Non-drug medical treatments – like physical maneuvers, diet, exercise, and cognitive behavioral therapy – have so far been too hard to find and recommend, writes Paul Glasziou of Bond University at Gold. Coast in the third in a series on drug use.
In 2017, while traveling through rural India, Rae Thomas’ teenage daughter began to feel dizzy and nauseous for several hours. Rae recalled hearing that a head rotation procedure can help fight the most common cause of persistent dizziness.
Using her cell phone, she found a description of the Epley maneuver (or canalith repositioning) on the Handbook of NonDrug Interventions (HANDI) website, watched the linked video a few times, and performed the procedure. Her daughter’s relief was immediate – though it needed to be repeated over the next few days. Rae was only aware of this option because she worked at the same university as the developers of HANDI.
the Epley maneuver is just one of dozens of effective “non-drug” treatments that are underused by physicians and patients.
Some have substantial effects, supported by research: exercise (as part of “pulmonary rehabilitation”) for patients with chronic respiratory disease can prevent 70 percent of hospital readmissions and deaths; Daily Solar cream can reduce invasive melanoma rates by 50%; and ‘external cephalic version’, transforming a baby in utero by pushing on the mother’s abdomen, can prevent 50 percent of unsafe breech births.
If there were equally effective drugs, doctors and patients alike would cry out for their access; companies would set high prices. But unlike their pharmaceutical brethren, these non-drug treatments are less researched, poorly described in this research, weakly regulated, and unmarketed – especially when they are free or cheap.
One explanation for their relative neglect has been the lack of a respected compendium, equivalent to pharmacopoeias (drug manuals) that physicians consult when prescribing. Instead, trials of effective non-drug treatments are widely scattered across the vast oceans of scientific literature. There is no regulatory body (like the TGA in Australia or the FDA in the United States) to rule on which ones are effective. And generally, no company has an interest in marketing them.
Non-drug treatments fall into several generic classes: exercise (general and specific), diet, cognitive behavioral therapy, physical maneuvers, but also a wide range of others.
Perhaps the most overlooked non-drug “treatment” is exercise for chronic illnesses – lung disease, heart failure, cancer fatigue, diabetes, depression, and so on. While exercise is often promoted for prevention in healthy people, sick people stand to gain the most, but they are often afraid of exercise. Exercise can cause symptoms such as shortness of breath and fatigue, but with persistence it will improve function and quality of life, often reduce relapses, and improve survival.
Over the past decade, we have recognized that specific exercises can often overcome functional deficits. Some of them are described in the popular book by Norman Doidge The brain that transforms which presents the discovery and impact of brain plasticity for rehabilitation. A clinical example is “mirror therapy” – where patients perform activities via feedback from a mirror – used successfully to treat phantom limb pain and regional pain syndromes after stroke.
To address the lack of a compendium, in 2013 the Royal College of General Practitioners (RACGP) in Australia began compiling effective non-drug interventions relevant to primary care.
Based on the format of modern pharmaceutical manuals, each HANDI the entry includes indications, contraindications and “dosage”. The goal is to make “prescribing” non-drug therapy almost as easy as writing a prescription for a drug. It allows clinicians to offer a greater choice of interventions to a patient, who may wish to avoid medications and the risks and lifestyle changes often associated with drug treatment regimens.
Since its launch in 2015, HANDI has grown in popularity with Australian GPs and has been incorporated into many local ‘clinical pathways’, but is underutilized compared to drug-based options.
HANDI is a step towards improving non-drug interventions, but other issues still need to be addressed. One problem is how poorly described non-drug treatments are in current medical trials – study has shown less than half are sufficiently clearly described to allow replication in follow-up studies; it also creates problems for reviewing the evidence and making recommendations.
Another obstacle is the lack of inclusion in medical education – pharmacology is taught but not as much in ‘non-pharmacology’. But perhaps the most important problem is that many of these non-drug treatments are free or cheap and have no copyright, so there is no one to benefit from them except the patient. .
The pandemic has taught us the important role of non-drug interventions – such as social distancing, crowd avoidance, better ventilation and masks. Hope this lesson is not forgotten.
The HANDI development process
The RACGP HANDI Working Group meets six times a year, collecting possible topics from a variety of sources. Each potential HANDI entry then goes through a three-step process before being published.
Step 1: Evidence and relevance assessment
The group evaluates the proposed non-drug intervention, examining two questions:
1. Is the evidence strong enough?
2. Is the intervention relevant and practical for general practitioners?
Treatment should be supported by at least two positive, good-quality randomized controlled trials (RCTs) with patient-relevant results, or one RCT with strong evidence to support the causal relationship to the study.
Step 2: Writing the HANDI entry
Next, a group member works with a medical writer to develop a detailed ‘how-to’ guide for using the non-drug intervention, which includes indications, contraindications, precautions, side effects, availability and description of the intervention, as well as resources for consumers.
Step 3: Final review and publication
The entry draft is reviewed at a subsequent committee meeting before being finalized and published on the HANDI website.
Paul Glasziou is Chair of the HANDI Project Team, Professor of Evidence Based Practice at Bond University, and Director of the Institute for Evidence Based Healthcare. His main interests include identifying and removing barriers to the use of high quality research in everyday clinical practice.
Professor Glasziou is supported by a scholarship from the NHMRC.