The US will try treating opioid addiction with fake medicine

If you can't afford to offer real medical care, why not offer fake medicine? The U.S. Medicare system is about to give this strategy a try, for treating back pain.

Last week, Medicare announced that it wants to start paying for studies of acupuncture as a treatment for low back pain, as reported by the Washington Post and Stat. The government's reason, according to Secretary of Health and Human Services Alex Azar, was that we need this option to help solve opioid addiction:
“Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”
If you break down HHS Secretary Azar's statement, it's mostly correct. Yes, treating opioid addition should explore all methods for treating chronic pain. And yes, this program will provide "new" options, even though the option in question is nonsense.

But (3) no, studying acupuncture will not expand our scientific understanding of "alternative approaches" to pain. Why not? Because thousands of studies have already been done, and the verdict was in, long ago, that acupuncture is nothing more than an elaborate placebo.

The problem is, acupuncture proponents never give up. Every time a study shows that acupuncture fails (and this has happened, repeatedly), they claim it wasn't done properly or make another excuse. I've even seen proponents argue that studies in which acupuncture failed were in fact successes, because acupuncture and placebo treatments both outperformed the "no treatment" option.

(Aside: we use placebo treatments because we've known for decades that any treatment, even a sugar pill, may show a benefit as compared to no treatment at all. Acupuncture research has created placebos by using fake needles that don't actually pierce the skin, or by placing needles in random places rather than the so-called acupuncture points. Scientifically speaking, if a treatment doesn't outperform a placebo, then the treatment is a failure.)

To make matters worse, the new HHS program will fund "pragmatic" clinical trials rather than the usual, gold-standard randomized trials (RCTs). Without going into details, let's just say that pragmatic trials are much less well-controlled than RCTs, allowing more room for mistakes and misinterpretation. This is a bad idea even when the intervention being studied is legitimate. It's an even worse idea here, where trials have shown, over and over, that acupuncture doesn't work.

Secretary Azar might be confused because the acupuncture industry has managed to get hundreds of studies published, many of them positive–but most of them are poorly designed, and who has time to read all that bad science? (The rare well-designed studies always show that acupuncture doesn't work.) Acupuncturists have even created pseudoscientific journals devoted entirely to acupuncture, as I wrote about in 2017. Some of these journals are published by respected scientific publishers, but they are still little more than fake journals.

Not surprisingly, with entire journals trying to fill each issue with acupuncture articles, last week's Medicare announcement noted that
"the agency [CMS] recognizes that the evidence base for acupuncture has grown in recent years". 
No, it hasn't. What has grown is the number of articles. Adding more garbage to a pile doesn't make it smell better.

For those who aren't familiar with the claims of acupuncture, let's do a very quick summary: acupuncturists stick needles in a person's body at specific points in order to manipulate a mystical life force that they call "qi" (proounced "chee"). This idea is "a pre-scientific superstition" that has no basis in medicine, physiology or biology, and has never had any good scientific evidence to support it.  Acupuncturists don't even agree on where the acupuncture points are, which should make it impossible to do a scientific study. It's not at all surprising that acupuncture doesn't work; indeed, if it did work, modern medicine would have to seriously examine what mechanism could possibly explain it.

But wait, argue proponents, what about all the wise traditional doctors in China who developed acupuncture over thousands of years? Well, it turns out that acupuncture wasn't popular in China until the mid-20th century, when Chairman Mao pulled a fast one on his population because he couldn't supply enough real medical care. Mao didn't use acupuncture himself and apparently didn't believe in it. I highly recommend this expose of Mao's scam, by Alan Levinovitz in Slate.

So rather than spend millions of dollars on yet another study of acupuncture for pain, I have a better suggestion for HHS: invest the funds in basic biomedical research, which has had a flat budget for more than a decade now. As long as it goes through proper peer review, almost any research will be far better than wasting the money on acupuncture.

Now, I'm not naive enough to think that Medicare will take my advice, but I can tell them right now what their new "pragmatic" trials will reveal. Acupuncturists will happily take the money, treat people suffering from back pain, and report that some of them experienced reductions in pain. Some of the patients will invariably agree, because back pain comes and goes, and it's hard to know why it went away.

