tag:theconversation.com,2011:/columns/michael-vagg-1771Medicandus – The Conversation2017-03-22T05:00:24Ztag:theconversation.com,2011:article/749812017-03-22T05:00:24Z2017-03-22T05:00:24ZSwisse cheese: there are too many holes in complementary medicine regulations already<p>Imagine, if you would, a company in a pre-budget submission demanding diplomatic assistance from their government to help them sell product overseas. Fair enough, you might say. If you don’t ask you won’t get. </p>
<p>Now imagine that company was one that sold products in an industry so notoriously shonky that when the Australian National Audit Office <a href="https://www.anao.gov.au/work/performance-audit/therapeutic-goods-regulation-complementary-medicines">did an investigation</a>, they concluded its supposed regulatory agency:</p>
<blockquote>
<p>has been aware that regulatory compliance has been poor since at least 2007.</p>
</blockquote>
<p>Oh, and that was back in August 2011. Things haven’t improved much since then.</p>
<p>Add to that the fact that the company demanding diplomatic representation overseas has a history of <a href="http://www.tgacrp.com.au/complaint-register/?_search=Swisse">multiple findings of regulatory breaches within Australia</a>. </p>
<p>I know it’s stretching the bounds of imagination, but try also to picture this company lobbying aggressively to be removed from the restrictions imposed on advertising and selling health products by the Therapeutic Goods Act 1989. They want to be free to create and market products which are inherently unfit for their advertised purpose and they don’t want red tape (otherwise known as consumer protection laws) getting in the way. </p>
<p>Enter <a href="https://www.theguardian.com/australia-news/2017/mar/20/swisse-pushes-coalition-to-reduce-role-of-therapeutic-goods-administration">this week’s effort</a> by the supplement manufacturer Swisse. They’ve done exactly what I was outlining above. To me, and others who watch this wretched industry closely, this looks like an unprecedented effort to <a href="http://www.alphadictionary.com/goodword/word/gull">gull</a> the Australian public of its legal protections. </p>
<p>With a TGA so weak as to be ignored with impunity, they feel confident enough to publicly claim the economic benefits of selling useless products to misguided consumers outweigh the erosion of our right to be told the truth in advertising and our absolute right to have a higher standard for health-related claims in advertising compared to other industries. </p>
<p>Swisse is by no means the only vitamin company to have issues with truth in advertising. Blackmores is another Australian brand with overseas ambitions. They are pushing into the enormous Chinese supplement market, and apparently not letting trivial things like <a href="http://www.theaustralian.com.au/business/companies/blackmores-fined-65000-in-china-for-false-claims/news-story/200cac6b72cf60609d80e3754a01a9de">fines for false advertising</a> get in the way of a <a href="http://www.theaustralian.com.au/business/companies/vitamin-maker-blackmores-in-chinese-recovery/news-story/0269d2452156be43976a6002d904166d">surging share price</a>. </p>
<p>The essential problem here for manufacturers is that they simply HAVE to mislead to sell their product, and our <a href="https://www.tga.gov.au/publication/therapeutic-goods-advertising-code">therapeutic claims regulatory code</a> inconveniently forbids this. All the talk about TGA reform and economic benefits and so on is deliberate obfuscation to misdirect the conversation away from the fact that there is no scientific reason to claim that these heavily-hyped products do anything they claim they can. Absent fundamental scientific credibility, the options they have are threefold. </p>
<ol>
<li><p>Business as usual. Ignore the regulations and treat legal action to defend against reported breaches as a cost of doing business. This is cheap and effective, especially in an industry where the credibility of the players is so low as to be incapable of worsening. It does however discourage really big mainstream acceptance and political patronage that is necessary to go from a family-owned medium sized business to a global multi-national.</p></li>
<li><p>Try to create some research that looks enough like science to be technically claimable as such. It will never be scientifically acceptable but you can fool lots of the consumers and perhaps some of the regulatory bodies with it. If you’re lucky you might also get some misguided health professionals on board. Swisse has tried this approach, with its controversial <a href="http://www.smh.com.au/comment/why-la-trobe-will-take-swisse-money-to-help-fund-research-on-its-products-20140207-32747.html">partnerships with Latrobe University</a> and <a href="http://www.smh.com.au/national/health/abcs-partnership-with-vitamin-giant-swisse-draws-universities-into-its-orbit-20160830-gr4gl1.html">the ABC</a> seemingly designed to create the appearance of respectable research being done. Blackmores has its <a href="https://www.blackmoresinstitute.org/research-and-partnerships/research-projects">Blackmores Institute</a> and sponsorship of a Research Centre at Southern Cross University in Queensland. </p></li>
<li><p>Go bold and strive to get rid of the regulations altogether. This is the thrust of the current submission. Even the withered embrace of the TGA has become too restrictive for the vitamin industry and it would appear they have judged the time propitious for a stab at rolling back the consumer protections enshrined in the current law.</p></li>
</ol>
<p>Far from the implied claim that vitamins represent such an important industry they should be represented in every Australian embassy in the national interest, I would say the opposite is true. I would go as far as to say that this is an industry built on monetising the insecurities, delusions and outright ignorance of consumers.</p>
<p>I for one wouldn’t miss it at all if it was outlawed altogether.</p>
<hr>
<p><em>Update: an earlier version of the article contained an incorrect reference to Mr Marcus Blackmore for which we apologise.</em></p><img src="https://counter.theconversation.com/content/74981/count.gif" alt="The Conversation" width="1" height="1" />
Imagine, if you would, a company in a pre-budget submission demanding diplomatic assistance from their government to help them sell product overseas. Fair enough, you might say. If you don’t ask you won’t…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/740912017-03-06T11:27:59Z2017-03-06T11:27:59ZPlease don’t do your own research on immunisation; you’ll get it wrong<p>Pauline Hanson has become the latest politician to <a href="http://www.abc.net.au/news/2017-03-06/health-groups-appalled-by-hanson-vaccination-remarks/8328714">flirt with the fringe view of immunisation denial</a>. Of course, like all thoroughly modern anti-vaxxers, she claims to be about choice and empowerment rather than denial of the overwhelming scientific consensus.</p>
<p>Of all the weasel words immunisation deniers use, I get most infuriated by the “do your own research” trope.</p>
<p>You don’t need to. Unless you’re a senior research scientist with your own lab, a posse of postdocs and serious wad of cash, we don’t need your help. </p>
<p>What Senator Hanson appears to mean is that she wants average people who find misinformation on the internet to be allowed to disagree with decades of rigorous, serious scientific effort. Unlike so many of my medical colleagues, I make an effort to keep up with goings-on in the anti-vax movement so I am grimly aware of the depths of hubris and folly that inform the “research” you so easily find when you innocently Google for vaccine information. The average person with high-school science knowledge and healthy faith in human decency has no chance.</p>
<p>Someone who has limited time and attention would not possibly bother to wade through the byzantine details of how <a href="http://www.bmj.com/content/342/bmj.c7452">Andrew Wakefield’s fraud was uncovered</a> and the scurrilous ongoing attempts to smear Brian Deer, the investigative journalist who brought it to light.</p>
