Polypharmacy

Article by Peter Bowditch

One of the standard ways to defend pseudomedicine is to show how less bad it is than real medicine. The most common method of doing this is to exaggerate and lie about the numbers of deaths in hospitals and compare the fabricated numbers with the number of people who die, as an example, in chiropractors' offices. No thinking person needs to have the absurdity of this sort of comparison pointed out to them, but the lie is usually compounded by claiming that real doctors don't care and are doing nothing about the carnage. One particularly insidious piece of sophistry is to (mis)quote numbers from a research project commissioned by the Australian government as evidence that no research is being done. I have seen this same research project, with the same deliberately misquoted numbers, used to prove that nothing is being done in the USA either. The argument then goes on to say that it is unreasonable for real medicine to complain about pseudomedicine before solving all the problems related to patient survival in hospitals. If the airlines refused to spend money on safety practices until the road toll had been reduced to zero then nobody would be prepared to fly anywhere, but this is exactly the sort of argument being used by the quack promoters. It's like saying: "You're not perfect, so I won't even try to be good".

Another approach is to claim that real medicines have not really been tested because all possible combinations of medications have not been subjected to clinical trials. This is just the sort of argument intended to deceive people who are baffled by the mildest mathematics. I read recently that the hydrogen atom is the best-understood thing in the universe because it is the only example of a two-body problem and so everything about it can be measured. This doesn't mean that nothing else is understood, only that that understanding must be somehow incomplete. Even testing all possible interactions between only two drugs is not possible because of the virtually infinite range of dosage ratios, so it is in a sense true to say that any combination of drugs is an untested prescription. It is true to say it, but it doesn't mean anything.

One of the differences between medicine and the alternative is that in medicine people generally know how much of a medication is being taken, what it does and, more importantly, how and why it does it. Knowing what part of the body is affected by a chemical allows for possible interactions and adverse events to be predicted, and when there is some doubt only vital medications are advised and all others are contraindicated. I will give three examples from my own experience and that of some acquaintances.

• Anyone taking warfarin or other anti-coagulant is advised not to take aspirin and to limit their intake of certain green vegetables. Nobody had to do any combination clinical trials to come to this conclusion - all that was necessary was to know what warfarin does, one of the side-effects of aspirin, and how warfarin and broccoli relate to the level of Vitamin K in the body.
• I take a medication which has a short half-life in the body so it has to be taken every day. (I can feel the effect of missing a daily dose.) There is another drug to treat the same condition, but there has to be at least 14 days between stopping one and starting the other because they both affect the same cells but in a slightly different manner. On the other hand, the only other drugs I ever take except in special circumstances are an antihistamine for hay fever and an analgesic for migraine. My pharmacist was able to confidently tell me that I could take all three at once and the only effect would possibly be a slight increase in the drowsiness that the migraine tablets can cause. (As the law requires that these have to be personally handed to me by a registered pharmacist who must remind me every time of the dangers of driving while using them, I wasn't too worried.) He could do this because there is no overlap (or none that matters) between the parts of the body affected by the different medications, and all three have known, specific activities.
• Possibly the most studied drug in the world is ethanol. When doctors, pharmacists and packages advise against mixing certain drugs with alcohol it isn't because they are being wowsers or because the combination of the drug and alcohol has necessarily been subjected to clinical trials. It's because they know what the effects of alcohol are. The package insert for my daily medication says that moderate alcohol consumption is allowed. I would expect that any interaction between alcohol and this drug would have been tested thoroughly, because, as a daily pill, the chemical is always in the body, alcohol is one of the things that people with this particular condition could use as a form of self-medication, and there is a real possibility of a severe reaction between alcohol and the drug. It was good to know that I could still enjoy the occasional beer or wine. My migraine tablets are another matter, and the prohibition of alcohol consumption is quite explicit. Again, I don't know whether any formal testing was done but I have been advised that one of the ingredients drastically enhances the intoxicating effects of alcohol and can even lead to blackouts. It is moot for me anyway, because I can honestly say that I have never wanted a drink when I have had a headache.

The "combinations aren't tested" argument is a straw man - it is a false statement of the opposing position. More than that, though, it is hypocritical when coming from supporters of "alternative medicine". Walk into any health food store and look at the range of "natural" and "herbal" products on the shelves. You will see row upon row of bottles containing mixtures of ingredients, with many ingredients occurring in several different mixtures to "treat" or "relieve" different ailments, and some of the ingredients being sold separately to cure yet more complaints. It is not uncommon to hear someone say that they are taking many different herbs, vitamins and supplements.

If it is bad for real doctors to prescribe untested combinations of drugs in a situation where the individual dosages and actions of the drugs are known, how much worse is it to take a mixture of medicines where it is impossible to know the actual dose taken of any component or even to know what all the components are or do and where nothing has been shown to work for anything anyway