Thread by @scott_mintzer

I’ve been too busy in the hospital lately to circle back to the CBD article in the NYT Magazine Health Issue whose cover I posted, but I’ve been meaning to, because whoo, what a doozy.

So, a mini-rant on cannabidiol, belief, evidence, & journalism. /1

nyti.ms/2Q3AsSh

When I read the piece, I was hoping for a balanced look at the CBD craze, the evidence thereof, and perhaps a critical look at the social phenomenon.

Instead we got mainly a potpourri of anecdotes, hopes, planned studies without results, and sundry speculation. /2

The author accurately notes that the seed of this whole phenomenon was young Charlotte Figi, who has a devastating form of epilepsy called Dravet's Syndrome, which improved miraculously, coincident with her mother giving her a cannabis compound. /3

But this is an area where we actually have good data, b/c there’s a company marketing a commercial CBD product for this purpose.

And it does work in Dravet Syndrome!


Modestly.

Reduces seizures by a mean of 23%. And hardly any dramatic responses.

nejm.org/doi/full/10.10…
/4

So, anybody extolling the virtues of CBD based on young Charlotte needs a science lesson.

Not that 23% reduction is meaningless, mind you, in a terrible disease where not much else works. Just sayin' that it’s no wonder drug. /5

Meanwhile we have all these folks desperate to get CBD for kids (despite the data showing an absence of dramatic responses), people running for office on cannabis platforms, even scientist parents, who damn well ought to know better, beating the drums for this stuff. /6

But, of course, everywhere you hear people talking about how CBD helps them or their kid for this or that symptom.

And the author mentions how some drugs, like aspirin, can be useful for a variety of conditions. So it’s plausible this could be true of CBD too, he says. /7

After all, CBD allegedly interacts with a slew of brain receptors, so its “biochemical promiscuity” may provide a “full-body massage at the molecular level.”

Real talk: when they’ve discovered this many actions, it’s only because they have no idea how a drug actually works. /8

There are other anticonvulsants about which one could say much the same thing.

Meanwhile, the author fails to mention the best example of a treatment that is well-established to work across a huge variety of conditions.

And that treatment is...

THE PLACEBO.

/9

And the placebo effect — which is exactly the reason we do clinical trials, after all — has been growing dramatically in recent years.

But nowhere does the author suggest the possibility that it might be responsible for any of the effects people report from CBD. /10

But wait... the placebo effect is essentially psychological.

Is it really possible that all these things that people report from CBD could simply be just psychsomatic? Does that actually happen in groups?

And here's where the Health Issue of the NYT Mag reaches peak irony. /11

B/c just a few pages away, in that very issue, is another piece about the strange symptoms suffered by US diplomats in Cuba, maybe due to some strange sonic weapon.

Yet that piece is all about how their symptoms might, in fact, just be psychological. /12

nyti.ms/2Htw5fn

(I’m not thrilled about that piece either, BTW, mainly b/c the neurologists he spoke to label these symptoms using the term “functional”. I consider this a bullshit neuro-euphemism for “psychogenic” which obfuscates both the true nature of symptoms & the necessary treatment.) /13

In fact, the author of that piece specifically says the process causing the diplomats' symptoms might be “the same… processes...underlying the placebo effect”.

And it is the same: patient experiences something, good or bad, attributes it to an external cause, & believes it./14

But that doesn’t make it true.

The embassy folks are SURE that their symptoms aren’t psychological... but that doesn’t make them correct.

And many people are SURE that CBD helps them with some symptom or other... but that doesn’t mean it’s a true biological effect. /15

One of my favorite bands, Radiohead, perhaps said it best in the refrain of this tune:

Just 'cause you feel it, doesn’t mean it’s there.

vimeo.com/101914072

/16

It's a pity the author of the CBD piece never talked to his colleague writing the Cuba piece. He might’ve learned something about the power of psychology, & then perhaps, indirectly, the importance of good trials to prove whether drugs actually work better than placebo. /17

Of course, he's not the first journalist to get baited into wanting to believe in hopeful anecdotes & miracle recoveries. As he writes, it even happened to CNN's Sanjay Gupta, whom I knew when we residents together at @UMich. And he’s a doctor. He really ought to know better. /18

So, by all means, study CBD for anything appropriate.

Even though CBD has no effect on the brain's cannabis-specific receptors, and is effectively just profiting off its name association with the drug everyone loves — making it basically the white chocolate of drugs. /19

But in the meantime, the rest of us can hope for better science journalism, with a little more skepticism, and more understanding of how medicine and clinical trials work, and a little less human interest tearjerking and Gummi Bear clickbait. /20x