Through the Looking Glass

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”
“The question is,” said Alice, “whether you can make words mean so many different things.”

• from Lewis B. Carroll’s Through the Looking Glass, chapter 6, 1934.

Ever notice how physicians and third parties mean so many different things when referring to “scientific evidence”?  We’ve heard the refrain many times, regarding optometric vision therapy, that there isn’t sufficient evidence that it works.  And you know from reading this blog that now that the CITT has presented an airtight case for the significant superiority of office based vision therapy to other treatment modalities, which fare not better than a placebo.  So now our critics have decided that they’ll yield on that, but it’s not relevant because CI is uncommon in children.  (I kid you not – we blogged about that in August.)

I was reminded this morning, when reading an article in the New York Times, that Humpty Dumpty and Alice might have easily shared their exchange regarding the double standard applied to the words”evidence based medicine”.  It’s become a familiar refrain that physicians feel very comfortable with off-label Rxing of drugs, well off the beaten path of Randomized Clinical Trials (RCTs), but think nothing of denigrating other treatment approaches because “there’s insufficient evidence that it works”

Consider the opening of the article:

Neither of the two drugs used most frequently to prevent migraines in children is more effective than a sugar pill, according to a study published on Thursday in The New England Journal of Medicine.  Researchers stopped the large trial early, saying the evidence was clear even though the drugs — the antidepressant amitriptyline (Elavil) and the epilepsy drug topiramate (Topamax)— had been shown to prevent migraines in adults.

“The medication didn’t perform as well as we thought it would, and the placebo performed better than you would think,” said Scott Powers, the lead author of the study and a director of the Headache Center at Cincinnati Children’s Hospital Medical Center.

Now here’s where the article really gets interesting.  You would think that with this data in hand from a randomized clinical trial, including the significant side effects that can accompany these drugs, physicians would be convinced to stop the off-lable use of these drugs with children.  Or at least to advise parents that using these drugs is no better than a placebo.  Not so fast … the article continues:

“Am I now going to feel obligated to tell patients that these drugs are no better than a placebo? No,” said Dr. Eugene R. Schnitzler, a professor of neurology and pediatrics at Loyola University Chicago Stritch School of Medicine.  “I’ll simply say, ‘We have data in adults that it’s effective, but less convincing data in children and adolescents.’”

Even if the drugs are not effective for children over all, “that doesn’t mean for any one individual, a drug might not work,” said Dr. David Gloss, a neurologist and a methodologist for the American Academy of Neurology.

Don’t you just love the selective Humpty Dumpty-ism here?