The Dangers of Anti-Intellectual Propaganda

[abj13]

but the point of the (cursory) data representation here is that, while they do clearly produce benefits, for many of these drugs, they are not likely to really do anything meaningful for the people you give them to.

Actually, the majority of the drugs you presented have significant benefits, you didn't find/post them. Whether it is preventing MI, stroke, asthma exacerbations, hospitalization, progression of congestive heart failure/chronic kidney disease, you don't really have a valid argument to say that most don't. Saying those benefits aren't meaningful for the patient is significantly inaccurate. Outside of #8, all of the drugs in the top ten have clear benefits to patients. If you want to argue the utility of one class like SSRI's, that's another can of worms. But trying to argue that a majority of medications don't do anything meaningful after using a cursory Pubmed search isn't valid, especially in a thread titled about the dangers of anti-intellectualism.

 

[sandorski]

You guys realize I wrote the list, right? By doing a very cursory set of pubmed searches. As far as, for example, lisinopril and statins go, sure there's a big range of indications or potential benefits and a whole bunch of outcomes. But are they clinically meaningful? It's not like a lower creatinine or a higher HDL are things that a person feels. Certainly, not having an MI or stroke or needing dialysis are clinically meaningful, but the point of the (cursory) data representation here is that, while they do clearly produce benefits, for many of these drugs, they are not likely to really do anything meaningful for the people you give them to. I still give plenty of them. I know the list is highly flawed. I could do much better but that's a whole lot of effort for very little benefit. It's put together just to illustrate a point.

As far as some of them being overprescribed, well, placebos work to. I see no problem with prescribing a safe medication whose benefit is only a little better than placebo if the benefit itself is worth having compared to the risk.

It's moot whether you wrote the list, it still doesn't show what you think it shows. Whether some or all are over-prescribed is another issue.

Here is one of a few similar you listed: "29 Bupropion 25,061,016 --> about 80% of antidepressant response is seen in placebo"

On the face of it that sounds pretty bad, but what does it mean?
-what constitutes the affects of the 80%?
-what constitutes the affects of the 20%?
-how does this drug compare to other drugs for the same conditions they are recommended for?
-how serious are these conditions?

 

[interchange]

Actually, the majority of the drugs you presented have significant benefits, you didn't find/post them. Whether it is preventing MI, stroke, asthma exacerbations, hospitalization, progression of congestive heart failure/chronic kidney disease, you don't really have a valid argument to say that most don't. Saying those benefits aren't meaningful for the patient is significantly inaccurate. Outside of #8, all of the drugs in the top ten have clear benefits to patients. If you want to argue the utility of one class like SSRI's, that's another can of worms. But trying to argue that a majority of medications don't do anything meaningful after using a cursory Pubmed search isn't valid, especially in a thread titled about the dangers of anti-intellectualism.

They absolutely have clinically meaningful benefits and should be prescribed. And those clinically meaningful benefits are realized for a minority of patients. They should still be prescribed because the benefits are likely to outweigh the risks. My list does not say that these medicines don't work.

It's moot whether you wrote the list, it still doesn't show what you think it shows. Whether some or all are over-prescribed is another issue.

Here is one of a few similar you listed: "29 Bupropion 25,061,016 --> about 80% of antidepressant response is seen in placebo"

On the face of it that sounds pretty bad, but what does it mean?
-what constitutes the affects of the 80%?
-what constitutes the affects of the 20%?
-how does this drug compare to other drugs for the same conditions they are recommended for?
-how serious are these conditions?

There isn't a single drug or class of drugs among antidepressants that clearly separates from another. The only (FDA-approved, let's just start with) treatment that is truly meaningfully different for depression is ECT.

Essentially what that means is, for example, a study may show:

Baseline HAM-D 25
Post-study HAM-D for placebo: 16
Post-study HAM-D for citalopram: 13.75

Major depressive disorder is the #1 leading cause of disability in the world with about a 15% suicide rate. Quite arguably the most serious medical illness there is.

 

[sandorski]

They absolutely have clinically meaningful benefits and should be prescribed. And those clinically meaningful benefits are realized for a minority of patients. They should still be prescribed because the benefits are likely to outweigh the risks. My list does not say that these medicines don't work.



