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Out of Order: Gift horses
January 2012
by Randall C. Willis  |  Email the author

Here's Johnny! Okay, actually, it's Randy. Nonetheless, I'm back.
A few months ago, the editor and publishers of Drug Discovery News decided to dredge up a chestnut from the past and asked if I would be interested in contributing editorially in 2012.  
I'm not sure why they asked me back—perhaps it has something to do with the Mayan calendar—but I'm happy to share my thoughts with all and sundry.
Truth be told, I've missed everyone—the ddn staff, of course, but also ddn's readers. I always enjoyed meeting you at conferences and hearing back from you when I said something particularly inflammatory. At the risk of seriously concerning Amy and the gang, I look forward to being inflammatory again.
A few weeks back, I read an interesting editorial in one of the local newspapers. If I understood correctly, it seemed that the Ontario Medical Association (OMA) was asking its members not to discuss non-Western medicine with their patients—everything from traditional Chinese medicine (TCM) to naturopathy, homeopathy to chiropractic—whether the member's opinions were positive or negative. The editorial was a decidedly vehement slam on this policy by one of the OMA's members.  
From his perspective, the policy was tantamount to practicing bad medicine, and given his tone, it seemed he felt it might have bordered on Hippocratic heresy. To him, any effort to keep him from squashing any patient's interest in non-Western medical practices was the equivalent of putting his patients directly in harm's way.
In fairness, I should disclaim that I have been a patient of TCM, naturopathy and chiropractic when I have felt that Western medicine has failed to address my ailments, and feel that I have had success with some of these practices. Much like the pharmaceutical and medical practices routinely discussed in this news magazine, I have found these other practices largely hit and miss.  
That some Ontario medical practitioners questioned the value of non-Western practices was not surprising. That there was such venom in the response, however, did catch me off guard. And it got me wondering about the black curtain that veils these methods.  
A quick Google search for the phrase "outcomes-based medicine" yields results in the tens of thousands. When you look at a lot of these results, however, the focus is on scientific method and not, ironically, on outcomes—which is the point of medicine, isn't it? If you think about it, does it really matter to the patient who is seeing no benefit from a given drug or treatment that 72 percent of patients in a clinical trial did see a benefit over the comparator? If the desired outcome is an improvement in the patient's disease symptoms (or even better, in his disease state), then I'd say no. This patient is seeing no benefit from all of those (possibly) carefully crafted clinical trials.  
I'm not advocating that we totally throw caution to the wind. But I don't think we need to necessarily throw the non-Western baby out with the non-FDA-approved bathwater. Many of these other practices have been around for centuries, if not millennia, and have been sufficiently effective in large enough patient populations to have lasted this long. In the past, the pharmaceutical industry has figured out how to make money from tree barks and saps, citrus mold and the delicate complexions of milkmaids. Surely we can figure out how to take advantage of this untapped knowledge—and unlike most natural products research, which has seemed to me to be founded on pure serendipity (not that I have a problem with serendipity), these areas of exploration have some real-world evidence to support them.
Given the regular, seemingly cyclical challenges the pharmaceutical industry has in coming up with the next generation of blockbusters based on the last generation of blockbusters, or in redefining blockbuster so that it refers to a drug that only significantly impacts left-handed construction workers with the TBD2 allele, where is the harm in throwing some of these tinctures and tablets into a little acetone and sloshing them across an HPLC? Or in analyzing extracts against animal or in-vitro models of various human diseases?
The only thing that's keeping these centuries of anecdotal data from becoming evidence-based medicine is … well, evidence. Rather than disregard all of this information because it wasn't officially sanctioned by bodies like the FDA or wasn't the result of carefully designed clinical trials, maybe the first step in the screening process for potential new drugs should be a simple question of what have the "neighbors" been doing for 400 years to deal with a given condition.  
There are no guarantees that any of this research would amount to anything meaningful, let alone lucrative. But then, how much of the work that is going on today comes with guarantees? Can we realistically expect a 100-percent success rate from replacing a hydroxyl with a methyl group on the 3-carbon of a benzyl side chain of an antibiotic that stopped working last year? Or the co-administration of an antiemetic with a new platinum-based oncology drug to deal with a particularly onerous side effect?  
I'm not advocating that we cease doing medicinal chemistry or adjusting the clinical practice guidelines. I'm just saying that maybe we should stop looking these potential gift horses in the mouth. To mix my metaphors, they may be a red herring, but herring is a good omega-3 source.  
Formerly the executive editor of ddn, Willis has worked at both ends of the pharmaceutical industry, from basic research to marketing, and has written about biomedical science for almost two decades.



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