<p>Only a dogged student of human nature would have the stomach to watch videos featuring the <a href="https://www.youtube.com/watch?v=b44XgR6hzcg">pseudoscientific ramblings</a> of the supposed intellectual leaders of this wretched movement. Yet many of us have done this for you. Trust me, there is no wisdom or learning in these cranks.</p>
<p>Only the real enthusiasts would have watched with bemusement last month as the Chiropractors’ Association of Australia (CAA) had a public spat on their own Facebook page with the AV-sN, Australia’s leading anti-vax organisation. CAA finally got around to demanding the removal of a link from AV-sN website endorsing their chiropractic philosophy of opposing immunisation. Their public statement read in part:</p>
<blockquote>
<p>It has come to our attention that the Australian Vaccination-sceptics Network contains a link to the CAA National website. We have requested that they remove this link to our website as a matter of urgency.</p>
<p>The Chiropractors’ Association of Australia (CAA) does not support the views promoted by the Australian Vaccination-sceptics Network.</p>
</blockquote>
<p>The former president of the anti-vaxxers then further embarrassed CAA by turning up in the comment section and lamenting:</p>
<blockquote>
<p>More and more chiropractors are speaking out against their governing body trying to tell them that they must ignore basic chiropractic philosophy of the power that made the body heals the body in order to gain acceptance from mainstream medicine. When will the CAA understand that mainstream medicine’s only concern is to maintain their own authoritarian monopoly and destroy any and all competitors?</p>
</blockquote>
<p>I’ve <a href="https://theconversation.com/concerns-about-chiros-are-about-quality-and-safety-not-some-phoney-turf-war-12738">previously documented</a> how CAA has been providing anti-vax speakers at official learning activities approved for professional development by their regulator, but you won’t find this information on the front page of your Google search. As recently as 2015, the CAA National Conference <a href="https://reasonablehank.com/2015/10/18/scratching-that-irritating-infection-at-the-chiropractors-association-of-australias-national-conference/">featured several speakers</a> with links to the antivax movement. But again, the background briefing needed to appreciate the importance of this is not available to any but the most hardcore anti-vax-watchers.</p>
<p>I could go on and on in this vein, but I’ll spare you. Suffice to say that everywhere you get suspicion and hostility about immunisation you also get shoddy thinking and misrepresentation of plain facts. You get routine denial of reality and genuinely unhinged discourse. Science becomes The Enemy. Ideology trumps evidence.</p>
<p>There is no worthwhile political debate to be had here. Giving such deformed pseudoscience any media oxygen at all is reckless. It is unworthy of a serious aspirant to political power. By parroting the coded messages of the anti-vax movement, and encouraging hesitant parents to “do their own research” Senator Hanson is enabling an unspeakable industry to thrive. Make no mistake, there are hucksters both big and small raking in money by manufacturing hostility towards one of the greatest gifts our benighted species has managed to give itself.</p>
<p>All these cretins want is the chance to get unwary, perhaps vulnerable parents in front of their finely tuned propaganda. </p>
<p>What Senator Hanson has just done is give them a flood of fresh eyeballs to sell to.</p><img src="https://counter.theconversation.com/content/74091/count.gif" alt="The Conversation" width="1" height="1" />
Pauline Hanson has become the latest politician to flirt with the fringe view of immunisation denial. Of course, like all thoroughly modern anti-vaxxers, she claims to be about choice and empowerment rather…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/705762016-12-19T00:33:26Z2016-12-19T00:33:26Z‘Bad backs, a bit of depression and so on’ - a throwaway line for some, a life sentence for others<p>Former prime minister Tony Abbott was <a href="http://www.smh.com.au/federal-politics/political-news/tony-abbott-slams-pensions-for-people-with-bad-backs-a-bit-of-depression-20161214-gtasat.html?platform=hootsuite">widely reported in the media</a> for remarks he made about the Disability Support Pension (DSP) while being interviewed on radio. This was a few days ago now, and no doubt Mr Abbott has gone on with his backbench duties and is perhaps getting ready for Christmas with his family. It’s old news now in media terms but the damage it has caused will go on for the people most affected by his talking point.</p>
<p>While I acknowledge you can’t be right all the time, and Mr Abbott may not necessarily have the chance to prepare for public statements when put on the spot, some of the comments he made regarding DSP eligibility were frankly misconceived.</p>
<p>Following the <a href="https://theconversation.com/dsp-reassessments-the-new-phrenology-26630">last article</a> I wrote in this column about DSP eligibility, I was contacted by a former Commonwealth-employed doctor. He wholeheartedly agreed with my view that independent medical examinations for DSP recipients were a waste of time and money.</p>
<p>He further wanted me to know that in his experience of conducting perhaps 10,000 examinations over the course of more than a decade, the number of malingerers he identified was in single figures. The experience of doctors like him was one of the main reasons why the system was changed to make the treating doctors the gatekeepers for medical assessment. All the evidence was they were doing a very good job at keeping out people who were ineligible.</p>
<p>It would appear to be a hallmark of Mr Abbott’s political career to ignore evidence when an ideological point can be made. It was his <a href="https://theconversation.com/time-to-stop-abusing-the-nhmrc-for-ideological-purposes-38151">government’s direction to the NHMRC</a> to waste time and money examining unscientific beliefs regarding “Wind Turbine Syndrome”, water fluoridation and homoeopathy. Money was no object when it came to stopping the boats, and apparently the same goes for cracking down on virtually non-existent DSP frauds.</p>
<p>For the former PM to say publicly that under his government, too many people were put onto the DSP is misguided for number of reasons. Firstly, and most obviously, he implies he has some predetermined knowledge of exactly what the correct number of DSP recipients in Australia is supposed to be. </p>
<p>Secondly, it implies ineligible individuals are being inappropriately placed onto DSP. Finally, he seems oddly ill-advised about major public health issues like depression and chronic pain, and the role they have in creating disability.</p>
<p>I have heard from many on the right of politics there are two problems with DSP recipients from a policy and economic point of view. Firstly, too many people are being given it, and secondly too few people are coming off it. </p>
<p>The second objection is the easier to deal with. The point of the DSP is it provides income support for individuals who are permanently unfit to work. I would have thought if the system was perfect nobody would ever come off. It should be difficult to gain access to for malingerers or those who are expected to recover and return to the workforce. A DSP which is fit for purpose should provide lifelong support for those with permanent problems. It is therefore fatuous to object that people are staying on for too long.</p>
<p>The first of the above objections is the bone of contention. I argue from both my own experiences and those of numerous of my patients the <a href="https://theconversation.com/people-on-the-dsp-are-not-wasting-money-unlike-the-politicians-who-stigmatise-them-25810">eligibility bar is not currently set too low</a>. The current system we have is the product of decades of work from dedicated bureaucrats and in fact is delivering robust outcomes in a very, very difficult area. </p>