There isn't a single drug or class of drugs among antidepressants that clearly separates from another. The only (FDA-approved, let's just start with) treatment that is truly meaningfully different for depression is ECT.

Essentially what that means is, for example, a study may show:

Baseline HAM-D 25
Post-study HAM-D for placebo: 16
Post-study HAM-D for citalopram: 13.75

Major depressive disorder is the #1 leading cause of disability in the world with about a 15% suicide rate. Quite arguably the most serious medical illness there is.

What are you basing your judgement on? Is it a Consensus amongst your Peers?

 

[interchange]

What are you basing your judgement on? Is it a Consensus amongst your Peers?

What judgment in particular? There really isn't anything in there that I'm stating that isn't based on the evidence, but of course they're a very generalized synthesis of evidence so there is plenty of room for more detail.

 

[abj13]

My list does not say that these medicines don't work.

Your very first comment on the very first drug:

"1 Lisinopril 115,508,573 --> actually does worse than placebo for all-cause mortality"

 

[interchange]

Your very first comment on the very first drug:

"1 Lisinopril 115,508,573 --> actually does worse than placebo for all-cause mortality"

I was unfair to lisinopril by reporting on 1 outcome only. Happy to retract that one to make room for the positive outcomes it does have. Anything else you want to comment on? The list is by no means complete.

 

[sandorski]

What judgment in particular? There really isn't anything in there that I'm stating that isn't based on the evidence, but of course they're a very generalized synthesis of evidence so there is plenty of room for more detail.

Whether what you posted is factual or not is too vague to have meaning. Your conclusion regarding these drugs v placebo is very stark. So how do you arrive at your Conclusion?

 

[abj13]

I was unfair to lisinopril by reporting on 1 outcome only. Happy to retract that one to make room for the positive outcomes it does have. Anything else you want to comment on? The list is by no means complete.

I think I've made my points. Just be careful using that list in the way you did.

 

[mect]

Personally, I think the problem with 'science based medicine' is that it hasn't, for most of it's history, lived up to that description. It's not that I would support 'alternative' medicine, not at all, but conventional medicine isn't as far from the 'alternative' as people sometimes seem to believe. It's only quite recently that it's started to become a bit scientific, and still it appears to be full of anecdote and artisanship. The fact that they had to specifically start a project for 'evidence-based medicine' surely says something? A lot of things doctors have done, up till very recently, have then turned out to not have much basis in proven science. They just believed it because it had become part of their 'craft'.

I think, funnily enough, the alleged efficacy of the placebo effect appears to be one of those theories that didn't get a close enough examination and when looked at more carefully turned out to be much more questionable than previously thought.

Personally I think it (placebo) is mainly about a patient's desire to please their doctor - causing them to report positive effects even when there really aren't any. Nobody wants to tell a doctor that their treatment had no effect. Hence it works best for self-reported conditions, and tends to wear off.

Just because medicine is a very complex and relatively new field of science doesn't mean that it is anywhere near alternative medicine. Yes, many medical theories are still in a state of flux. But look at infant mortality rates. Look at conditions like AIDS. 200 years ago a best case scenario from a major injury was often amputation. Vaccines have saved millions of lives. The fact that science based medicine isn't perfect in no way means that it is only marginally better than alternative medicine.

 

[interchange]

Whether what you posted is factual or not is too vague to have meaning. Your conclusion regarding these drugs v placebo is very stark. So how do you arrive at your Conclusion?

Well I really should have cited the sources for each drug. I didn't because of effort and because the articles aren't free to anyone unless they have University library access. But I essentially went to pubmed and searched for recent meta-analyses and looked for ones reporting on important clinical outcomes relating to the most common clinical use of the drug. For example, opioids certainly have efficacy and indication in acute settings for, e.g. postoperative pain, but most of those rx are for chronic use for chronic pain which is not indicated. Albuterol definitely works as a bronchodilator and saves lives, but many rx are for people with milder asthma whose illness is not life threatening and the relevant use is comfort for which placebo inhalers work very nearly the same.

