/ NICE and Randomised Control Trials

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Rob Exile Ward 31 Oct 2019

How frigging hard are these to understand? I don't want the NHS to pay for homeopathy, or 'medicinal cannabis' for that matter; at least, not until their efficacy has been proven.

4
Bob Kemp 31 Oct 2019
In reply to Rob Exile Ward:

As I understand it the NHS has banned homeopathic prescribing, so I guess you're referring to this:

http://www.pulsetoday.co.uk/news/all-news/nhs-england-address-serious-concerns-over-potential-homeopathy-reaccreditation/20039592.article

What's new in the medicinal cannabis debate?

Dave Garnett 31 Oct 2019
In reply to Rob Exile Ward:

> How frigging hard are these to understand? I don't want the NHS to pay for homeopathy, or 'medicinal cannabis' for that matter; at least, not until their efficacy has been proven.

I'd say these are two quite different issues.  Totally with you on homeopathy, but I think there's pretty good (though anecdotal) evidence that cannabinoids can be useful for treating refractory epilepsy and some forms of chronic pain. 

Sorting out how much of its claimed benefit in anxiety and depression is down to a placebo effect will take some decent properly controlled trials, and doing that will require a change in the political climate.  I'd agree that, given that there's also an apparent link with serious mental illness, this is not something we want to do without a lot more information.   

2
Rob Exile Ward 31 Oct 2019
In reply to Bob Kemp:

I was watching Naga Munchetty this morning and she just couldn't understand why the NHS wouldn't pay for treatment based on anecdotal evidence.

Jon Stewart 31 Oct 2019
In reply to Dave Garnett:

The evidence on pain isn't brilliant, and for anxiety it's non-existent.

https://www.bmj.com/content/362/bmj.k3230/rr-2

On epilepsy it's a bit different because there's more case report type evidence for severe paediatric cases, so slightly more promising.

deepsoup 31 Oct 2019
In reply to Rob Exile Ward:

>  not until their efficacy has been proven.

On the one hand, yes! 

On the other hand the need for a randomised placebo-controlled trial is in itself proof that a placebo can be an effective treatment.  Philosophically it's a bitter pill to swallow, but pragmatically I'd have no problem with NHS doctors prescribing a placebo if it works and it's good value for money.

BFG 31 Oct 2019
In reply to deepsoup:

I don't have a problem with placebs being prescribed. I do have a problem with doctors lying to patients. For the homeopathy placebo to work the latter is required.

1
stevieb 31 Oct 2019
In reply to Rob Exile Ward:

Can you still get homeopathy on the French health service? I always thought one benefit was that it offered the doctor a chance to prescribe a placebo

elsewhere 31 Oct 2019
In reply to BFG:

> I don't have a problem with placebs being prescribed. I do have a problem with doctors lying to patients. For the homeopathy placebo to work the latter is required.

Placebos work even if the doctor says they are placebos. 

https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect

Not sure if they work better if the doctor lies.

captain paranoia 31 Oct 2019
In reply to deepsoup:

> Philosophically it's a bitter pill to swallow

Placebos are generally sugar pills, surely...?

deepsoup 31 Oct 2019
In reply to BFG:

> I do have a problem with doctors lying to patients.

I agree, and that makes it difficult to prescribe a placebo.  Gone are the days when a GP could send someone off with a prescription for some sugar pills.  It may even be a contributory factor to the looming threat of antibiotic resistance that doctors have often found themselves prescribing antibiotics as a placebo.  ("Oh FFS - here's a prescription for some Amoxycillin for your flu now please just get out of my surgery.")

"This contains no active ingredients at all, but there are anecdotal reports of it being effective in cases like this and I think it may help you."   <- This is not a lie.

Looking at the bigger picture, you might argue that doctors appearing to accept that homeopathy is effective though we know it really isn't could be corrosive to our (as a society) value for science, evidence etc.  And I would absolutely agree with you, philosophically it sucks.