<p>Prevention and early treatment of mental and physical ill-health should be the main game at this point. It has been known for years hostile employers and poor job satisfaction are among the <a href="http://www.rtwknowledge.org/article_print.php?article_id=192">most potent barriers</a> to returning to work for those with either depression or back pain. Investing in ways of reducing workplace bullying and improving management standards, especially improving occupational safety issues would be an obvious, evidence-informed way of reducing the numbers becoming eligible for DSP. </p>
<p>A politician who is actually serious about reducing DSP eligibility should be embarrassed and ashamed about achieving this by denying genuine claimants instead of taking action to stop them ending up in that situation.</p>
<p>As for Mr Abbott’s characterisation of back pain and depression as “not permanent conditions” I can only shake my head. In fact, this may be the most damaging comment he made. In one throwaway remark, this politician of considerable influence speaking to a large audience reinforced perhaps the most <a href="https://en.wikipedia.org/wiki/Ableism">ableist</a> and ignorant stereotype that blights the lives of sufferers of those conditions. </p>
<p>Having been PM, he simply should have been more responsible. He did not take seriously two of the leading causes of disability and ill-health throughout the planet. These are not trivial problems you can get over with a “can-do” attitude or by “toughing it out”. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150638/original/image-20161219-26093-cjh82l.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Graphic showing global causes of disability burden.</span>
<span class="attribution"><span class="source">Dr Andrew Briggs, presented at Australian Pain Society conference 2016</span></span>
</figcaption>
</figure>
<p>Someone with diabetes may have perfect blood sugar readings for months at a time if they manage their diet, exercise, and medications just right. They still have diabetes. Someone with persistent low back pain that has gone on longer than 12 months is always going to have to manage that pain: every day, forever. </p>
<p>People with serious mood disorders put enormous amounts of emotional effort into appearing better than they are so they are not judged by people saying exactly the sort of thing Mr Abbott did.</p>
<p>Nobody chooses to become eligible for DSP. It’s not a lifestyle choice that has anything to recommend it. If Mr Abbott (or any politician) truly cares about the very difficult issue of preventing working-age Australians ending up in the poverty trap of chronic illness, my door is open. I would be happy to collect a few dozen of my patients who receive DSP and let him tell me which of them I should have told they were fit for work after all. I might even point out a few useful policy ideas that might work in the real world.</p>
<p>A few hours of hearing about relationships destroyed, houses sold, family members alienated, jobs lost, children disadvantaged and lives generally upended by the onset of chronic illness might just be enough of a glimpse to enable Mr Abbott to learn to empathise. Perhaps it’s too much to hope for to get closer to ending the stigma of being disabled and unable to work. I’m probably being hopelessly optimistic to think there is even a genuine appetite for addressing even some of the entrenched discrimination my patients face from every employer they send a CV to.</p>
<p>I’d settle for simply seeing less of the unthinking ableism that makes life harder for those already up against it.</p><img src="https://counter.theconversation.com/content/70576/count.gif" alt="The Conversation" width="1" height="1" />
Former prime minister Tony Abbott was widely reported in the media for remarks he made about the Disability Support Pension (DSP) while being interviewed on radio. This was a few days ago now, and no doubt…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/676312016-12-09T23:50:49Z2016-12-09T23:50:49ZNew evidence gives supporters of chiropractic a headache<p>A <a href="http://onlinelibrary.wiley.com/doi/10.1111/ene.13166/abstract">paper was published</a> and <a href="http://chiropractors.asn.au/resources/latest-news/item/695-chiropractors-welcome-latest-evidence-on-headaches">much discussed online</a> recently, which demonstrates all the problems that I - and other critics - have with the way research is done and interpreted in the world of chiropractic. </p>
<p>The study looked at the effect of chiropractic neck manipulation on people who have migraines.</p>
<p>On the face of it, the article concerned looks like a pretty fair and well conducted study. Despite the methodological difficulties of randomisation and blinding of participants with manual therapies, a genuine effort was made as part of the study design to allow for this. </p>
<p>The trial was a three-armed study comparing chiropractic spinal manipulation (CMST) with a sham manual therapy and a group who continued with their usual care. </p>
<p>Although the deliverers of the manual therapy would know what they were providing, a level of blinding to treatment allocation was possible. It was refreshing to see as well that they had checked to confirm that the blinding of subjects was maintained throughout the study. This is extremely important in assessing the validity of a study, and as the authors point out </p>
<blockquote>
<p>The importance of our successful blinding is emphasized by the fact that all previous manual-therapy RCTs on headache lack placebo._ </p>
</blockquote>
<p>The outcome measures chosen were reasonably fair and representative of the group studied. The statistical analysis was conventional enough. They had performed power calculations using a reasonable comparator, which again increases confidence in the validity of the results and shows they were taking the methodology seriously.</p>
<p>The robustness of the methodology is likely the reason it was included in the European Journal of Neurology – a solid, second-tier journal with a credible reputation.</p>
<p>I would not quibble with the summary of their conclusion, published in the paper’s abstract, that said:</p>
<blockquote>
<p>It is possible to conduct a manual-therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.</p>
</blockquote>
<p>This is the correct scientific interpretation of the data. If it was a drug trial, we would conclude there was no pharmacologically relevant effect within the parameters shown, and it would be considered a negative study.</p>
<p>How very different then is the analysis of the same study by chiropractors. The Chiropractors’ Association of Australia (CAA) mentioned it in <a href="http://chiropractors.asn.au/resources/latest-news/item/695-chiropractors-welcome-latest-evidence-on-headaches">their press release</a> titled saying “chiropractors welcome latest evidence of headaches”. The relevant quote is:</p>
<blockquote>
<p>A paper published in the European Journal of Neurology in September 2016 was the latest in a series of papers to confirm the effectiveness of chiropractic health care in treating people with migraines. The study of 104 people in Norway found that Migraine symptoms were substantially reduced as a result of chiropractic treatment.</p>
</blockquote>
<p>Critical reporting of this study, such as found on the website of the <a href="http://www.acsh.org/news/2016/11/29/have-migraine-get-back-rub-skip-chiropractor-10495">American Council on Science and Health</a>, throws up some interesting conversations and interpretations in the comments section. </p>
<p>While I don’t generally read online comment sections (apart from this column naturally) it’s worth making the effort in this particular case. The author of that piece has made the same basic epidemiological arguments as I have above, and come to the correct conclusion that it is a negative study. </p>