As for antidepressants, this is the article that really affected the media: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2253608/

However, the difficulty here is that I'm not saying the drugs are bad and we shouldn't prescribe them when large placebo effect is part of the treatment. When the illness is worse and the potential for harm low, go for it. There are few studies, but some antidepressant trials have wait-list controls as well, which gets about a 25% improvement in depression relative to active drug. So doing nothing is bad. Likely you have different groups: non-responders, placebo responders, and drug responders. Non-responders won't get better. Placebo responders will get better with either drug or placebo but won't with nothing, drug responders either will only get better with drug and not placebo or will get much better with drug than placebo. I can't know who is who before offering the treatment. You can't know after, either. So since the illness is the most disabling in the world, I don't care how patients get better, and I don't know what got them better either, but I'm gonna try and I'm gonna succeed a lot more often by trying than doing nothing.

 

[Amused]

Question

Are you referencing single studies or meta studies? Does the conclusion of the study you picked agree with the findings of the majority of studies?

Yes, please post the citations.

 

[realibrad]

Question

Are you referencing single studies or meta studies? Does the conclusion of the study you picked agree with the findings of the majority of studies?

Yes, please post the citations.

I would imagine meta studies, as he literally said meta studies and linked a meta analysis for one of the things he referenced.

 

[interchange]

Question

Are you referencing single studies or meta studies? Does the conclusion of the study you picked agree with the findings of the majority of studies?

Yes, please post the citations.

Virtually all of what I drew from were large meta-analyses. I'll post citations but it will take a while. Sorry for not doing so before. I intended really only to illustrate an idea and not to render judgment on any particular treatment, but I see that was short sighted so I'm happy to put in more work, it's just gonna take a while.

 

[pmv]

Just because medicine is a very complex and relatively new field of science doesn't mean that it is anywhere near alternative medicine. Yes, many medical theories are still in a state of flux. But look at infant mortality rates. Look at conditions like AIDS. 200 years ago a best case scenario from a major injury was often amputation. Vaccines have saved millions of lives. The fact that science based medicine isn't perfect in no way means that it is only marginally better than alternative medicine.

I think you are taking my point as being slightly stronger than it is. I'm not saying conventional (i.e. actual) medicine is as bad as alternative medicine, but that it is closer than one would hope and certainly closer than many seem to think. Certainly in terms of time since the two were indistinguishable.

Also 'major injuries' means trauma care, and actually that's one area I agree great progress has been made - they are excellent at sticking you back together after you've been shot or hit by a truck (though I'd rather far more emphasis were placed on doing more to prevent people being shot or run over in the first place).

But, sheesh, there is a huge long list of non-injury-related and chronic conditions that are not well understood, where medics don't know the cause and can't cure, but instead just give drugs that may or may not help, with hugely variable efficacy and loads of side-effects. And throughout the history of the field there's always been a vast range of conditions that went entirely undiagnosed or unrecognised - it seems complacent to assume that _now_ we know nearly everything. I just know so many people with unpleasant conditions for which there's not much good treatment, and, more to the point, the underlying cause and mechanisms are not understood very well.

And an unfortunate, unintentional side-effect of so many health campaigns seems to be to give people the impression that all diseases are lifestyle-related and that if you eat and exercise correctly you'll be fine forever. When in fact healthy-lifestyle people come down with idiopathic nasty diseases all the time. A lot of it is so poorly understood that it might as well be random (they always seem to involve a hand-waving claim about 'unidentified genetic factors plus a so-far unidentified environmental trigger').

And a lot of what gets credited to medicine is really more down to increased living standards, improved food production, better hygiene and the work of sanitation engineers.

I'm not denying most medics aren't caring and conscientious or that they have to study hard for a very long time. But I still feel people seem to overestimate what medicine actually knows. I always think of Dr McCoy in one of those Star Trek episodes where the gang travel back to our era and he ends up muttering 'medieval' when faced with our current medical practice. I'm pretty sure that's how future medics will actually see us.

 

[mect]

I think you are taking my point as being slightly stronger than it is. I'm not saying conventional (i.e. actual) medicine is as bad as alternative medicine, but that it is closer than one would hope and certainly closer than many seem to think. Certainly in terms of time since the two were indistinguishable.

Also 'major injuries' means trauma care, and actually that's one area I agree great progress has been made - they are excellent at sticking you back together after you've been shot or hit by a truck (though I'd rather far more emphasis were placed on doing more to prevent people being shot or run over in the first place).