Then the acupuncturists will say, "look, it works! Now please cover acupuncture for all Medicare patients." Then we'll spend more tax dollars on pseudoscience, and patients will be in just as much pain as ever. If Medicare falls for this (and I fear they will), then Chairman Mao will have fooled the U.S. government, just as he fooled many of his own people half a century ago.

The loneliest word, and the extinction crisis

We're in the midst of an extinction crisis. Just two months ago, an international committee known as IPBES released a report, compiled over 3 years by 145 experts from 50 countries, that said 1,000,000 plant and animal species are threatened with extinction, many within the next few decades.

Martha, the very last passenger
pigeon, shown when she was
still alive.
Before getting to that report, I want to introduce a word that I only just learned: endling. An endling (the word was coined in 1996) is the last surviving member of a species. One example was Martha, the very last passenger pigeon, who died in the Cinncinnati Zoo in 1914. Passenger pigeons numbered in the billions in the 19th century, but humans wiped them out.

In 2012 we lost another endling, Lonesome George–the very last Pinto Island tortoise from the Galapagos Islands–who died at around age 100.

If you want to see a particularly poignant example of an endling, watch this rare and heartbreaking video of Benjamin, the very last Tasmanian tiger (or thylacine), pacing around his cramped enclosure in Hobart, Tasmania. This film from 1933 is the last known motion picture of a living thylacine. Benjamin died in 1936.
Two Tasmanian tigers in the Washington, D.C. zoo, in a photo
taken around 1904. Photo credit: Baker; E.J. Keller. from the
Smithsonian Institution archives

We have records of other endlings too: the last Caspian tiger was killed in the 1950s in Uzbekistan, and the last great auks were killed for specimen collectors in 1844.

Unfortunately, we're likely to see more and more endlings in the years to come. The causes of extinction are varied, and many of them are related to human activities. The IPBES ranked the culprits, in descending order, as:

  1. changes in land and sea use,
  2. direct exploitation of organisms,
  3. climate change,
  4. pollution, and
  5. invasive alien species.

In response to the IPBES report, the House of Representatives held a hearing in May to discuss the findings. Republicans on the committee took the opportunity to display a new form of denialism: extinction denialism. As reported in The Guardian, Representatives Tom McClintock and Rob Bishop used their time to attack the reputations of the report's authors, rather than addressing the very serious consequences of large-scale extinction. They called two climate-change deniers as witnesses, who also used their time to attack the authors.

This is a classic strategy used by deniers: attack the messenger, rather than dealing with the substance of the report. Let's consider just a few of the report's main findings (see much more here):

  • Across the planet, 75% of the land and about 66% of the marine environments have been significantly altered by human actions.
  • Up to $577 billion in annual global crops are at risk from pollinator loss (bees and other insects)
  • In 2015, 33% of marine fish stocks were being harvested at unsustainable levels; 60% were maximally sustainably fished.
  • Plastic pollution has increased tenfold since 1980, 300-400 million tons of heavy metals, solvents, toxic sludge and other wastes from industrial facilities are dumped annually into the world’s waters, and fertilizers entering coastal ecosystems have produced more than 400 ocean ‘dead zones’, covering a combined area greater than that of the United Kingdom.

The report is a call to action. It explains that transformative change is needed to protect and restore nature, and collective action is needed to overcome special interests such as the fossil fuel industry, which donates heavily to politicians. The Congressional hearing was a vivid demonstration of how effective the anti-environmental lobbyists have been.

Endling is the saddest word in any language. If we humans continue to treat nature as we've done in the past, we're going to see many more videos like the one of Benjamin, the last Tasmanian tiger. Let's hope we can do better.

Does the length of your fingers predict sexual orientation?

Imagine my surprise last week when I saw an article in Science that claimed "finger lengths can predict personality and health."* Huh?

The author, science writer Mitch Leslie, gives us the rather startling number that over the past 20 years, more than 1400 papers have been published linking finger lengths to personality, sexual orientation, cardiovascular disease, cancer, and more.

What is this magical finger length ratio? Simple: it's the ratio between the lengths of your index (2nd) and ring (4th) fingers, also called the 2D:4D ratio. Take a look: is your index finger longer than your ring finger?

