Promoting evidence‐based non‐drug interventions: time for a non‐pharmacopoeia?

A compilation of effective non-drug treatments could help increase their uptake in clinical practice n 2004, the Journal published a randomised controlled trial of graded exercise for chronic fatigue syndrome (CFS). 1 As with several similar trials, this trial found that graded exercise was an effective intervention. But what is graded exercise? In response to numerous emails from both doctors and CFS patients who wanted further details of the exercise program , the authors of the study published a second article that provided the additional " how to " details and addressed different scenarios. 2 I now keep the pdf file of this second article on my general practice computer to give to, and discuss with, CFS patients. The difficulties in accessing information on this simple, non-drug intervention are in stark contrast to the helpful tools available for prescribing pharmaceuticals: formularies, prescription pads, and pharmacies. The problem is not unique to graded exercise. In a review of studies selected for the journal Evidence-Based Medicine, we found that the adequacy of treatment descriptions in trials and systematic reviews appeared to be worse for non-drug treatments than drug treatments, 3 with only about 30% of non-drug treatments (compared with 66% of drug treatments) being directly replicable from the information given. Fortunately, obtaining additional information from references, searches and authors increased this figure to around 65%. 3 The poor descriptions and lack of easy reference may help explain the slow uptake of some effective non-drug treatments. For example, while the Epley manoeuvre for benign positional vertigo has been known as a simple effective physical treatment for over a quarter of a century, a German survey suggested that it is used in only 8% of affected patients. 4 Though many general practitioners seem have heard of it, informal surveys of GPs at large educational seminars have shown that few know how to do it and fewer actually use it. For medicinal treatments, the need for an encyclopaedic collection with clear descriptions of how to prepare them was recognised long ago. Pharmacopoeias date back to at least the first century AD, when Pliny catalogued the herbal medicines in use in ancient Rome (Box). 5 In the United Kingdom, the first list of approved drugs with information on preparation methods was published to try to harmonise pharmaceutical standards through the merger of the London, Edinburgh and Dublin pharmaco-poeias. Today, we cannot imagine the practice of medicine …