But, sheesh, there is a huge long list of non-injury-related and chronic conditions that are not well understood, where medics don't know the cause and can't cure, but instead just give drugs that may or may not help, with hugely variable efficacy and loads of side-effects. And throughout the history of the field there's always been a vast range of conditions that went entirely undiagnosed or unrecognised - it seems complacent to assume that _now_ we know nearly everything. I just know so many people with unpleasant conditions for which there's not much good treatment, and, more to the point, the underlying cause and mechanisms are not understood very well.

And an unfortunate, unintentional side-effect of so many health campaigns seems to be to give people the impression that all diseases are lifestyle-related and that if you eat and exercise correctly you'll be fine forever. When in fact healthy-lifestyle people come down with idiopathic nasty diseases all the time. A lot of it is so poorly understood that it might as well be random (they always seem to involve a hand-waving claim about 'unidentified genetic factors plus a so-far unidentified environmental trigger').

And a lot of what gets credited to medicine is really more down to increased living standards, improved food production, better hygiene and the work of sanitation engineers.

I'm not denying most medics aren't caring and conscientious or that they have to study hard for a very long time. But I still feel people seem to overestimate what medicine actually knows. I always think of Dr McCoy in one of those Star Trek episodes where the gang travel back to our era and he ends up muttering 'medieval' when faced with our current medical practice. I'm pretty sure that's how future medics will actually see us.

I suppose it all depends on the comparisons one chooses to make. Absolutely there are many thing we barely understand in medicine. But the same is true for essentially all disciplines of science. The more we learn, the more we realize we don't know. If you think about hygiene and sanitation engineers, the only reason we know that those are factors is due to science based medicine. The only reason we know what constitutes a healthy diet (to the extent that we do) is due to science based medicine. My only issues with the stance that science based medicine is only marginally better than alternative medicine are 1) all the progress that has been made is due to science and 2) people use that as an excuse for rejecting the opinions of science in favor of those from alternative health care providers.

 

[interchange]

One of the (perhaps the most important) things medical care provides is a sense of understanding and control. That sense is way oversold, but we'd be far worse off of it were any other way.

 

[realibrad]

One of the (perhaps the most important) things medical care provides is a sense of understanding and control. That sense is way oversold, but we'd be far worse off of it were any other way.

People seem to have an amazing ability to satiate that desire. I don't know if important is the right word, but I think I get what you are saying. The reason I say that is because people will far too often look to seek treatment that they think gives them the greatest amounts of understanding and control and that can be dangerous when you get into medicine. Understanding and control should be tested, because, far too often they can be false. Real and false will make people feel better which can many times be good enough, but sometimes with some things it can be deadly.

 

[mect]

People seem to have an amazing ability to satiate that desire. I don't know if important is the right word, but I think I get what you are saying. The reason I say that is because people will far too often look to seek treatment that they think gives them the greatest amounts of understanding and control and that can be dangerous when you get into medicine. Understanding and control should be tested, because, far too often they can be false. Real and false will make people feel better which can many times be good enough, but sometimes with some things it can be deadly.

I'd say the bigger danger is people will look at the limitations of science based medicine (which is actually much more open and honest about its limitations compared to alternative medicine), see that it doesn't give them a very good answer, and in response turn to alternative medicine which gives them a firm but false answer. Science based medicine can't explain much about Autism, so people turn to alternative medicine, and stop getting vaccinated and doing other really stupid things because science based medicine doesn't give them the concrete answers they're looking for. People want an explanation for things, and if science can't do it, they'll turn to religion, witch doctors, or anyone else that is willing to tell them why something is the way it is, and they willing go and throw their virgins into the volcano.

 

[interchange]

People seem to have an amazing ability to satiate that desire. I don't know if important is the right word, but I think I get what you are saying. The reason I say that is because people will far too often look to seek treatment that they think gives them the greatest amounts of understanding and control and that can be dangerous when you get into medicine. Understanding and control should be tested, because, far too often they can be false. Real and false will make people feel better which can many times be good enough, but sometimes with some things it can be deadly.

Utterly amazing ability indeed. Like a historic landslide victory despite millions of illegal votes going to the opposition and the most attended inauguration ever. It bothers me that people don't appreciate the likelihood that Trump isn't lying at all when he says these things.