<p>One of the commenters accuses the author of deliberate bias and makes the following piquant observation:</p>
<blockquote>
<p>To show how much spin this “article” has the title could have been: Have a Migraine? Skip the meds, sham and Gonstead CSMT both effective. more than medical care.</p>
</blockquote>
<p>This commenter appears to be making the same error of interpretation as the CAA. The point of a three-armed study is to differentiate between the effect of any intervention in the study (due to placebo responses) and the improvement due to simply being observed in an artificial situation (known as <a href="https://en.wikipedia.org/wiki/Hawthorne_effect">the Hawthorne effect</a>).</p>
<p>If a treatment is genuinely efficacious, one expects to see three divergent curves with: a minor improvement in the no-intervention group; a larger improvement in the sham intervention group; and a clearly larger improvement in the true intervention group. </p>
<p>A treatment which lacks effectiveness will produce results in which the two intervention groups are indistinguishable. That is exactly what this study returned. Observe the graphs for yourself.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149484/original/image-20161209-31364-1xm0xly.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The graphs that tell the story.</span>
<span class="attribution"><span class="source">European Journal of Neurology</span></span>
</figcaption>
</figure>
<p>Note carefully that the authors of the original study are careful to claim the only conclusion that can be drawn is that it is feasible to conduct a manual therapy study in a single-blinded fashion. </p>
<p>They made no claims about the efficacy of the intervention apart from the fact it was equivalent to sham, and in fact are explicit about the fact they believe the treatment effects were all placebo. Outright claiming the opposite is a new peak of disingenuousness for supporters of chiropractic.</p>
<p>Another characteristic of treatments which do not have efficacy is that the more rigorous the study, the more the claimed effect disappears into the statistical noise. To be definitive about a lack of efficacy, a much larger study would be needed. </p>
<p>The results above would not inspire me to spend a couple of million dollars on a study with 200 people in every arm. Results like this over the years have killed off hundreds of medications which were being developed by Big Pharma.</p>
<p>Academic chiropractors are in the invidious position of trying to establish that an ideologically-based treatment system has a scientific basis. They should be careful what they wish for when conducting rigorous studies, as they may find their fondest beliefs being dashed on the rocks of reality.</p><img src="https://counter.theconversation.com/content/67631/count.gif" alt="The Conversation" width="1" height="1" />
A paper was published and much discussed online recently, which demonstrates all the problems that I - and other critics - have with the way research is done and interpreted in the world of chiropractic…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/686602016-11-11T04:01:24Z2016-11-11T04:01:24ZOn a bad day, some blue sky..<p>It’s a funny way that I make my living.</p>
<p>I spend anything up to 10 hours a day sitting at a desk talking to people with problems. I work in a practice which has set out to develop a culture of sharing triumphs, disasters and frustrations alike within the team. On the whole, I love my work, delighting in the constantly unfolding panorama of human experiences before me, and trying to choose from my palette of treatments the artful touches I could apply to improve the look of the picture.</p>
<p>But I can still have days like yesterday.</p>
<p>I met a man my own age whose 18 year marriage, young family and career were effectively lost as a result of a single incident on a bad day five years ago. He had fought hard against every loss and indignity that had piled up against him. He could hardly have done more, but there he was still paying a very heavy price for something that was never his fault. He won’t get back to where he was, and it’ll be a big job even to construct a new normal that gives him a life he will be happy to live with.</p>
<p>I also had my worst fears about another patient confirmed. She had missed an appointment with one of our team members and we asked the police to perform a welfare check, based on our very high suspicion they would not find her alive. Judged by the usual measures, her suicide risk had been redlining for most of this year. </p>
<p>Responses had been planned, and discussions about risk mitigation had occurred at various times throughout the year within our team. I had seen her two weeks ago and did not pick up any particular change that might have precipitated her action. Such deaths happen in our practice a few times a year and it never really gets much easier to respond to them. One has to stay professional, but I will be flat for a few days as will all of us who worked with her. There will be the sombre formalities of a coroner’s review which we have begun preparing for. </p>
<p>The profession I have chosen and the patients with whom I work are both groups with suicide rates well above the community average, but it’s still a difficult topic to discuss. By sharing this with you all, I hope I may bring some awareness to these sad facts, and help break down the taboo surrounding discussions of suicidality and mental health in general.</p>
<p>I received that news while talking to a different patient, who was in the middle of describing for me a minor miracle of modern medicine. After 40 years of near daily headaches, a new treatment that we introduced into this country a couple of years ago has produced five months of almost complete relief. She reckons she has nearly forgotten what a bad migraine feels like. The amount of potent triptan medication she has needed in the five months would have lasted her about a fortnight in the old days.</p>
<p>Earlier in the session, I caught up with an elderly lady who came to Australia in the great wave of post-war migration from a devastated Europe. She had developed back pain from injuries in a high-speed car accident four years ago. The process of legal and bureaucratic wrangling which resulted in my performing a successful, simple procedure had taken more than a year. </p>
<p>Part of that process involved my diagnosis being repudiated on behalf of the insurer by another specialist from outside my field. This happens often and is just another one of the petty humiliations one puts up with as gracefully as possible when engaging with compensation systems. </p>
<p>Since that procedure, which took about 20 minutes in theatre, she has been able to do her own shopping again, drive independently for up to half an hour, and visit her grandchildren whenever she wants. Small gains perhaps, but very meaningful for the lady concerned. Her son has aged visibly in the months it has taken to fight the necessary battles for funding approval, but you can see in his eyes when he looks at his mother that he’s proud he toughed it out for her.</p>
<p>So you get the wins and the losses thrown together on top of each other. Days like yesterday leave you emotionally spent, whatever else happens to be going on in your personal life. The training and skills I have spent my entire adult life developing are often tested and still at times found wanting. </p>
<p>The line between open and critical self-awareness on the one hand and paralysing self-doubt on the other can be indistinct at times. The best treatments we have in pain medicine only work one-third of the time as well as would like them to, so humility is appropriate. The patients I look after usually have predicaments rather than diagnoses. They don’t just need medical care, but they may also need protection from victimisation, stigmatisation and the misguided good intentions of others. They need education, coaching and support as much as they need expert diagnosis and treatment. </p>
