.

The following studies were cited as evidence of the power of the placebo effect:

A 2002 study found that sham knee surgery involving only an incision but nothing else did as much to relieve arthritis pain as the standard real procedure.

A 2009 study found that the same was true of a common back operation for osteoporosis.

A 2008 study in the British Medical Journal showed that patients receiving sham treatment for irritable bowel syndrome (which is one of the 10 disorders that most frequently bring patients to doctors and which has been estimated to cost the U.S. up to $30 billion a year) did as well as patients typically do [sic] on the standard drug [which is?] for the disorder.

A 2001 study showed that in patients suffering from Parkinson's disease, a placebo treatment caused dopamine production to surge.

A German Medical Association (which has, over the years, designed, conducted and published some really high quality research!) study this year found that 59% of patients with stomach discomfort were helped by sham treatments.

A 2008 survey found that "about half" of U.S. physicians admit they routinely prescribe treatments they don't think are likely to be of direct physical benefit.

Tapping the skin in random places with a metal tube can "reliably produce" results "identical to" those of acupuncture needles inserted into [classically described] acupuncture points of the system's energy meridians.

Then there is the litany (to which we can surely add less recent fiascos) of FDA approved drugs that later failed to work against the disease for which they were licensed or (and/or) came with horrific side effects:

Freedman adds to this list the (accurate) observation that even the cholesterol lowering statins are now regarded to be of questionable benefit in lowering the risk of a first heart attack, and notes sardonically, "the use for which they are most widely prescribed."

Also: "Recent studies have shown heart-bypass surgery and the emplacement of stents to prop open arteries to be of surprisingly little help in extending the lives of most patients."

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Among the more 'macro' thinking observations in the article, none is probably more on the nose than that of UCSF biologist and Nobel Laureate Elizabeth Blackburn. She observes:

"Modern medicine was formed around success in fighting infections disease. ... To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. ... We face an entirely different set of medical challenges today (heart disease, prostate cancer, breast cancer, diabetes, obesity and other chronic disease now account for three-quarters of health care spending), but we haven't rethought the way we fight illness. The medical establishment still waits for us to develop some sign of one of these illnesses then seeks to treat us with drugs and surgery."

And as if to illustrate Blackburn's point, Freedman includes, a couple of pages later, the case of Mary Pinkard, a 54-year old woman with a long history of extreme fatigue, sinus discomfort, and other symptoms which under the care of conventional physicians resulted in three operations on her sinuses and a hysterectomy, as well as long, intense courses of antibiotics--none of it very helpful. After she began seeing an osteopath who was also trained in acupuncture and other alternative approaches, she says the improvements have been dramatic: hasn't been sick in five months and hasn't had to take any drugs. She says it was well worth the $2,500 she has had to pay out of pocket.

I would like to add one final section on how medical students 'lose their healer mindset,' but that will have to wait until this weekend.