Interview with NCCAM Director, Dr. Briggs
(Second Opinion Live, ReachMD)
The following is a transcript from an interview with Dr. Josephine P. Briggs, director of NCCAM, and Drs. Michael Greenberg and Matthew Birnholz, the hosts of Second Option Live on ReachMD XM 106. This program originally aired live on Wednesday, January 6, 2010.
Q= Michael Greenberg, M.D., and Matthew Birnholz, M.D.
A=Josephine P. Briggs, M.D.
Q: And now we'd like to welcome our guest for this week, Dr. Josephine Briggs. She's an internist and nephrologist as well as an accomplished researcher, and she currently directs the National Center for Complementary and Alternative Medicine [(NCCAM)].
Eighty-three million Americans spend an estimated $33.9 billion on complementary and alternative medicine [(CAM)]—I don't like to call it that either—in managing their own health. Dr. Briggs and her agency are researching the science behind these treatments, whether they are acupuncture, dietary supplements, massage therapy, or meditation.
So we've invited Dr. Briggs on her agency's 10th anniversary to look back at their accomplishments, the evidence they're building on popular CAM therapies out there, and future research directions. Josephine, it's great to have you with us today.
A: Thank you for having me. Glad to join you.
Q: I have a quick question to start off because I've been looking through some of your previous positions enroute to joining this agency of NIH [National Institutes of Health]. You directed the neighboring Division of Kidney, Urologic, and Hematologic Diseases [at the National Institute of Diabetes and Digestive and Kidney Diseases] for close to 10 years. Then you seemed to join the Howard Hughes Medical Institute as senior scientific officer for a few more years. Then from there, you took your current position focused on CAM. So my question is, how did CAM therapy and research enter into the picture for you during those other posts? Or did it and, if not, was this a whole new ballpark for you?
A: Well, to a certain extent it is a new ballpark, but a fascinating one. The first director of the Center for Complementary and Alternative Medicine was Steve Straus. Steve Straus was a leading vaccine investigator here at the NIH, and he and I partnered on a number of projects. We put together a big workshop on placebos. I was at that point overseeing a portfolio of research in which I was just struck with the magnitude of the placebo effect and thought it was worth getting people to talk about. Steve was also very interested in that because it is certainly one component of the way a lot of alternative therapies may help people. So Steve and I partnered on that, and it got me very interested in mind-body medicine and learning more about how hope and expectancy and all these other things that go into placebo responses help people.
At Hughes I was overseeing very interesting, wonderful science but I missed the active role of overseeing human subjects research, which is in some ways my first love. So I was very pleased to be selected for this complex and interesting job.
Q: What's your personal feeling about, once again, “complementary” therapies? You know, I hate that term. They're therapies that are nonallopathic, let's call them that.
Q: What's your personal feeling about them?
A: Well, you know it is a big grab bag. We're talking about an incredible range of different interventions that people undertake, often as self-care, to improve health conditions or promote health and wellness. In some settings I'm impressed that these modalities may help, for example, with pain management. Obviously the broad umbrella includes some therapies that are potentially dangerous or are very bad alternatives to conventional care. But NCCAM's mission is to make sure there's good science going into things that are important to Americans' public health.
Q: I think that's great. Let me ask you a question I've asked—I've done a number of interviews with people doing alternative therapies in standard settings, like shock trauma units. Our Western therapies are based on a model that the body is very mechanical. If you go to the chemical level, the physical level, it's a machine; we replace parts. We use drugs, and the—let's call them the Eastern therapies—are based more on the human being as a spiritual energetic field.
Q: Right? And so those therapies are based upon that. How do you translate those therapies into the Western model? Because if you're just going to take acupuncture needles and stick them into somebody instead of giving them penicillin, that's really not what we're talking about here. How do you deal with that?
