This is intended to be a sort of a patchwork layman’s guide as to why less medical research might be a good idea. I’ll be interested to see whether I manage to stay focussed for long enough to manage a post that vaguely fits that description. I’ve been alerted via the Holford Watch and Bad Science blogs to many interesting books, academic papers and websites and a couple of those prompted this post.
Advocates for various forms of Alternative Medicine are fond of claiming that more research is required. What I think they mean by this is that they want to keep testing until they find a positive effect. Or rather, they want scientists to keep testing their treatments for them – the AltMed industry and supporters often don’t seem too keen to spend money running tests themselves. While we all know that Big Pharma are pill pushers who spend twice as much on advertising and marketing as they do on research, Big Quacka Spend 18 and a half times more on marketing than on research. It hardly seems worth conducting more tests in, for example, homeopathy – because quite apart from the fact that we can already see from the tests that have already been conducted that homeopathy’s effects are most likely placebo (and the better designed the trial, the more likely this will be the finding whereas badly designed studies prone to bias are more likely to find a small positive effect and small studies with few participants make a negligible contribution to our knowledge of a treatment), homeopathy is utterly implausible as a treatment. I’ll leave Alternative Medicine now and look at medical trials that do look at plausible treatments (rather than 200-year-old witchcraft).
Professor Trisha Greenhalgh in Evidence and Marketing, a part of her book How To Read A Paper that featured in the BMJ [see links at bottom of page for more], made the point that Doctors should not accept the newness of a product as an argument for changing to it (apart from anything else, rare but serious adverse reactions to new drugs may be poorly documented) and also referred to marketing of and evidence for NSAIDs. I looked at Testing Treatments [see links] to see what Evans, Thornton and Chalmers had to say about newness and there is a whole chapter titled New – but no better or even worse. “Almost invariably there will be uncertainties about effects and effectiveness when new treatments are devised – treatment effects are very seldom overwhelmingly obvious. So carefully designed fair tests are necessary to identify the effects reliably (see Chapter 3). Without a fair – unbiased – evaluation, the risk is that useless or even harmful treatments are deemed helpful or, conversely, that helpful treatments are dismissed as useless. Untested theories about treatments effects, however convincing they may sound, are not enough.” I also wanted to see what they had to say about NSAIDs – and found this in chapter six: “Four focus groups – of patients, rheumatologists, physiotherapists, and general practitioners […] were unanimous in making clear that they did not want any more trials sponsored by pharmaceutical companies comparing yet another non-steroidal anti-inflammatory drug (the group of drugs that includes, for example, ibuprofen) against a placebo (dummy drug).” So while they state that new products require fair, unbiased evaluation, they later make the point that not all evaluation is useful.
Less research, better research, and research for the right reasons is the sixth chapter of this book and it deals with what a BMJ editorial called “the scandal of poor medical research”. The mismatch between what patients and practitioners want and what researchers are looking into is not confined to osteoarthritis, but is apparent in other areas of research. Of me-too drugs they say “Minor changes in drug formulation rarely lead to the drugs having substantially new, more useful effects, yet these types of studies dominate research into treatments for arthritis and for other disorders. What a waste of resources!” and point out that one reason is that Big Pharma conduct research in order to make money for their shareholders [I’m paraphrasing here, BTW]. That pharmaceutical firms make me-too drugs at least partly accounts for the gap in expenditure between R&D and marketing – as I wrote earlier, Big Pharma spends twice as much on marketing as it does on research. In order to persuade prescribers to use their newer, more expensive drugs, pharma firms often commission several small studies showing that their drug is better than placebo. I was surprised to read that “drug licensing authorities often make the problem worse by insisting that new drugs should be compared with placebos, rather than with existing effective treatments.” The next point in this chapter relates to “the increasingly dubious relationships between universities and industry”, and you can read more about this relationship in other places, such as on Prof David Colquhoun’s blog Improbable Science.
More interesting points are made in chapter six, mostly things that would never have occurred to me. One is that “Many people within universities and research funding organisations believe that improvements in health are most likely to stem from attempts to unravel basic mechanisms of disease. So, they do research in laboratories and with animals. Although such basic research is unquestionably needed, there is precious little evidence to support this bias towards it.” It’s fantastic that Chalmers, Evans and Thornton are addressing issues such as this, but I don’t seem to have read much about any kind of improvement in these areas. I’m not sure how many people are listening to these views, still less doing anything about them – but that’s possibly because I haven’t tended to read this sort of thing before and I may have also missed all those stories in the national media about these issues [erm, The Guardian may be an exception here but I’m pretty sure the other nationals have published little if anything about them]. The upshot is that lots of lab research has been done that is not necessarily telling us anything valuable and that may not have been properly evaluated. A side-effect of this is that there are lots of studies out there (millions are published every year in medical research, apparently) and this means that Alternative Medicine gurus have lots of chaff to sift through – if they are sufficiently plausible and are able to cherry pick enough studies to support their ideas they can use referenciness to make it appear as if their ideas are valid. Perhaps if medical research didn’t produce so many studies there would be less chaff and fewer opportunuites for the businessmen in, for example, nutritionism to don a cloak of scientific respectability. The main problem though, I think, is that this is (as the authors of Testing Treatments say) a shocking waste of resources.
I’ve gone on for quite long enough now and I’ve barely scratched the surface of chapter six of Testing Treatments, let alone the whole book, so I’m going to go for a pint now. i’ll leave you with this:
DODGY, DEVIOUS, AND DUPED?
Writing a light-hearted article for a Christmas edition of the British Medical Journal, two researchers created a spoof company called HARLOT plc to provide a series of services for trial sponsors. For example:
‘We can guarantee positive results for the manufacturers of dodgy drugs and devices who are seeking to increase their market shares, for health professional guilds who want to increase the demand for their unnecessary diagnostic and therapeutic services, and for local and national health departments who are seeking to implement irrational and self serving health policies . . . for dodgy ‘‘me too” drugs . . . as long as your ‘‘me too” drug isn’t a lot worse than a sip of triple distilled water, [our E-Zee-Me-Too Protocol team] can guarantee you a positive trial.’ To their astonishment, the authors received some apparently serious inquiries about the amazing HARLOT plc portfolio.
Sackett DL, Oxman AD. HARLOT plc: an amalgamation of the world’s two oldest professions.
British Medical Journal 2003;327:1442-5.
Links: Trisha Greenhalgh in the BMJ on Evidence and Marketing (found via http://www.badscience.net/); Testing Treatments e-book (found via http://holfordwatch.info/); Amazon linky for teh Greenhalgh book; Amazon linky for Testing Treatments.