<p>Some days I feel like I should hand back the letters after my name because I don’t think I deserve to have them anymore. I feel like I haven’t made a lick of difference to anyone. But those days pass.</p>
<p>I’ve learnt I can’t be all things to all people, but maybe to a few of them I can be just what they need at a particular time. That’s ambitious enough in any branch of medicine.</p>
<p><em><strong>If this discussion has caused any issues, please reach out to Lifeline on 13 11 14 or talk to a health professional</strong></em></p><img src="https://counter.theconversation.com/content/68660/count.gif" alt="The Conversation" width="1" height="1" />
It’s a funny way that I make my living. I spend anything up to 10 hours a day sitting at a desk talking to people with problems. I work in a practice which has set out to develop a culture of sharing triumphs…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/674602016-10-21T05:39:31Z2016-10-21T05:39:31ZBubbles of nothing are not something. Let’s not get too excited about non-deceptive placebo use<p>My attention fell this week on the reporting of an article accepted for publication in one of the main journals in my field. According to <a href="http://www.abc.net.au/news/2016-10-19/it-turns-out-placebos-work-even-when-you-know-theyre-placebos/7945438">the ABC</a>, placebo treatments for pain can be effective even when patients know that it’s a placebo.</p>
<p>The source for this report is the <a href="http://journals.lww.com/pain/Abstract/publishahead/Open_label_placebo_treatment_in_chronic_low_back.99404.aspx">following article</a> which is about to be published in the premier pain research journal <em>Pain</em> (as an interesting aside, note how the more authoritative a scientific journal is, the shorter its name is. I give you <em>Nature</em>, <em>Science</em>, <em>Cell</em>, <em>Circulation</em>, <em>Lung</em> to name just a few).</p>
<p>On closer examination, this publication becomes somewhat less newsworthy. It has all the classic hallmarks of a fluke result that is partly the result of the statistics used, and partly over-interpretation of fairly modest results. Given the authors claim they:</p>
<blockquote>
<p>turn our understanding of the placebo effect on its head</p>
</blockquote>
<p>I thought I had better take a look since this would be big news if true.</p>
<p>The study took place in Portugal, in a hospital pain clinic enrolling chronic back pain patients. The methodology was a small randomised controlled trial. Although double-blinding could have been possible and would have added substantially to the strength of the study design, for some reason there was a clear difference between the way the two groups were treated. </p>
<p>The group who received the open-label placebo treatment were given large orange capsules while the “treatment as usual” (TAU) group received nothing. Double- blinding could have been achieved by giving all the subjects placebo pills but having a separate researcher deliver the information about treatment allocation.</p>
<p>Instead, the placebo group were given a special briefing that was not given to the other group. To further compound the difference in treatment, the TAU group were told they would be given an opportunity to take the pills after the three weeks of the study period had been completed. Such a design is often used as a recruitment tool, but it inevitably enhances expectations and is part of a separate, distinct bias in research known as the <a href="https://en.wikipedia.org/wiki/Hawthorne_effect">Hawthorne effect</a>.</p>
<p>There are a couple of other, smaller more technical flaws in the design but even if we decide not to quibble about those details, the results are far from impressive. </p>
<p>The authors report that despite their effective randomisation procedures, there was a difference in baseline pain score of 1.25 on a 10 point scale. This is not a small difference. The claimed effect of the placebo treatment was 1.5 points. Allowing that the treatment as usual group was already suffering slightly less pain on average, one would anticipate the gains from any treatment to be slightly smaller. That is exactly what was shown.</p>
<p>In assessing a new treatment for consideration in clinical use, the minimum effect size that will attract interest is at least 2.0 points on a 10 point scale. </p>
<p>The other outcome measure they used was the <a href="http://www.rmdq.org/">Roland-Morris Disability Questionnaire</a>, which is a reliable and widely used research tool. The RMDQ is the most appropriate choice for research involving mild-to-moderate degrees of chronic pain so no complaints there. </p>
<p>However, there are some issues with the results which are not discussed in the paper. The RDMQ can be used with confidence to follow changes in disability only if the change in scores is greater than <a href="https://www.ncbi.nlm.nih.gov/pubmed/8606899">four points out of the 24 point scale</a>. The reported changes in RDMQ scores were well below this threshold, hence this is at best an equivocal result and should be interpreted as such. One would be hoping for more than three weeks of improvement from a potentially unethical intervention. The study only followed patients to three weeks which is not even long enough for the well-documented <a href="http://medical-dictionary.thefreedictionary.com/placebo">“placebo sag”</a> effect to kick in.</p>
<p>Small study size and short duration of follow-up tend to cause difficulties in the interpretation of potentially unexpected results because most unusual results disappear when the size of the study is increased. This is because the type of statistics used in small studies tend to flatter the intervention, an small differences between the study groups can be magnified.</p>
<p>Even if the results of this study were worthy of the breathless headlines, there still remains the issue that non-deceptive use of placebos is inherently unethical in my opinion because it medicalises the therapeutic transaction and entrenches a power disparity between patient and clinician. </p>
<p>In my experience, educated and empowered patients make good decisions about their treatment and experience less distress and better adjustment to their changed circumstances. The open-label placebo protocol used in this study was still deceptive as the use of Hawthorne effect was so powerful that most of the TAU group requested pill prescription after the three-week period and then demonstrated the same level of improvement as the intervention group in the study. </p>
<p>The only surprising thing to me about this finding was that the effect size was not large enough to be clinically relevant, given there was so much stacking of odds in their favour. So although the authors claim the protocol is not outright deceptive, it seems to me still very manipulative and exploits the ignorance of the patient about the lack of long-term efficacy that can be expected from placebo treatments.</p>
<p>So, once again, I will settle back into my armchair and keep reading my journals in pursuit of genuinely effective treatments that I can call upon for the benefit of my patients. I will not seek cheap shortcuts by manipulating my position of authority and instead will continue to try to educate and engage the people I look after so they become collaborators in their own long-term management.</p><img src="https://counter.theconversation.com/content/67460/count.gif" alt="The Conversation" width="1" height="1" />