But medical treatment is often worth pursuing in spite of a detrimental side-effect, and look at us - we are already a nation of drooling slack-jawed halfwits!  Refusing to use an effective medicine ("no more effective than placebo" ≠ "not efficacious") on such grounds is like refusing to prescribe something for a double amputee's headaches on the grounds that it can cause swelling of the toes.

1
deepsoup 31 Oct 2019
In reply to captain paranoia:

I'm glad you saw what I did there.

deepsoup 31 Oct 2019
In reply to BFG:

> I do have a problem with doctors lying to patients. For the homeopathy placebo to work the latter is required.

I was playing Devil's advocate somewhat, but I see he has other advocates already, so allow me to reverse my position completely and agree with you.  (Phew, that's better, it felt weird arguing in favour of homeopathy on here.*)

Prescribing a homeopathic treatment as a placebo is not lying to the patient, but it is outsourcing some lying to the patient. 
"I honestly think this treatment may make you feel better , so I'm going to refer you to my colleague who practices 'alternative medicine' ."

Blimey, it's difficult this nuance business innit?

In some forums you can add a poll to a post.  If this was one of them I might suggest a question to the group:

Attempting to apply a rigidly binary rule to a  complicated situation is**:

  • a) right
  • b) wrong

.

.

.

Edit to add - footnotes:
* - but does at least take me back to a time when we bickered at length on here about things other than Brexit.  Ah, happy days.
** - oops.

Post edited at 11:04
Eric9Points 31 Oct 2019
In reply to Jon Stewart:

> The evidence on pain isn't brilliant, and for anxiety it's non-existent.

> On epilepsy it's a bit different because there's more case report type evidence for severe paediatric cases, so slightly more promising.


Fine but my experience is meeting people whose pain or anxiety have been effectively controlled by cannabis.

In the case of chronic pain the person I knew was able to give up the daily use of opioids and rely entirely on cannabis. Surely replacing a dangerous drug with a safe one is something shouldn't require a lot of study before trials are started.

8
Michael Hood 31 Oct 2019
In reply to whoever:

For "traditional" homeopathy, by which I mean where the dilutions are done to 10 to the power of stupid, where there is virtually zero chance of any "active" ingredient molecule actually being in a bottle, then I agree that it's basically a placebo. Maybe a good placebo, but that's all it is.

However, there are some things that get sold under the homeopathy label (or with homeopathic stuff) where any dilutions are such that there almost certainly are some active molecules. I'm quite happy to accept that these may have some actual benefit. There are plenty of traditional/herbal "medicines" out there that can do some good, and I wouldn't want any potential benefits there to be lost because they've been tarred with the homeopathic brush (not that you'd know with <0 tar molecules once the water had evaporated ).

7
Jon Stewart 31 Oct 2019
In reply to Eric9Points:

> Fine but my experience is meeting people whose pain or anxiety have been effectively controlled by cannabis.

> In the case of chronic pain the person I knew was able to give up the daily use of opioids and rely entirely on cannabis. Surely replacing a dangerous drug with a safe one is something shouldn't require a lot of study before trials are started.

If you haven't done the studies, you don't know it's safe. Trials are a good idea.

I believe strongly that an individual should have the freedom to make the decision to take cannabis rather than opioids for their pain if they wish. But I don't think the NHS should be prescribing anything that doesn't meet the standards of evidence that are in place through NICE. (I'm not qualified to comment on whether the standards of evidence NICE work to are optimal btw - I can only presume they are, since they're the experts and I'm not).

Eric9Points 31 Oct 2019
In reply to Jon Stewart:

> If you haven't done the studies, you don't know it's safe.

Ever heard of anyone dying of cannabis? Me neither.

Opioids kill every day.

There must be a way of streamlining the qualification process for a drug that is obviously safer than the one it is intended to replace.

