Amazon

Making Clinical Trials Sexy

If you're buying a new TV, how do you go about it? My guess is that you probably have a look around the shops or internet, find a model you like, then get online to find some reviews of it and decide whether or not to buy based on what you've read. You may well scroll down to the reviews if you're buying something on Amazon, before you click the "Buy" button. If you book a holiday, you're probably straight on Trip Advisor to see what other people- humans just like yourself- have got to say about the hotel.

It is perfectly reasonable behaviour. We understand and respond to the personal experiences of other people- its part of our nature, stitched into our being. Each review is a little story, and humans love stories, especially when they are about other humans.

Its therefore a hugely unfortunate problem that, when it comes to healthcare, stories just aren't good enough. When peoples' lives are hanging in the balance, reviews and testimonials just aren't up to scratch. Here's why:

I have guttate psoriasis. Imagine I go on holiday (alas this is merely a pipedream this year, thanks to what feels like millions of large unexpected bills that seem to keep turning up in my life) and lo and behold, when I return, my psoriasis has cleared up. I conclude that it is definitely the sunshine that has cured it, and proceed to proclaim that I have found the ultimate 100% effective cure for psoriasis.

Is it reasonable that I have come to that conclusion, based only on my own experience? No, not at all. Why have I focused on the sunshine aspect alone? Maybe a week spent relaxing is what has actually cured it. Maybe its because I've changed my diet on holiday and have been eating lots of lovely fresh fruit and vegetables and fish?  Maybe it is because there is a magic ingredient in Sangria which miraculously beats rogue skin cells into submission. What if chlorine in swimming pool water is my skin superhero? Maybe-just maybe- its because guttate psoriasis can be self-limiting, and it has just faded away of its own accord. With just my experience to go on, there is no way I will ever be able to know what it is that has made my condition improve.

What I would need to do to be able to decide is to scale things up. Get as many people as possible with guttate psoriasis, and divide them into at least two groups- one exposed to sunlight, one not. I'd have to try to control the peoples' behaviour as best as I could for the other factors like diet, chlorine exposure, sangria intake, stress etc. Whilst I could never completely control for everything, if the group exposed to sunshine experience a significantly better improvement in their psoriasis, then I could say with more certainty that it is the sunshine that did it rather than anything else.

This is the beauty and elegance of a clinical trial. They are simply the best, slickest, most reliable way we have of teasing out whether a treatment actually does make a difference. They're like an anthology of stories, carefully selected and analysed by researchers in a bid to start finding an answer to a treatment question. Whilst they're not 100% perfect, they're certainly the best sort of information we have at the moment on which to base any decisions about which treatment to choose for which disease, and for which patient.

This is, however, very easy to forget when you actually have to read one. I do not have a mathematically inclined brain, and when faced with tables full of numbers, p values, confidence intervals, hazard ratios, relative and absolute risks etc, my grey matter is usually to be found quivering and wimpering in the corner of my skull. I have to really try hard to focus on the stats and results when reading a clinical trial- its a constant fight to wrench my thoughts back onto the page, when they keep merrily skipping away to think about kittens or bunnies or *that* picture of a minipig wearing red wellies. And I say this as a geeky pharmacist who has undertaken a decent amount of training in how to read a clinical trial. What hope then, does an individual patient or regular joe have of understanding trial data?

A quick glance at pretty much any website selling an 'alternative medicine' and you'll notice there is usually a "Testimonials" page on there. Many other types of healthcare sites also use testimonials to prove their treatment works. They're easy to read, often full of personality, and can really seem to speak to you as a reader. They may seem convincing, but as you've (hopefully) seen from my example above, they simply can't be used to decide if a product works or not. A glossy celebrity story endorsing a product in a magazine is infinitely more sexy than ten pages full of stats and graphs in a medical journal.

Testimonials and reviews are, at first glance, more attractive and more seductive than the more dowdy clinical trial. So what can we do to help the clinical trial apply a bit of lippy, spray some perfume on itself, and don its heels to get out on the town and make people weak at the knees? My short answer is I don't know. Campaigns like International Clinical Trials Day help of course, but at the moment it feels like we're swimming against the tide somewhat. My ultimate dream would be a primetime TV series, fronted by a hunky Brian Cox type. If he can make physics sexy enough to be at the forefront of our entertainment, surely there is some way that we can do the same for one of the best inventions in healthcare? I'd like to get to a place were it's second nature for everyone, whether they be a patients, pharmacist, healthcare professional or general geek, instinctively bypasses testimonials to look for clinical trial evidence instead.