It turns out that most people have slightly longer ring fingers than index fingers, and in men the difference is a bit larger. If the ringer finger is longer, than the 2D:4D ratio is less than one. One recent study reported that this ratio was 0.947 in men and 0.965 in women. Another study found average values of 0.984 and 0.994 for men and women. Not only is this a tiny difference, but in every study, the 2D:4D ratio among men and women overlapped, meaning the number alone doesn't tell you very much.

Nonetheless, some researchers have taken this tiny physiological difference and run with it. Nearly 20 years ago, Berkeley psychologist Marc Breedlove (now at Michigan State) published a study in Nature where he and his colleagues measured finger-length ratios in 720 adults in San Francisco. Based on this data, they concluded that finger-length ratios show
"evidence that homosexual women are exposed to more prenatal androgen than heterosexual women are; also, men with more than one older brother, who are more likely than first-born males to be homosexual in adulthood, are exposed to more prenatal androgen than eldest sons."
Whoa! They are not only claiming that the 2D:4D ratio is predictive of homosexuality, but also that exposure to prenatal androgen is the root cause of both finger lengths and sexual orientation. (Confusing correlation with causation, perhaps?) Not surprisingly, this claim is not widely accepted.

There are many, many more claims out there. In 2010, the BBC boldly reported that 
“The length of a man's fingers can provide clues to his risk of prostate cancer, according to new research.”
based on this study in the British Journal of Cancer. That study found that men whose index fingers were longer than their ring fingers had a reduced risk of cancer. (I don't believe it for a second, but if it makes you feel better, go ahead.) And a 2016 report found that both men and women with a low 2D:4D ratio (longer ring fingers) had better athletic abilities. 

The Science article goes on to explain, though, that "the results often can't be replicated." Most of these studies are small, the measurement techniques vary widely, and efforts to reproduce them (when others have tried, which isn't that often) usually fail. It didn't take me long to find a few, such as this study from 2012, which swas the 2nd failure to replicate a result claiming a link between sex hormone exposure and the 2D:4D ratio.
The author's left hand

After reading the whole Science article, one comes away with the impression that finger ratio science is almost certainly bogus. The presentation, though, gives far more space to the claims of those who believe in it, and one gets the strong impression that the journalist (Mitch Leslie) is on their side. A hint to that is in his last sentence where, after saying that the two sides are "talking past one another," he writes "more than 20 papers using the digit ratio have already come out last year."

And since the last sentence is often a giveaway for what the writer really thinks, let me conclude by saying that both my ring fingers are longer than my index fingers.

[*The print version of Science contains precisely this claim in the subheading to the article: "Some researchers say a simple ratio of finger lengths can predict personality and health." Interestingly, the online version of the same article does not have this headline. Instead, it reads "Scientists try to debunk idea that finger length can reveal personality and health." It appears as if the online editors were more skeptical than the print editors.]

Google ran a secret experiment to search for cold fusion. Did they find it?

A non-working cold fusion apparatus
at the San Diego Naval Warfare 
Center. Source: Wikipedia
The journal Nature last week revealed the results of a 4-year, $10 million experiment to test cold fusion. The experiments were kept secret in order to avoid the negative publicity that cold fusion attracted when it burst upon the scene 30 years ago.

I've been talking to a few non-scientists about this, and it appears that many people don't know about the cold fusion saga, so here's a quick recap: back in 1989, two chemists at the University of Utah, Stanley Pons and Martin Fleischmann, held a press conference to announce a startling discovery: they had generated fusion energy at room temperature. If true, this would have been a profound, civilization-changing discovery: cold fusion had the potential to provide nearly free energy to the entire world, eliminating our dependence on fossil fuels and promising unheard-of economic and environmental benefits.

[A physics aside for those who might be curious: fusion energy is produced when two atoms are smashed together to form a new, heavier atom. Four hydrogen atoms can be fused to form one helium atom, for example. A tiny bit of mass is converted to energy in the process, and that tiny amount produces enormous amounts of energy, as given by Einstein's famous equation, E=MC2. Fusion is the process that powers the sun and other stars, but humans have never been able to control it. It's also the source of the energy released by a thermonuclear bomb. The only nuclear energy we humans can control is fission, which is what nuclear power plants use. And the only fusion we know about requires crazily high temperatures, which is why room temperature would be "cold."]