That need for cohesive meaning is the greatest need any human being has. It's hard to appreciate that when you come from the position that is most common in society: that such cohesive meaning isn't constantly under threat and that the childhood self which represented when it was is some discarded past.

 

[interchange]

I'd say the bigger danger is people will look at the limitations of science based medicine (which is actually much more open and honest about its limitations compared to alternative medicine), see that it doesn't give them a very good answer, and in response turn to alternative medicine which gives them a firm but false answer. Science based medicine can't explain much about Autism, so people turn to alternative medicine, and stop getting vaccinated and doing other really stupid things because science based medicine doesn't give them the concrete answers they're looking for. People want an explanation for things, and if science can't do it, they'll turn to religion, witch doctors, or anyone else that is willing to tell them why something is the way it is, and they willing go and throw their virgins into the volcano.

We need to be both authoritative and accountable. Not one or the other.

 

[realibrad]

I'd say the bigger danger is people will look at the limitations of science based medicine (which is actually much more open and honest about its limitations compared to alternative medicine), see that it doesn't give them a very good answer, and in response turn to alternative medicine which gives them a firm but false answer. Science based medicine can't explain much about Autism, so people turn to alternative medicine, and stop getting vaccinated and doing other really stupid things because science based medicine doesn't give them the concrete answers they're looking for. People want an explanation for things, and if science can't do it, they'll turn to religion, witch doctors, or anyone else that is willing to tell them why something is the way it is, and they willing go and throw their virgins into the volcano.

I think that is what I was trying to say. Its like the woman who gave her kid bleach to try and cure autism. She found something that said it can sure, but science says we dont know enough yet to know how.

 

[realibrad]

Utterly amazing ability indeed. Like a historic landslide victory despite millions of illegal votes going to the opposition and the most attended inauguration ever. It bothers me that people don't appreciate the likelihood that Trump isn't lying at all when he says these things.

That need for cohesive meaning is the greatest need any human being has. It's hard to appreciate that when you come from the position that is most common in society: that such cohesive meaning isn't constantly under threat and that the childhood self which represented when it was is some discarded past.

A big problem is trying to reach people like that. If they can get to their position because it makes them feel good, then logic is going to make them feel bad. They will fight very hard to keep that comfort, and will do some amazing things to fight against losing that. Even to the point of hurting themselves.

 

[woolfe9998]

Let's see here...

Top 30 prescribed drugs in 2017:
1 Lisinopril 115,508,573 --> actually does worse than placebo for all-cause mortality
2 Levothyroxine 99,992,248 --> not a placebo; synthetically produced biologically equivalent to natural T4 hormone
3 Metformin Hydrochloride 86,125,658 --> one of the best drugs, definitely not a placebo
4 Simvastatin 81,518,801 --> statins as a class have a number needed to treat of 167 patients over 4.1 years to prevent 1 death
5 Atorvastatin 74,227,208 --> statins as a class have a number needed to treat of 167 patients over 4.1 years to prevent 1 death
6 Metoprolol 72,320,918 --> effective for heart failure and rate control in AFib; not a placebo
7 Omeprazole 71,929,303 --> about twice as effective as placebo for GERD
8 Acetaminophen/Hydrocodone Bitartrate 68,756,036 --> there is no study that shows long-term opioid treatment is better than placebo; opioids are the best placebo ever
9 Amlodipine Besylate 63,722,510 --> about 45% of the blood pressure lowering effects matched with placebo
10 Hydrochlorothiazide 50,428,398 --> about 40% of the blood pressure lowering effects matched with placebo
11 Albuterol 48,189,599 --> 50% subjective improvement vs 45% subjective improvement from placebo inhaler; does have measurable difference in pulmonary function tests
12 Gabapentin 39,361,473 --> many different indications, but for most pain indications it beats placebo by about 40% benefit to 25% benefit, so more than half of benefit is placebo effect
13 Sertraline Hydrochloride 37,723,879 --> about 80% of antidepressant response is seen in placebo
14 Losartan Potassium 37,330,149 --> about half of BP lowering effect is matched with placebo
15 Furosemide 37,104,417 --> not gonna look it up; it definitely works as a diuretic, but not sure about any mortality outcome/etc.
16 Azithromycin 31,988,786 --> not a placebo but about 1 in 3 antibiotic prescriptions are not indicated
17 Acetaminophen 31,926,190 --> effective in acute dental/operative pain; no better for back pain or osteoarthritis than placebo
18 Atenolol 30,837,679 --> gonna skip this one; all antihypertensives have similar efficacy; not usually used for CHF so not sure its efficacy there
19 Insulin Human 30,588,285 --> not a placebo
20 Fluticasone 30,573,156 --> many outcomes I'm looking at, but about 65% of efficacy seen in placebo
21 Citalopram 29,737,921 --> about 80% of antidepressant response is seen in placebo
22 Pravastatin Sodium 29,717,750 --> statins as a class have a number needed to treat of 167 patients over 4.1 years to prevent 1 death
23 Alprazolam 28,897,888 --> about 50% difference from placebo, but possibly the worst drug in existence
24 Potassium 28,365,609 --> not a placebo, but mostly prescribed as replacement for side effects of diuretics
25 Amoxicillin 27,585,663 --> not a placebo but about 1 in 3 antibiotic prescriptions are not indicated
26 Tramadol Hydrochloride 25,809,738 --> there is no study that shows long-term opioid treatment is better than placebo; opioids are the best placebo ever
27 Montelukast 25,670,394 --> not a placebo, not a great deal of efficacy either
28 Trazodone Hydrochloride 25,521,675 --> about 80% of antidepressant response is seen in placebo
29 Bupropion 25,061,016 --> about 80% of antidepressant response is seen in placebo
30 Rosuvastatin Calcium 24,760,853 --> statins as a class have a number needed to treat of 167 patients over 4.1 years to prevent 1 death