7
cb294 31 Oct 2019
In reply to Rob Exile Ward:

You cannot legally have a thread on homeopathy without this

https://www.youtube.com/watch?v=HMGIbOGu8q0

and this

https://www.youtube.com/watch?v=qHNQqCCOoZ8

CB

Jon Stewart 31 Oct 2019
In reply to Eric9Points:

> Ever heard of anyone dying of cannabis? Me neither.

> Opioids kill every day.

> There must be a way of streamlining the qualification process for a drug that is obviously safer than the one it is intended to replace.

But being safe isn't enough - it's got to be effective as well!

In the case of cannabis, it just needs to be available legally so people have the freedom to try it and see for themselves whether it works for them. The evidence that it is as effective as opioids for treating pain isn't there, so doctors should not prescribe it for patients suffering pain if it's not going to work. I'm not saying that opioids aren't overprescribed (I don't know), but I don't believe for a second that there is an equally effective but less harmful option available in cannabis. It's just not a strong analgesic like an opioid. 

Pan Ron 31 Oct 2019
In reply to Rob Exile Ward:

Proof of efficacy seems very difficult to prove though.

2
cb294 31 Oct 2019
In reply to Pan Ron:

Why? Routine question of stage III clinical trials. 

CB

Toerag 01 Nov 2019
In reply to Eric9Points:

> Ever heard of anyone dying of cannabis? Me neither.

I'm pretty sure many of those people smoking it are going to be suffering fatal lung diseases sooner or later, then there's those having psychotic episodes* killing themselves in some way or other, or the whole 'gateway drug' scenario.

* from what little I've read, I don't think cannabis causes mental health issues, but it's an amplifier for existing issues in much the same way as alcohol is.

Jon Stewart 01 Nov 2019
In reply to Toerag:

> I'm pretty sure many of those people smoking it are going to be suffering fatal lung diseases sooner or later, then there's those having psychotic episodes* killing themselves in some way or other, or the whole 'gateway drug' scenario.

> * from what little I've read, I don't think cannabis causes mental health issues, but it's an amplifier for existing issues in much the same way as alcohol is.

Do you believe in the 'gateway drug' theory?

Recreational drug taking is a behaviour that people with certain personality traits (chiefly openness to experience) engage in. Problematic drug use and addiction is caused by other personality factors and social factors, failure in education, unemployment, etc. Drug deaths are caused by other case-specific factors such as heroin being stronger than the user expects, or particularly risky behaviour by someone who's basically got nothing to lose.

So while it's probably true that most problem drug users and drug deaths started out with cannabis use, it's a total misattribution of causation. Most people who die alcohol related deaths probably started out by drinking beer socially, but we don't think that beer is the cause of those deaths - indeed, we don't even ban alcohol. We appreciate that people become alcoholics because of factors specific to them, not factors specific to alcohol.

1
Stuart William 02 Nov 2019
In reply to Jon Stewart:

Hear hear. If you are wanting to know why someone develops problematic drug taking behaviours then "what drug did they take first?" is entirely the wrong question. Far more relevant are the individual and social factors that led them to those behaviours. If someone's substance use is reaching concerning levels a better question might be "what problems are they trying to solve or escape with this behaviour?" That's a very simplistic take on it but likely to get you closer to a sensible explanation for what they are doing.

The vast majority of people are entirely capable of using a wide range of drugs in moderation without developing addictive or problematic behaviours. Just look around at the number of people able to drink recreationally without becoming alcoholic.

elsewhere 02 Nov 2019
In reply to Stuart William:

> The vast majority of people are entirely capable of using a wide range of drugs in moderation without developing addictive or problematic behaviours. Just look around at the number of people able to drink recreationally without becoming alcoholic.

Nicotine is an exception to that?

Dax H 03 Nov 2019
In reply to Jon Stewart:

> Do you believe in the 'gateway drug' theory?

Very much so but not in the if you use cannabis you will move to harder stuff on your own theory. 

Having been around a lot of drug takers in my life I have seen far too many being given a free sample of something stronger by their dealer. This wouldn't happen if you could buy weed from the local chemist. 

