Mud slinging (Part 1)

Listening is a fastrack to learning. Time spent with arthritis sufferers in Moree thermal pools informed me of the benefits of medicinal marijuana after hearing how an elderly couple inadvertently spent too long in a pungent smoke filled café at Nimbin. Indeed, the largest number of reviewers at cast an overwhelmingly endorsing vote for the weed. The side-effects preclude living a normal life, however reality has always been overrated and opt-out for many. Winfried Häuser led an investigation into evidence-based interdisciplinary guidelines across Germany, Israel and Canada but cautiously advised undertaking research by clinical trial of cannabinoids before addressing licensing. Mineral springs or balneotherapy were recommended though, an idea which was extended by researchers at the University of Pisa who compared the short-lived relief of a thermal treatment with the enduring benefit of a mudbath, in the journal of Clinical and Experimental Rheumatology.

IMG_1745Bazzichi and Lucacchini et al didn’t rely on subjective opinion of symptoms, rather going so far as to apply salivary protein analysis to differentiate an improved therapy. Justification enough for a trip to the murky sulphurous pools of Ngawha in New Zealand – their ‘Doctor’ being pictured. Not only have this team listened to their patients’ stories, but they’re cognizant of expert skepticism and the demands of evidence base. To no avail unfortunately, since founder of the Arthritis Research Centre Prof Fred Wolfe in his blog derides the study as about as useful as a Chianti/Riesling comparison… “Really! Does anyone really think that mud baths are a truly useful therapy for FM? What also caught my eye was all of the ‘sophisticated’ and expensive tests that were done and what it all costs.” A cost benefit analysis requires a crystal ball for evaluating future returns from the pioneering work in proteomic salivary analysis. Thus far it’s proven useful in distinguishing Sjogren’s syndrome from other sicca syndromes such as presented by fibromites.  Relief from this discomfort of dry mouth compounded by the nuisance of a runny nose (non-allergic rhinitis) is one of the attractions of guaifenesin as a treatment, besides its neurological effects. Again lampooned on fmperplex as “Quackery”, but another unfortunate discard of babe with the dirty bathing water. Arif Donmez and team from Istanbul Dept of Medical Ecology concede that their clinical trial of a balneotherapy course, showing a diminishing improvement during 9 months of followup may have been influenced by residual benefit of a break from the daily grind. Pain was objectively measured by inflicting it with a dolorimeter however, which would have erased pleasant memories! Ouch!!

Bad medicine (Part 1)

“People have died from the drugs I have prescribed…..We Doctors have a destructive therapeutic mind set and this is causing widespread and long term harm to society “. So begins a typically thought-provoking Bad Medicine view and a discussion excerpt in the British Medical Journal, in response to the report by a forensic toxicologist that 35% of heroin overdose victims had misused gabapentin or pregabalin (editorial 15 Aug 2013). How apt are the asps of the caduceus – adopted erroneously by the medical profession in the 19th century as a result of a mistake by the US Army Medical Corps? The Hippocratic Oath began with the words “I swear by Apollo the Physician and by Asclepius …… (whose staff in mythology had only the one snake!)…. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect”. To err is truly human, and physicians are no more exempt from blunders. The two snakes of the medical caduceus actually belong to the staff of Hermes – God of commerce and thieves, and guide to the Underworld. Hellarious!cad

The fatalities’ poisoning was associated with abuse in order to enhance euphoric effects of opioids, and GPs have been alerted to avoid iatrogenic involvement (remember do no harm!). Information is readily accessible, however overly abundant. Distilled summaries are published by the Cochrane Collaboration. Investigating any benefits of the GABA-likes gabapentin or pregabalin would reveal systematic reviews of studies by Üçeyler, Sommer and Häuser et al finding that “The amount and quality of evidence were insufficient to draw definite conclusions on the efficacy and safety of gabapentin …………. The anticonvulsant, pregabalin, demonstrated a small benefit over placebo in reducing pain and sleep problems. Pregabalin use was shown not to substantially reduce fatigue compared with placebo. Study dropout rates due to adverse events were higher with pregabalin use compared with placebo.”  Häuser co-authored an 11-year study of fibromyalgia outcomes with Dr Fred Wolfe which reported in the European Journal of Pain Sept 2012 a conclusion that “Drug costs are substantially higher because of NCAD (pregabalin, duloxetine, milnacipran) use, but we found no evidence of clinical benefit for NCAD compared with prior therapy.”(tri-cyclic anti-depressants ie amitriptyline). Confirmed by Prof Beth Smith’s meta-analysis of 51 publications in 2011 concluding “Amitriptyline was similar to duloxetine, milnacipran, and pregabalin on outcomes of pain and fatigue“. Wolfe’s colleague Dr John Quintner wrote that “a minority of patients will report substantial benefit with Lyrica… Many will have no or trivial benefit, or will discontinue the drug because of adverse events“. Which somewhat contradicts the tick of approval given by the US FDA, and it gets no better. The April 2010 Journal of the American Medical Association article ‘Anticonvulsant Medications and the Risk of Suicide, Attempted Suicide, or Violent Death’ points to an increased risk with the taking of gabapentin. Which is where we started…. and whence we shall return

Not my problem

James Stoxen, head of Team Doctors (chiropractors to the stars) has enjoyed many decades untroubled by fibromyalgia symptoms, thanks to hardcore barefoot running. Reasoning that a musculoskeletal disorder can be beaten in the gym, his lectures on themes around “Walk and Run For Life via Lever Mechanisms or Spring Mechanisms” are in demand. Moving into mainstream, we’ve learnt that conferring of a medical degree doesn’t assure granting of insight into conditions. In the book pictured, Brandon advises ab crunches for fibromyalgics to help in dealing with stress. Hopefully this workout won’t be prescribed by Dr Ruse when he does his intern years. Dr Amand of the Fibromyalgia Treatment Centre can never be accused of insensitivity to the condition – he suffers from it. His book “What your Doctor may NOT tell you about Fibromyalgia” mixes empirical data and patient narrative with theoretical postulations, and their organisation’s commitment to investigate FM can never be challenged. Although their research points to an immunological disorder (Pubmed ID 18535166) the rheumatologists to whom patients are referred are in disagreement. Seems it’s officially not a disease but a functional somatic syndrome, classified under ICD9 in the ‘Unspecified myalgias’ family of diseases under soft tissue disorders.

Amazon copyrightThe treatment? Obvious to everyone (but me) are anti-depressants. Even more mind-numbing are the runarounds a patient endures under the ‘multi-disciplinary approach’. In making FM everyone’s problem it has ended up being no-ones responsibility. This ripens the opportunity for regular announcement of miracle breakthroughs, since instant solutions certainly look better than longterm prospects under the regulated healthcare system.