Year, I figured you were talking mainly about medications. Dispensing pills is part of what doctors do. It isn't all of it. Diagnostics alone save countless lives. How does the alcoholic know his liver is damaged and that he'll die if he doesn't stop drinking?

Medications obviously have a mixed track record, though I have to say, if I'm taking a pill to treat a serious problem, I'll take 20% better than placebo. It's statistically significant.

I take Omeprazole for GERD by the way. Without it, I have heartburn to varying degrees almost every minute of every day. no matter what I do or do not eat. With one of those pills in the morning, I never get any at all. The consequence of untreated GERD is often a pre-cancerous condition in the esophagus which can turn into esophogeal cancer. Happened to my dad. But unlike my grandmother, he believed in modern medicine. They had insisted he get an endoscopy once every 6 months, and accordingly they caught it at stage 1. They were then able to cure it by surgically removing his esophagus, without the need for chemo. He was saved first by diagnostics, second by surgery. While hopefully I never get it at all because of the medication.

I felt your post was being overly dismissive of medical efficacy. Lifespans in western countries have increased by ~65% over the past 100 years. AFAIK most of that is due to modern medicine.

 

[interchange]

Year, I figured you were talking mainly about medications. Dispensing pills is part of what doctors do. It isn't all of it. Diagnostics alone save countless lives. How does the alcoholic know his liver is damaged and that he'll die if he doesn't stop drinking?

Medications obviously have a mixed track record, though I have to say, if I'm taking a pill to treat a serious problem, I'll take 20% better than placebo. It's statistically significant.

I take Omeprazole for GERD by the way. Without it, I have heartburn to varying degrees almost every minute of every day. no matter what I do or do not eat. With one of those pills in the morning, I never get any at all. The consequence of untreated GERD is often a pre-cancerous condition in the esophagus which can turn into esophogeal cancer. Happened to my dad. But unlike my grandmother, he believed in modern medicine. They had insisted he get an endoscopy once every 6 months, and accordingly they caught it at stage 1. They were then able to cure it by surgically removing his esophagus, without the need for chemo. He was saved first by diagnostics, second by surgery. While hopefully I never get it at all because of the medication.

I felt your post was being overly dismissive of medical efficacy. Lifespans in western countries have increased by ~65% over the past 100 years. AFAIK most of that is due to modern medicine.

I know. All I said a was a lot of it was placebo or not much better. A lot of it isn't and is much better. Most importantly, though, placebo effects are actually really good parts of medical care. I mean, if I believed medical care was a sham, I really would ethically give up practicing medicine. It isn't, and my field is one where placebo effects are among the strongest. And I think it's the most undervalued field of medicine despite that.