Do you have any ideas? Have you had any really good experiences of explaining clinical trials to patients? Are there any techniques we can use to simplify the stats and make trials more accessible to all? My friend Nancy had a great idea of including a Plain English summary as part of an abstract for every trial. Is there anything else we could do? Let me know, however outlandish your idea, either by commenting, tweeting me (@SparkleWildfire), or dropping me an e-mail at my new shiny sparkly e-mail address healthydoseofskepticism@gmail.com

Hxxx

Amazon sometimes frightens me, if I'm honest.

A while ago @DianthusMed alerted me to the fact that Amazon UK are selling unlicensed medicines imported from the US via its Marketplace. Adam got in touch with Amazon, and the particular brand he bought are no longer available on their website, but of course there are still a whole range of other unlicensed loratadine brands available to buy with just one click.

I dug a little bit deeper and discovered that this could actually be more dangerous than some non-drowsy anti-allergy medicines- along with some problems selling licensed medicines as well.

Some inane browsing brought me to a page selling Syndol. I noticed it because of the price- its being sold at a whopping £39.99 for 30 tablets. I presume this is due to the fact that Syndol are currently on a long term manufacturing problem. Syndol do have a UK product license, and are sold over the counter in pharmacies. They're kept behind the counter for a number of reasons, and require quite a lot of patient counselling for appropriate use: they contain paracetamol, therefore shouldn't be used in conjunction with any other paracetamol products (they're one of those shiny combination products which people might not realize contains paracetamol). They contain codeine, which is very addictive and should be used for no more than 3 days at a time. They contain doxylamine, which causes drowsiness, making them even more abusable and dangerous. I use these occasionally myself if I get horrible, migraine-type headaches. They seem to work, but I also sleep the sleep of the dead for 5 hours, then wake up feeling zombie-like for a good few hours after that. If I sell these over the counter, I check that the patient isn't using them regularly, that they understand about the paracetamol, and that they will make me drowsy. Whilst the sellers do state they might need more information from you before selling them, they seem to me to be pretty inappropriate for an internet sale- sometimes you can tell if a patient is misusing them by their body language etc. the largest pack size it is available in is 30, for all of these reasons. And charging £39.99 for an addictive substance which is out of stock elsewhere just seems manipulative.

And here's the most horrifying thing: Amazon, trying to be helpful, suggest a package that we can buy, based on what other customers have bought together:

Umm, right. So Amazon have been selling Syndol + Syndol+ Sleep Aid, an unlicensed US product (doxylamine) together, and they're suggesting we do the same. This combination, if taken together, could well be deadly. There's the issue of paracetamol toxicity, codeine and doxylamine addiction, and the potential for self-harm to consider here.

This is, of course, just the tip of the Iceberg, Click on the Sleep Aid tablets and you're encouraged to buy Sleep Aid, Sleep Aid and Unisom. Click on Sominex (a UK-licensed product) and you're advised to buy it alongside Sleep Aid and Nytol. Any of these combinations have a huge potential to harm.

I'm going on about licensed and unlicensed products here. So what am I on about? Well, in the simplest terms, a product that is licensed in the UK, and used according to the manufacturer's instructions, is guaranteed to have met certain standards of quality, efficacy and safety. If it hasn't got a license, you haven't got that guarantee. It might be fine, or it might be made of rat poison and brick dust, you just don't know.

I know I get taken in by these packages on Amazon all the time, when I'm buying DVDs or books, or other items. At least none of these are going to have that much of an effect on my health (although I'm sure some would argue that my love for Korean extreme horror must be having some effect).

This sort of multi-product purchase encouragement goes against many of the reasons why products are sold through a pharmacy in the first place.

Amazon have been through the mill lately, what with the Keep Calm and Rape T-shirtsand their selling of unlicensed cancer medicines. Well, I'm going to add my little chirp to all that noise too. I'm sure there are complicated technical reasons behind why they have this frequently bought together sections on medicines, but frankly I don't care.

Hxxx