Doctoring the evidence

If your doctor is any good, they’re users of theCochraneLibrary.org founded by Sir Iain Chalmers, whose online book I’ve previously linked. Reports of treatments are gathered systematically, to avoid cherry-picking of that evidence which is more favourable to pre-conceived ideas. An assessment of bias follows formal rules, and a statistical meta-analysis (trainsmashing) of outcome results conveys confidence limits in the solution. All reviews are written to the same format and lay folk can benefit from this collective wisdom (if they’ve learnt from reading Testing Treatments), since they’re altruistically distributed in many countries. 1424312_368966716574253_1835599297_n
Authoring is an act of selflessness by prestigious experts in their field, although displeased editors can dismiss any work if it disagrees with their perspective. Fibromyalgia was considered too different an etiology from neuropathy to jointly consider a common treatment, even though the Cochrane group editor published his own ‘Oxycodone for Neuropathic Pain and Fibromyalgia’ a fortnight earlier. The same team included a Pfizer employee when reviewing anti-convulsants for acute and chronic pain, yet more hippocratic hypocrisy.
Co-founder Prof Peter Gøtzsche published in 2013 the exposé: ‘Deadly Medicines and Organised Crime: How Big Pharma has Corrupted Healthcare’, an excerpt from pg84 follows. ”A rare admission that doctors’ opinions are for sale to the highest bidder was provided by Canadian rheumatologist Peter Tugwell, who wrote a letter to several major companies soliciting funds for (Continuing Medical Education) conferences on behalf of an organisation called OMERACT: We think that support for such a meeting would be very profitable for a company with a worldwide interest in drugs targeted in these field. The impact of sponsorship will be high…” This is the very same Cochrane’s Prof P.Tugwell who co-authors with musculoskeletal editor Prof Rachelle Buchbinder on OMERACT progress. After the 12th biennial conference we’re yet to discover how rheumies intend to measure outcome improvement – seemingly a major impediment to actually doing any investigations into treatments. May’s junket to Budapest has yet to be reported (10 months later), but watch for a breakthrough report (once the holiday photos have been put in order) at: http://omeract.org/conference_proceedings.html
The weblinked chapter ‘Pushing children into suicide with happy pills’ is preceded by ‘Psychiatry, the drug industry’s paradise’, opening with a delusional claim that “Psychiatrists are also ‘educated’ with industry’s hospitality more often than any other specialty”. Citation given is Ray Moynihan’s “suspicion”,  in turn citing a report co-written with Lisa Bero and submitted to BMJ but not published. Their précis of Medicines Australia Education Event reports actually found psychiatrists to be 5th placed in per head promotional spending, back in 2008. In the most recent report rheumatology is clearly the most rewarded specialty – sponsored by pharma with $1mil to attend overseas conferences and another $1mil for pain management seminars at home. Sadly, the sanctimonious supply of evidence for your doctor’s decisions is dirty at the source.

It’s not apparent just who the leading pushers of happy pills may be, but the anti-depressant amitriptyline/Endep has two trials on the go – Flavia Cicuttini hopes to fix backpain and Anita Wluka sees opportunity in osteoarthritis. These rheumies from Buchbinder’s department at Monash are hosting the Melbourne leg of Peter’s Mentalaz 2015 tour, and despite NHMRC public funding of their studies the justifying proposals for this 54-year old drug are secret (requesting memo response: “the protocol is not in the public domain”). Easy money – Prof Cicuttini is listed in the Assigner Academy, which determines the members of the Peer Review Panels for grant approvals. Their recent review of the accumulated evidence  ‘Are depression, anxiety and poor mental health risk factors for knee pain?’ states that one high-quality study was found correlating depression with 4.4% of variation in osteo knee pain & disability scores (r=0.21), ie 95.6% of pain perception was attributable to other factors (notably self-efficacy). Their 2014 report ‘Relationship Between Mental Health and Foot Pain’ concludes that “Mental health is associated with changes in foot pain”. Which omits the keyword ‘not’, since the Mental Health domain of the Mental Component Summary was nonsignificant – however the Vitality domain (survey items Pep & life, Energy, Worn out, Tired) was the determinant of deterioration. The implication that ongoing pain is associated with mental illness (survey items Nervousness, Down in dumps, Peacefulness, Blues & sadness, Happiness) is plain, dumb wrong.

Hardly good reasons to step out of specialty and into psych, so what are the risks? Tolerable, but after dry mouth weight gain is 2nd worst  – tho’ a mobility scooter will fix that.  They also cited three “high-quality” * trials of Cymbalta/duloxetine for knee osteo, but two of these were conducted by the manufacturer. Mmm, you can just smell that quality. It’s also a riskier drug than Endep due to addiction – the US FDA has classified Cymbalta Withdrawal Syndrome, and (shhh, don’t tell anyone) suicide risk (the FDA concealed deaths during trials behind “Some clinical trial data are considered trade secrets, or commercially protected information“). Is amitriptyline any good for pain? A Cochrane review of trial results for neuralgia states “The fact that there is no supportive unbiased evidence for a beneficial effect is disappointing, but has to be balanced against decades of successful treatment in many patients“. Will it work for you? Until pharmacogenomics comes into maturity, read the tealeaves …. or ask for a quick serotonin bloodtest to judge for yourself whether you’re deficient.

Conflict of interest declaration: I’m distrustful of physicians due to a conviction that secretive money flags corruption, and alternative therapies hold greater promise for this reason alone.

* Rather than rely upon CONSORT or GRADE standard checklists, PEDro assessed ‘quality’. Sí, this is true. Not even the late, great Dave Sackett could fictionalise better material.
PS Questions as to who’s watching the watchers overflows onto an earlier post. And did I mention that NHMRC Director of Grants is Monash alumnus?

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1 Comment

  1. Pingback: Celebrex™ on trial | F'n Myalgia

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