My attention fell this week on the reporting of an article accepted for publication in one of the main journals in my field. According to the ABC, placebo treatments for pain can be effective even when…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/653422016-09-15T04:05:53Z2016-09-15T04:05:53ZNHMRC fluoride paper: relax, Australian citizens, your pineal glands are safe<p>When not being forced to waste their time and formidable expertise researching furphies like <a href="https://theconversation.com/au/topics/wind-turbine-syndrome-4382">wind turbine syndrome</a> or homeopathy, the National Health and Medical Research Council (NHMRC) can get on with producing exemplary public health statements like <a href="https://consultations.nhmrc.gov.au/files/consultations/drafts/nhmrc-fluoride-information.pdf">their newest one on water fluoridation</a>. </p>
<p>Begun in 2014 in response to <a href="https://theconversation.com/fluoride-conspiracies-activism-harm-to-children-17723">this sort of conspiracy-mongering</a>, the NHMRC has collected an overwhelming weight of evidence in support of the safety and benefit of adding tiny amounts of fluoride to drinking water supplies. </p>
<p>This document is a draft released for public comment. I would love to be able to read the public submissions they are going to get. None of the favoured conspiracy claims are supported.</p>
<p>It most emphatically did not find any evidence that fluoride lowers IQ, as suggested by a <a href="https://openparachute.wordpress.com/2014/02/20/repeating-bad-sicence-on-fluoride/">badly done and even more badly reported paper from 2012</a>. </p>
<p>Neither did it find any support for the idea that fluoride at levels obtained by current fluoridation practices caused significant dental fluorosis, such as brittle or discoloured teeth from excessive fluoride being incorporated into teeth. </p>
<p>Still less was there any support for fluoride acting as a <a href="https://sciencebasedlife.wordpress.com/2011/10/17/fluoride-in-the-water-for-your-teeth-or-government-mind-control/">mind control agent</a>!</p>
<p>The draft paper sets out in excellent prose the value of its work and how it has been done. It is easy to understand and reading through it, I was struck by how well the considerable scientific grunt work had been made to sound easy and logical. In particular, the couple of pages the authors have devoted to their methodology is outstandingly clear and easily understood. </p>
<p>Sections are also included on the ethics and cost-effectiveness of water fluoridation, distilled into useful factoids such as:</p>
<ul>
<li><p>For every A$1 spent on fluoridation, A$7-18 is saved in dental treatment costs</p></li>
<li><p>Over the last 25 years in Victoria, around A$1 billion dollars has been saved in treatment costs and reduced absenteeism</p></li>
<li><p>Stopping water fluoridation would increase health inequality in the nation as a whole.</p></li>
</ul>
<p>I would recommend the NHMRC fluoride paper as a public document for anyone with an interest in the issue, or indeed as a basic study of how to do public health policy. Most people I suspect will just go about their lives secure in the knowledge that sensible, reasonable public health professionals are making good decisions in the national interest. </p>
<p>Or at least, that’s what we would be thinking given that we are apparently docile and obedient from all the <a href="http://fluoridealert.org/issues/health/pineal-gland/">fluoride accumulating in our pineal glands…</a></p><img src="https://counter.theconversation.com/content/65342/count.gif" alt="The Conversation" width="1" height="1" />
When not being forced to waste their time and formidable expertise researching furphies like wind turbine syndrome or homeopathy, the National Health and Medical Research Council (NHMRC) can get on with…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649522016-09-06T02:20:57Z2016-09-06T02:20:57ZPlease can we give up on complementary, alternative and ‘integrative therapies’ now?<p>A purportedly <a href="http://mayocl.in/2cfstjE">serious publication</a> in a <a href="http://www.mayoclinicproceedings.org/current">serious forum</a> that was published this week has given rise to a <a href="https://nccih.nih.gov/research/blog/US-pain-review">bunch of</a> <a href="https://consumer.healthday.com/bone-and-joint-information-4/pain-health-news-520/briefs-emb-9-1-8amet-nondrug-treatments-pain-mcp-nccih-release-batch-2852-714441.html">breathless CAM-related headlines </a> in my news feed. CAM being Complementary and Alternative Therapies.</p>
<p>I presume that this is what the authors and their employer wanted, as the supposed good news story is in fact one of the most blatant examples of <a href="https://theconversation.com/quackademic-medicine-coming-soon-to-a-uni-near-you-22810">quackacademic</a> confabulation I have seen in ages. By this I mean that all is not what it appears with this review. </p>
<p>Firstly, the article in question was not prepared as an original research article. This is important, as <a href="http://nationalpainreport.com/nih-study-gives-primary-care-docs-needed-evidence-to-complement-chronic-pain-treatments-8831348.html">some of the headlines</a> seem to claim this is “new evidence”. </p>
<p>Look at the table of contents in the journal. It is part of a “CME Credit” symposium. This is an exercise where the editor invites summary articles on behalf of the journal from experts in a field to create what is supposed to be an uncontroversial and impartial review of the state of consensus opinion based on the literature in any given field. </p>
<p>Busy doctors read the review and complete some questions, then claim the learning time for their professional development. I am responsible for a lot of this sort of thing in my professional life, so I know that they are not always peer reviewed and can sometimes go off the rails if the expert panel is not carefully chosen. They are most definitely not considered a means of introducing new findings. </p>
<p>The article is apparently the first in a “Pain Medicine Symposium” to be offered over several editions of the journal. I would have expected to see a few names I recognised from the <a href="http://www.painmed.org/">American Academy of Pain Medicine</a> or the <a href="http://www.iasp-pain.org/">International Association for the Study of Pain</a>, or maybe even the <a href="http://americanpainsociety.org/">American Pain Society</a> among the authors. But did I?</p>
<p>Nope. </p>
<p>They all came from the <a href="https://nccih.nih.gov/">National Centre for Complementary and Integrative Health</a> (NCCIH). The lead author is an epidemiologist, and the co-authors include a naturopath with publications about echinacea and colds, a chiropractor (who at least has published about yoga and pain), a cardiologist who works in the regulatory affairs part of NCCIH and a statistician. Not exactly representative of mainstream opinion within the specialty of pain medicine I would submit.</p>
<p>Not to worry, I thought. There might be something to learn so let’s dive in. They start out reasonably enough sketching out some basic facts about the huge societal impact of persistent pain in the United States, which is similar to most countries. They nominate a few selected treatments: acupuncture, spinal manipulation, massage, meditation, “natural product supplements” and yoga, Tai Chi and qigong which all get lumped together, though they are in fact wildly different in practice and contradictory in theoretical concept. </p>
<p>After then setting out a few plausible-sounding excuses for what follows, which constitute the barest academic fig leaf to cover their sectarian belief systems, they also go on to specifically exclude cancer pain from their review. Why? I can guess. Even sincerely deluded cranks have some vestiges of conscience and wouldn’t stoop to taking advantage of cancer patients. (Or <a href="https://integrativeonc.org/about-us/about-sio">would they</a>?)</p>
<p>Having cherry-picked the topics and modalities that have thrown up the most randomly positive studies over the years, they then set out a steady stream of mostly negative studies which they somehow conclude support their argument that there is some useful clinical evidence for some of the therapies. </p>