Badgers 03 Nov 2019
In reply to Eric9Points:

> Ever heard of anyone dying of cannabis? Me neither.

Yes - terminal lung cancer, psychosis resulting in death and bullous lung disease leading to pneumothoraces (not fatal, but v close) all come to mind. It is a drug, it has risks (admittedly less than opiates, cocaine, alcohol etc.. in the way we use them in our society at present)... The pure safety of cannabis is a dangerous myth. 

However, if we can get some appropriate evidence of benefit we should use it, in an informed manner. I work in an area where placebo controlled trials cannot happen (v rare diseases). I prescribe a lot off licence, based upon deduction, case report, parallel conditions, occasionally guess work and giving something a try. It requires an open and flexible system to bring in new drugs and new applications and a careful open dialogue with patients. I agree that the current system is far too restrictive. 

But the use of homeopathy on the NHS (at some considerable cost) is unacceptable, especially when we can't prescribe some proven (or at least rational) drugs to patients. 

Jon Stewart 03 Nov 2019
In reply to Dax H:

> Having been around a lot of drug takers in my life I have seen far too many being given a free sample of something stronger by their dealer.

But in a world where drugs, and information about drugs, are easily available, would that user try the "harder" drug anyway? And what type of free samples are you talking about? I struggle to believe that being given a sample of a drug is much of a causal factor to creating problematic use.

A free sample of smack isn't going to get you addicted to smack - it'll probably just make you sick. Likewise, a bit of coke isn't going to turn you into a cokehead. If you're the kind of person who finds the idea of coke appealing, you're going to try it anyway. A dealer gives out a free tab of acid, or pill, then great (so long as the user takes it in the right setting).

Reflecting on my experience and that of all my peers, most of whom are experienced with all common recreational drugs, the only one I've seen have a real problematic pattern with is cannabis. And none of us were offered drugs we'd not tried before by our weed dealers, we sought these out by ourselves. When I was kid, some friends did get involved with heroin, 2 of whom became addicts and their lives went down the pan. But others in that same scene tried heroin a couple of times and it didn't do them any harm. I think heroin is pretty unique - I would regard it as "don't play with fire". But do weed dealers really give free samples of heroin out to their clients?

> This wouldn't happen if you could buy weed from the local chemist. 

I think if weed was decriminalised/legalised, then so should most other drugs e.g. MDMA, psychedelics, speed. Cocaine is a funny one, no not sure about that. I don't see the rationale for legalising cannabis but not other party drugs, when cannabis is the one most likely to harm a person's prospects (by being stoned and ineffective all the time, and then getting lung cancer).

SouthernSteve 03 Nov 2019
In reply to Eric9Points:

> Ever heard of anyone dying of cannabis? Me neither.

Drummer, O. H., et al. (2019). "Cannabis as a cause of death: A review." Forensic Sci Int 298: 298-306.

I agree - they are much less likely to be a cause of problems than the opioids, but I couldn't resist a quick pubmed search ;-)

squarepeg 03 Nov 2019
In reply to Rob Exile Ward:

How do you get from cbd oil for pain, to being high on dope?

Dax H 04 Nov 2019
In reply to Jon Stewart:

> And none of us were offered drugs we'd not tried before by our weed dealers, we sought these out by ourselves.

Thats the beauty of anecdotal evidence, yours contradicts mine but both are correct. 

Bob Kemp 04 Nov 2019
In reply to Jon Stewart:

You could add to your arguments for legalisation for all drugs the wider negative social and environmental consequences of illegal drug distribution networks. Drug gangs engaged in human trafficking of workers for cannabis farms, narco-deforestation, MDMA by-product pollution and so on...

Jon Stewart 04 Nov 2019
In reply to Dax H:

> Thats the beauty of anecdotal evidence, yours contradicts mine but both are correct. 

But did your friends develop problematic use of substances which they wouldn't have otherwise tried? 


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