A: At times there are mismatches between conventional scientific methods and studying complementary and alternative medicine, but I think most of the time those problems can be solved. We are after rigorous tests of whether things work. Acupuncture is an interesting example of some of the problems. If you very precisely match the context and whole experience of acupuncture but don't exactly put the needles on the meridians, you may still get benefit because the whole context of care that has developed through thousands of years of Chinese experimentation may be part of how acupuncture works, and it may not simply be the needles or the meridians. I think that's what the research really is pointing to. Nonetheless, acupuncture does seem for at least susceptible people to be an intervention that modifies the perception of pain, and the data on that I think is coming together.
Q: When you use the word “susceptible” people there's a suggestion there that you're susceptible to something. It almost sounds like you are putting it in on the basis of fraud, like I'm susceptible to this charlatan or…
A: Maybe it's a bad word. Acupuncturists even in China—I was in a traditional Chinese medicine facility in China—recognize when they try to do acupuncture anesthesia that some people get better analgesia than others. So whether this is similar to hypnotizability and other susceptibility kind of mind-body interventions, I don't know. I think it works better for some people than others.
Q: It's really interesting in terms of you telling us how you got into this through monitoring placebo effects and then looking at complementary and alternative medicine, which I think a lot of practitioners, you know, more conservative, traditional practitioners if we want to call them that, will say that a lot of CAM therapies rely on placebo.
Q: And I'm wondering if you had to change your views after studying or looking into and examining things such as acupuncture, which is getting a little bit more support from the evidence that you've been building, if you've had to broaden your field of view a little bit, or if you still maintain that healthy dose of skepticism with what you do here?
A: I'm naturally a skeptic, and I maintain a pretty healthy dose of skepticism. I'm used to running double-blind trials of drugs. I think that's the right way to approach studying drug effects. I'm not sure that it's the right approach, however, to ask some health care questions, like does this help you with your pain?, where blinding may not really get us closer to the real question. But to stay skeptical is, I think, part of being a rigorous scientist.
Q: So here's a question for you. What's in your medicine chest today? Is there anything that you're having in your personal medicine chest that you wouldn't have used before because you've been exposed to it?
A: I'm staying pretty skeptical. I was just on vacation with my grownup sons and their partners and my husband, and we all had colds. I tend, when I have a cold, to go for things like honey in some tea or maybe a little rum with the tea, and the kids were reaching for the Nyquil®. I like these natural remedies, if possible, but I certainly take vitamin D and I take calcium. I do a little yoga; I do a lot of exercise, but I'm not a regular supplement user.
Q: I think what you just said brings up a really interesting question. What you're talking about are two alternatives. You like the honey in tea (I do too, by the way, and steam); they like the Nyquil®. So actually, shouldn't we say that everything is an alternative, including a surgical approach is an alternative? Like in gallbladder disease, you can have a medical approach, a surgical approach. They're both alternatives. I'd get that stone out of there.
A: I think we all want evidence; that's what it comes down to. In management of colds, at least for adults, these are all probably perfectly reasonable, perfectly safe alternatives. For young babies we've learned that some of the over-the-counter remedies may not be as safe a remedy, or alternatives, as we thought. But for serious and important health decisions, I'm a believer in evidence.
Q: So are we. But the public goes out and buys billions of dollars worth of these therapies. I see them in the stores, too. Why do you think that's so? Do you think that it is the placebo effect or that doctors are just not satisfying patients—that we can't cure them? What's the big push?
A: That's an interesting question, and I don't really know the answer. One thing I do want to say is that we're pretty convinced that the NIH-sponsored research is impacting on what the public is doing. Our investigators just published a large study on ginkgo for the treatment of cognitive decline—very negative study. The supplement industry is concerned that will [have an] impact on sales, and certainly the past history of the other large studies, many of which have been negative, is that they have impacted sales.
A: However, we've also created a fair amount of evidence that fish oil may be beneficial, and that's also impacting sales. So the science, we think, is impacting what the public does.
Q: If you'll give me a minute here. If you're joining us or taking your fish oil, you're listening to “Second Opinion Live” on reachmdxm160. I'm Dr. Michael Greenberg alongside Dr. Matt Birnholz. Find us on Twitter at ReachMD or find us by phone, 888-MD1-REACH—that's 888-631-7322. We're talking with the Director of the National Center for Complementary and Alternative Medicine at the National Institutes of Health, Dr. Josephine Briggs, and she is charming.