Unfortunately for Pons and Fleischmann, whose reputations were forever tarnished, the 1989 experiments were fatally flawed. Many scientists tried to reproduce the results, but they all failed, and the criticism mounted quickly. Pons and Fleischmann never published their findings, and cold fusion later became a meme for flawed or impossible scientific results. Even today, calling something "cold fusion" is form of ridicule.

Despite the dramatic failure 30 years ago, cold fusion isn't fundamentally impossible, unlike homeopathy, acupuncture, reiki, or other forms of pseudoscience. Fusion is a very real phenomenon, and no one really knows if it might be possible to sustain a fusion reaction at low temperatures, or what those temperature limits might be. This is what led Google and the scientific team they funded to give cold fusion another serious look.

The new Google-funded experiments were run by a team of about 30 graduate students, postdoctoral fellows, and professors. The seven leaders of the team, who include scientists from UBC, MIT, the University of Maryland, LBL, and Google, described their findings in a paper just published in Nature. After four years of careful experiments, they conclude:
"So far, we have found no evidence of anomalous effects claimed by proponents of cold fusion."
In other words, they couldn't get cold fusion to work. They tried 3 different experimental setups that have been proposed by others, but despite their best efforts, nothing produced any signs of fusion energy.

The news isn't all negative. The scientists emphasized that in the course of trying to produce cold fusion, they had to design new instrumentation and study new types of materials that have received little attention before now. They wrote:
"... evaluating cold fusion led our programme to study materials and phenomena that we otherwise might not have considered. We set out looking for cold fusion, and instead benefited contemporary research topics in unexpected ways."
They cite go on to say:
"Finding breakthroughs requires risk taking, and we contend that revisiting cold fusion is a risk worth taking."
I have to agree with them here. As the scientists themselves pointed out, even though their experiments didn't produce cold fusion, "this exploration of matter far from equilibrium is likely to have a substantial impact on future energy technologies." In other words, if we keep trying, who knows what we might find?


Does ginkgo biloba enhance memory? I forgot.

I recently saw an ad that claimed ginkgo biloba can treat the signs of dementia. A quick search on Amazon.com yielded hundreds of products, many claiming that gingko is a "brain sharpener" or that it "supports focus, memory, brain function and mental performance," or other similar claims.

Ginkgo biloba is a supplement made from the leaves of the gingko biloba tree, which is native to China. The supplements industry claims that gingko has been used for thousands of years to improve memory and stave off dementia. While that may be true (though I doubt it), the argument that a medical treatment was used by pre-scientific cultures is not exactly compelling. After all, people died very young in ancient times, and medical knowledge was little more than superstition, for the most part. I don't know about you, but when I'm looking for medicine, I want the latest stuff.

"But wait!" say ginkgo biloba's advocates: maybe those ancient folk doctors were onto something. Maybe so–and it didn't take me long to find multiple studies testing what those ancients supposedly believed about gingko biloba:

  1. Here's a review from 2009 that looked at gingko biloba for dementia and milder cognitive impairment. It reported that "the evidence that Ginkgo biloba has clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unreliable." Not exactly a ringing endorsement.
  2. Here's another study, from 2012, looking at the effect of gingko biloba on memory in healthy individuals. Is it a "brain sharpener"? Well, no. This study found that gingko "had no ascertainable positive effects on a range of targeted cognitive functions in healthy individuals." In other words, a total dud.
  3. And here's an even more recent study, from 2015. The result: "no convincing evidence ... that demonstrated Ginkgo biloba in late-life can prevent the development of dementia. Using it for this indication is not suggested."

Given that the science says this doesn't work, you might wonder how it is that hundreds of gingko biloba products are still on the market, all of them with claims about memory. Simple: it's a dietary supplement, not a drug, which means that it is essentially unregulated (in the U.S.). The FDA won't step in unless the marketing claims get so outrageous that they cross the line into medicine–and even then, the FDA rarely does more than send a sternly worded letter.

As I've written before, supplement marketing is like the wild west. You generally can't trust anything you read from the manufacturers, except perhaps the ingredients list. And even the ingredients are sometimes inaccurate and contaminated.