<p>The Science Based Medicine blog has <a href="https://www.sciencebasedmedicine.org/an-overhyped-review-of-cam-for-chronic-pain-by-the-nccih-and-mayo-clinic-dont-put-away-your-opioids-just-yet/">set out an excellent critique</a> of the methods and results of the review. But the authors would not have gotten this paper published even in an invited slot without the mandatory disclaimers about the shortcomings of the studies. These are worth looking at in detail. First:</p>
<blockquote>
<p>The trial samples tend to be white, female, and older, with very few, if any, minority group participants; as such, the generalizability of the findings to the breadth of patients seen by primary care physicians in the United States is still unresolved.</p>
</blockquote>
<p>Ummm, I can resolve it. They aren’t at all generalizable, since the world does not consist entirely of elderly white female people. Next caveat:</p>
<blockquote>
<p>Often, the trials reviewed were small, with fewer than 100 total participants. Small trials are prone to more variability and to false-negative results.</p>
</blockquote>
<p>No kidding. This is a <a href="https://theconversation.com/bigger-is-definitely-better-when-it-comes-to-finding-out-the-truth-about-treatment-effects-8011">well-known problem</a>. If you combine the results of lots of small, bad trials you don’t reliably get closer to the truth. So why, after hundreds of trials and tens of millions of research dollars are we still getting acupuncture studies with a couple of dozen participants? </p>
<p>A false-negative result is one in which a real treatment is inappropriately rejected by the results of the study. However, an underpowered study is also <a href="http://www.nature.com/nrn/journal/v14/n5/full/nrn3475.html">far less likely to be reliable if positive</a>. Doing underpowered studies using variable study designs is the exact opposite of what savvy research funders require. You don’t want to waste buckets of cash doing studies which can’t be compared or assimilated down the track to get you closer to the truth.</p>
<p>Given that they admit their analysis is entirely of suspect positive results from poorly-designed underpowered studies, it hardly seems worth discussing any further. But we will look at the next caveat the authors put forward:</p>
<blockquote>
<p>In many of the trials in which the statistical superiority of a given complementary health approach was reported, it was not clear if the differences vs the control group were clinically relevant.</p>
</blockquote>
<p>In plain English, this means you would not notice the benefit of the treatment in real life. Maybe the treatment helps but it’s not worth bothering with even if it does help. In pain medicine this is all-important, as we are currently on a crusade to reduce the prescribing of drugs such as sustained-release opioids and benzodiazepenes in situations where they have <a href="https://theconversation.com/opioids-may-not-be-the-most-harmful-pain-drugs-after-all-33010">poor efficacy and significant risk</a>. We have a couple of decades of research showing that small, short-term reductions in pain intensity are not associated with improved quality of life or health status. </p>
<blockquote>
<p>For most complementary approaches, there are no standard treatment protocols or algorithms, and in the case of dietary supplements, no rigorously established dosages and products; as such, trials of a given complementary approach rarely compare the exact same intervention.</p>
</blockquote>
<p>This is the bald truth. There is no standardisation of therapies, no quality control of products, nothing at all but spin and fervent belief. The situation with acupuncture for example is <a href="https://www.painscience.com/articles/acupuncture-for-pain.php">nicely summed up</a> by <a href="https://www.painscience.com/articles/acupuncture-for-pain.php">Paul Ingraham</a> of the Pain Science blog:</p>
<blockquote>
<p>the most favourable evidence available is also the oldest, weakest and the most biased, and even that evidence is underwhelming, benefits that barely register as clinically significant — much ado about not much, even if it’s actually real, which no better study has ever confirmed.</p>
</blockquote>
<p>So to recap, NCCIH released <a href="https://nccih.nih.gov/research/results/spotlight/five-painful-conditions">a statement for the press</a> as if this represented new research, when their employees actually published a CME activity rehashing mostly old data, that by their own admission drew from highly unreliable studies and even if accurate was not generalizable to the population as a whole. </p>
<p>Never even mind that some of the therapies are conceptually exclusive of each other and biologically implausible. The press release of this <a href="http://www.urbandictionary.com/define.php?term=through%20the%20looking%20glass">through-the-looking-glass</a> piece of “research” was then widely distributed to inform the public of the exact opposite of what the data presented actually showed. This apparently represents the pinnacle of quality in CAM research. It’s certainly the most expensively-funded.</p>
<p>I will be closely watching with interest the next part of the Pain Medicine Symposium from Mayo Clinic Proceedings. I hope the editors were mortified to see the opportunism with which the solid reputation of their publication was exploited by the media beat-up that followed. They have let their readership and their academic integrity down badly with this review. I can hardly believe they will embarrass themselves so badly again.</p><img src="https://counter.theconversation.com/content/64952/count.gif" alt="The Conversation" width="1" height="1" />
A purportedly serious publication in a serious forum that was published this week has given rise to a bunch of breathless CAM-related headlines in my news feed. CAM being Complementary and Alternative…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/642272016-08-23T01:03:43Z2016-08-23T01:03:43ZDoctors or activists? Who draws the line?<p>The Division of Paediatrics and Child Health of the Royal Australasian College of Physicians (RACP) has released a <a href="https://www.racp.edu.au/news-and-events/all-news/news-details?id=1bfc55af-bbb2-61c2-b08b-ff00001c3177">strongly worded statement</a> about the harm caused to children in immigration detention. The statement in part asserts “as a country, we are failing the most vulnerable people in our care.” The RACP itself has been <a href="https://www.mja.com.au/journal/2015/202/11/let-children-go-advocacy-children-detention-royal-australasian-college">publicly opposed to the detention of child refugees</a> since the policy was introduced. </p>
<p>Regardless of where one sits on the political spectrum, it is impossible to deny that feelings run high on this issue. Is it helpful for doctors to weigh in publicly? Who should decide what issues doctors have a responsibility to comment publicly on?</p>
<p>Medical specialty groups are represented formally by quasi-academic bodies known as Colleges. Some smaller specialty groups such as the Australasian Faculty of Rehabilitation Medicine and the Faculty of Pain Medicine are organized into Faculties of larger Colleges. To be recognized as a “specialist” in your discipline you need to be offered Fellowship of a College or Faculty. </p>
<p>This process has a number of archaic features and is slightly different for every specialty. At the end of the day, though, the formal leaders of medical Colleges and Faculties speak for their Fellows in public debates. When it does happen, it can be taken as a near-unanimous consensus of all the Australian and New Zealand practitioners in that specialty group. </p>
<p>For this reason, such statements have been fairly rare and are only released on matters in which the leadership of the College sees an immediate need to add an authoritative voice to the public debate about an issue of the day. Medical leaders are generally not keen to be seen as activists. </p>