Now Dr. Briggs, here's a question since we've kind of moved a little bit into supplements. We don't want to cover it too long. But I mean, what is your take on current supplement regulation in this country? I mean, it is a massive industry that creates a lot of what we would call snake oil out there that's just not regulated. But I'm wondering what, in your interesting position, your take is on that?
A: Well, something that concerns me greatly and is clearly receiving congressional attention is the fact that the supplements for weight loss, for sexual function, for athletic performance are sometimes adulterated with active agents, and I think that's a substantial concern. I think the FDA's worried about it, Congress is worried about it, and it seems to me the biggest safety concern in supplements right now.
Q: How about the other side of that issue? My patients come in with things that they claim are supposed to work for things, and if you read the package insert, it says “not intended to treat any disease or cure any disease” or do anything, after all, except have you pay for it. People are buying the stuff and people are allowed to sell it legally.
A: I think that there are some important concerns here. I think one of the things that worries me is the tendency of people to take lots of pills, and that includes supplements, and in fact overuse of prescription medications as well. I read that there's some recent data from the CDC [Centers for Disease Control and Prevention] that people in nursing homes are taking on average 10 different active medications. We all know how horrified we are when we see somebody walk into our offices with a bag of 12 or 15 supplements and 5 prescription meds; the chance of interactions are huge. So these are big concerns, not just supplement overuse but generally too much pill popping.
Q: Right, and I'm horrified because I don't know what half of them are (then they show me these names), nor what they're doing.
Q: Well, why don't we move into some talk about the Center itself. I mean this is something that's obviously top of mind for you. It's been around for 10 years now, this agency, and [we] want to hear about some of the accomplishments and some of the biggest setbacks and challenges that you think have come through the doors in the last 10 years.
A: One real achievement of NCCAM's has been the large, very carefully performed, randomized clinical trials of a number of dietary supplements. I just mentioned the ginkgo study. There are studies on St. John's Wort, on echinacea, on fish oils, and these have been very well performed, very carefully developed studies. There were a lot of challenges in developing well-characterized products and, in general, in approaching this whole area. But I think the studies have been, by and large, very well implemented and have had substantial public impact. I think that the other area that we are seeing impact has to do with pain management. There are guidelines from the American Pain Society and the American College of Physicians on the value of massage, manipulative therapies, and acupuncture as part of the management of low-back pain. Every doc who manages people with low-back pain knows what a tough problem this is. But we're beginning to see a body of data that suggests that in some settings these approaches can be effectively integrated into care and help. So I see those as two big achievements. We're also learning lots of interesting fundamental science on how compounds in green tea affect our biology and health. The cocoa flavonoids may affect inflammatory disorders. I mentioned some of the fish oil work in humans. There's also very interesting work on nonessential fatty acids and their effect on biology that I think will yield a better understanding of how our diets affect our biology. Another great area is probiotics. We're learning some very interesting things as we learn more about the bugs that live in us, about ways in which modifying them may affect disease. So I think a lot of good things have come together over the last decade.
Q: I've heard some work about probiotics from Europe—that they actually can help avoid eczema if mothers take them while they're pregnant, just some research starting.
A: Yeah. It's a very interesting hypothesis, and it really deserves more work. There's pretty good evidence that probiotics help with necrotizing enterocolitis in newborn babies, premature newborn babies. But the possibility, particularly in nonbreastfed babies, that adding probiotics to formula may affect the ultimate development of allergies, I think, is very promising and really worthy of more work.
Q: I think the work that you're doing is really good, and we like that you're bringing science into it. We thank you for joining us today.
A: Well, I've enjoyed being part of your conversation, and thanks for inviting me.
Q: Thank you. Our guest today has been Dr. Josephine Briggs, Director of NCCAM, which is the National Center for Complementary and Alternative Medicine.
(END OF INTERVIEW)