(By the way, I find it especially amusing when a pill that has no effect is advertised as "double strength," as Walgreens does for one of their gingko products, here.)

So be skeptical about the marketing claims for gingko biloba. Even NCCIH, the NIH institute whose mission is to promote "alternative" medicine, is remarkably clear about this, stating that:

  • "There’s no conclusive evidence that ginkgo is helpful for any health condition.
  • Ginkgo doesn’t help prevent or slow dementia or cognitive decline.
  • There’s no strong evidence that ginkgo helps with memory enhancement in healthy people, blood pressure, intermittent claudication, tinnitus, age-related macular degeneration, the risk of having a heart attack or stroke, or with other conditions."

I must say, I'm feeling a bit better about NCCIH these days. They got this one right. The bottom line: don't waste your money on gingko biloba.

Why does anyone believe this works? The dangers of cupping.

Cupping therapy. If this looks painful and possibly damaging
to the skin, that's because it is.
People are easily fooled. Even smart people.

I'm not talking about voters in the U.S. and the UK, although both groups have recently demonstrated how easily they can be conned into voting against their own interests. You can read plenty of articles about that elsewhere.

No, I'm talking about the wide variety of health treatments that call themselves alternative medicine, integrative medicine, traditional Chinese medicine, energy medicine, and other names. These are all just marketing terms, but many people, including some physicians and scientists, seem captivated by them.

This week I'm going to look at "cupping," a rather bizarre treatment that, for reasons that escape me, seems to be growing in popularity.

I just returned from a scientific conference, where I happened to speak with an editor for a major scientific journal who also follows this blog. She remarked that she liked some of my articles, but she disagreed with me about cupping, which I wrote about during the 2016 Olympics, where swimmer Michael Phelps was observed to have the circular welts that are after-effects of cupping. This editor's argument boiled down to "it works for me," which left me somewhat flabbergasted.

And just two weeks ago, when I was at my physical therapist's office getting treatment for a shoulder injury, I heard her discussing cupping with another therapist. I then noticed a large box containing cupping equipment on one of the counters. Thankfully, my therapist didn't suggest cupping for me; I'm not sure how I would have replied.

What is cupping? It's a technique where you take glass cups, heat the air inside them, and then place them on the skin. Because hot air is less dense, it creates suction as it cools, which sucks your skin up into the glass. (Some cupping sets use pumps rather than heat to create this effect.) Imagine someone giving you a massive hickey, and then doing another dozen or so all over your back, or legs, or wherever the cupping therapist thinks you need it. If that sounds kind of gross, it is.

Quacktitioners Practitioners of cupping think that it somehow corrects your "qi," a mysterious life force that simply doesn't exist. When pressed, they often remark that it "improves blood flow," a catch-all explanation that has no scientific basis and that is more or less meaningless. What really happens, as the physician and blogger Orac noted, is this:
"The suction from cupping breaks capillaries, which is why not infrequently there are bruises left in the shape of the cups afterward.... If you repeatedly injure the same area of skin over time ... by placing the cups in exactly the same place over and over again, the skin there can actually die."
So maybe cupping isn't so good for you.

Cupping is ridiculous. There's no scientific or medical evidence that it provides any benefit, and it clearly carries some risk of harm. A recent review in a journal dedicated to alternative medicine–one of the friendliest possible venues for this kind of pseudoscience–concluded that
"No explicit recommendation for or against the use of cupping for athletes can be made. More studies are necessary."
Right. That's what proponents of pseudoscience always say when the evidence fails to support their bogus claims. Let us do more studies, they argue, and eventually we'll prove what we already believe. That's a recipe for bad science.

Even NCCIH, the arm of NIH dedicated to studying complementary and integrative nonsense medicine, can't bring itself to endorse cupping. Their summary states:

  • There’s been some research on cupping, but most of it is of low quality.
  • Cupping may help reduce pain, but the evidence for this isn’t very strong.
  • There’s not enough high-quality research to allow conclusions to be reached about whether cupping is helpful for other conditions.

In other words, some bad scientists have conducted a few studies but haven't proven anything. But wait, it gets worse. NCCIH goes on to warn that:

  • Cupping can cause side effects such as persistent skin discoloration, scars, burns, and infections, and may worsen eczema or psoriasis. 
  • Rare cases of severe side effects have been reported, such as bleeding inside the skull (after cupping on the scalp) and anemia from blood loss (after repeated wet cupping). 