<p>Their main job is to regulate and accredit the standard of medical training and practice within their specialty and they are obliged to work with Governments of all stripes for the good of the community. Political stuff can be <a href="https://theconversation.com/patient-advocate-or-doctors-union-how-the-ama-flexes-its-political-muscle-60444">left to the Australian Medical Association</a> to engage with.</p>
<p>In recent times, though, it seems medical Colleges have been speaking out more frequently in public debate. The Royal Australian College of General Practitioners was <a href="http://www.racgp.org.au/yourracgp/news/media-releases/">very active in the election campaign </a> releasing 14 statements in June alone. Mental health is frequently a topic of community discussion, and the Royal Australian and New Zealand College of Psychiatrists releases a <a href="https://www.ranzcp.org/News-policy/Media-Centre.aspx">media statement virtually every week</a> on relevant topics including suicide among military veterans, Don Dale centre and the Nauru files. </p>
<p>While some of these statements are politically contentious if seen through partisan eyes, they are released because most doctors accept that advocacy on behalf of our patients is a critical part of the service we provide to society in return for the training and privileges we receive. The public trust us to act as a conscience when we become aware of threats to the health of any part of the community. </p>
<p>Politicians have an uneasy relationship with activist medical organisations. They love to demonise the AMA as the “doctor’s union” when it suits them, but they find it much harder to dismiss academic bodies such as the Colleges as self-interested lobby groups. Typically their points of view are based heavily on scientific evidence combined with real-world experience. Such statements can be a formidable endorsement of a policy or an insurmountable roadblock.</p>
<p>Doctors see ourselves as having a privileged position in society, gleaned from our years of academic training and constant exposure to dealing with the consequences of the community’s misadventures and tragedies. Our perspective is unique, and frequently uncomfortable to hear. We know and see much more than we can ever tell. No group knows so well the actual cost in money, tears and lost potential of dealing with the health consequences of preventable tragedies.</p>
<p>As activists, the medical profession can be irresistible. But we have to use that power wisely and sparingly, since there is only so much exposure to its own flaws society will put up with at a time. When Colleges speak out, it would pay to listen.</p><img src="https://counter.theconversation.com/content/64227/count.gif" alt="The Conversation" width="1" height="1" />
The Division of Paediatrics and Child Health of the Royal Australasian College of Physicians (RACP) has released a strongly worded statement about the harm caused to children in immigration detention…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/633122016-08-01T00:00:42Z2016-08-01T00:00:42ZThe casual stigmatisation of opioid use is lazy journalism<p>I was a bit annoyed by <a href="http://www.theage.com.au/national/health/opioid-addiction-treatments-get-people-off-painkillers-but-it-is-a-hard-road-20160729-gqgizg">this article</a> that appeared on The Age website and was retweeted widely. The title -_ Opioid addiction: Treatments get people off painkillers, but it is a hard road_ - suggests the story is about prescription opioid addiction. </p>
<p>The body of the piece then sets out the familiar narrative (to me at least) that current prescribing trends in Australia are not yet following the best available evidence for treatment of persistent pain. Too much opioid prescribing, too little investment in pain services which can provide a flexible, comprehensive response to the problem.</p>
<p>The patient described in the piece does not sound like he was addicted to opioids. He sounds far more typical of the majority of opioid users with persistent pain. He was taking the drugs rationally and as prescribed, in an attempt to improve his pain. He was experiencing cognitive and other side effects that are common at high doses. </p>
<p>When offered a better option, he weaned himself off the useless medication under supervision and now has less sedation and more skills to self-manage his pain. </p>
<p>I get really frustrated when stories like this are portrayed as a heroic battle against addiction. They are not. It is lazy or cynical journalism to say so. Ceasing opioids is an end in itself if one is treating an addiction. It is not necessarily an end in itself if you are treating persistent pain. Intelligent reporting would not confuse the two.</p>
<p>The real story is that the evidence has changed and pain clinicians no longer think there are manageable consequences to high-dose prescribing. We also recognise that there are a number of much more effective therapies to help people manage their pain. There are plenty of reasons people do better when they see a pain service that takes a comprehensive approach to the problem of chronic pain. </p>
<p>To start with, there are sometimes relatively little-known but treatable conditions such as soft-tissue pain in the neck and back of the hip. I see a few of these each week and they usually do very well once the problem is adequately recognised. </p>
<p>In addition to a clearer diagnosis, expert care can target medications more rationally based on the mechanism of the pain, rather than purely the diagnosis. Using antidepressant medications for diabetic peripheral neuropathy pain seems counter-intuitive but can be very effective. </p>
<p>Interventions such as nerve blocks and injections can be a useful circuit-breaker to enable better participation in an overall rehabilitation program. Occasionally they work so well no further treatment is needed, but no pain clinician worth their salt would contemplate using them as the whole treatment most of the time. </p>
<p>Newer, more high-tech and invasive therapies such as neuromodulation devices, are offering genuinely exciting potential for impressive individual results. Here is <a href="http://www.geelongadvertiser.com.au/news/geelong/womans-foot-pain-nightmare-solved-by-geelong-doctor/news-story/2fb61a5863f30259ba7eefcac1e6b029">an example</a> from my colleague’s practice of a desperate situation improved by expert care. </p>
<p>Training in the cognitive skills and emotional adaption required to put them into practice is labour-intensive and requires a dedicated allied health team. The evidence supporting the effectiveness of multidisciplinary pain care is as good as any of the more medically-driven treatment. </p>
<p>Remuneration and referral patterns don’t reflect this fact. In truth, you don’t get the best results without milking every part of the team for all they can give. You never know which team member may hold the key to unlocking the biggest gains for any given patient.</p>
<p>Media reporting of the retreat from opioid prescribing for persistent pain should not focus on saving people from addiction, but should emphasise the more positive story, which is that we are seriously improving the care we can offer people with chronic pain. </p>
<p>Casually referring to the silent majority of pain sufferers taking medications as they are meant to as “addicted” does nothing to further the discussion. Using complicated social and medical problems as clickbait is not just lazy journalism but adds to the everyday stigma surrounding persistent pain and its treatment.</p><img src="https://counter.theconversation.com/content/63312/count.gif" alt="The Conversation" width="1" height="1" />
I was a bit annoyed by this article that appeared on The Age website and was retweeted widely. The title -_ Opioid addiction: Treatments get people off painkillers, but it is a hard road_ - suggests the…Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Barwon HealthLicensed as Creative Commons – attribution, no derivatives.