And still, otherwise intelligent people say "it works for me." I'm left speechless.

The bottom line: save your money and your skin. Don't let anyone suck it into those cups.

Measles is back. Blame the anti-vaxxers.

In the year 2000, the CDC announced that measles had been eliminated from the U.S. This was a fantastic public health achievement, made possible by the measles vaccine, which is 99% effective and which has virtually no side effects.

Unfortunately, measles is back. Just last week, the CDC announced that we've had at least 695 cases this year, the most since 2000, primarily from 3 large outbreaks, one in the state of Washington and two in New York. Because the CDC's surveillance is far from perfect, the true number of measles cases is likely much higher. And we're only four months into the year.

Also this week, UCLA and CalState-LA had to quarantine over 700 students and staff members who were exposed to measles from an outbreak in the Los Angeles area. At UCLA, one student who had measles attended multiple classes while still contagious, exposing hundreds of others to the highly contagious virus, according to a message from the university's chancellor.

No one has died as of yet, but if we don't quash these outbreaks, it's only a matter of time before someone will die. Measles has a fatality rate of 0.2%, or 2 deaths per thousand cases. That may sound small, but it's truly frightening when you consider that the U.S. had an estimated 500,000 cases per year before the vaccine was introduced in 1963.

Given the risks of measles, and given the remarkable effectiveness and safety of the vaccine, why don't people vaccinate their children? The primary reason is simple: it's the highly vocal, supremely confident, and utterly misinformed anti-vaccine movement. Anti-vaxxers spread their message daily on Facebook, Twitter, websites, and other media outlets. (I will not link to any of them here because I don't want to increase their influence.) They have launched systematic efforts throughout the U.S. and in other countries to convince parents not to vaccinate their children, claiming that vaccines cause a variety of harms, none of which are correct. (I won't list those here either, because even mentioning them gives the claims credibility.)

In one of the two outbreaks in New York, anti-vaxxers distributed highly misleading pamphlets in an effort to convince parents in an ultra-religious Jewish community not to vaccinate their kids. The anonymously-published pamphlet was "filled with wild conspiracy theories and inaccurate data," but it seems to have worked, as least among some of the parents.

The anti-vax movement is also behind the state-by-state effort to allow parents to opt out of vaccinations for their children in public schools. We're finally seeing some states roll this back, but it is still far too easy for parents to claim an "ethical" or "religious" exemption, allowing them to put their unvaccinated kids in school and thereby expose countless other children to measles and other preventable diseases. (I put those words in quotes because there is no valid ethical or religious objection to vaccines. All major religions strongly support vaccination.) Anti-vax websites provide how-to instructions telling parents how to get exemptions for their kids, and a small number of anti-vax doctors (I'm looking at you, Bob Sears) readily dispense large numbers of anti-vax exemptions. This needs to end.

The modern anti-vaccine movement started in 1998, with a fraudulent paper about the measles, mumps, and rubella vaccine, published by a former doctor who lost his medical license after the fraud was revealed. The lead author was eventually revealed to have taken large sums of money (unbeknownst to his co-authors) from lawyers who were trying to build a case to sue vaccine makers. That same ex-doctor, who I also won't name here (his initials are AW), is now a hero to the anti-vax movement, and he travels the world spreading his toxic message. He's even made an anti-vax movie.

I sincerely hope we won't see any children die before the anti-vaccine movement finally goes away. For any parents who are thinking that they won't vaccinate their kids, I urge them to read the heartbreaking words of Roald Dahl (author of Charlie and the Chocolate Factory, The BFG, and many other wonderful books), whose oldest daughter Olivia died of measles in 1962, at the age of seven:
"...one morning, when [Olivia] was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn't do anything.
'Are you feeling all right?' I asked her.
'I feel all sleepy,' she said.In an hour, she was unconscious. In twelve hours she was dead.The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her." 
The measles vaccine was a miracle of modern medicine, and it's been administered safely to hundreds of millions of people. Measles is a dangerous illness, but we can prevent it. No parent should have to go through what Roald Dahl went through.