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Credulity about acupuncture infiltrates the New England Journal of Medicine

One of the things that disturbs me the most about where medicine is going is the infiltration of quackery into academic medicine. So prevalent is this unfortunate phenomenon that Doctor RW even coined a truly apt term for it: Quackademic medicine. In essence, pseudoscientific and even prescientific ideas are rapidly being “integrated” with science-based medicine, or, as I tend to view it, quackery is being “integrated” with scientific medicine, to the gradual erosion of scientific standards in medicine. No quackery is too quacky, it seems. Even homeopathy and naturopathy can seemingly find their way into academic medical centers.

Probably the most common form of pseudoscience to wend its way into what should be bastions of scientific medicine is acupuncture. Harvard, Stanford, Yale, M. D. Anderson, and many others, they’ve all fallen under the sway of the idea that somehow sticking thin little needles into points that bear no relationship to any known anatomic structure and that supposedly “unblock” the flow of some sort of “life energy” that can’t be detected by any means that science has. Most recently, as I described, studies that seek to “prove that acupuncture works” have found their way into high quality, high impact journals whose editors should know better but apparently can’t recognize that the evidence in the study doesn’t actually show what the authors claim it shows. Even so, there are some journals that I didn’t expect to see this sort of infiltration of quackademic medicine. Granted, I never expected it to show itself in one of the Nature journals, as it did in the study I just mentioned. I also never expected it to show up in that flagship of clinical journals, a journal that is one of the highest impact and most read medical journals that exists. I’m talking the New England Journal of Medicine, and, unfortunately, I’m also talking an unfortunately credulous article from Dr. Brian M. Berman, who is the founder of the Center for Integrative Medicine, University of Maryland School of Medicine and the holder of multiple NCCAM center grants, and other institutions, entitled Acupuncture for Chronic Low Back Pain.

The article appeared under the section of the NEJM known as Clinical Therapeutics. Articles published in this section begin:

…with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the authors’ clinical recommendations.

And this is the clinical vignette:

A 45-year-old construction worker with a 7-year history of intermittent low back pain is seen by his family physician. The pain has gradually increased over the past 4 months, despite pain medications, physical therapy, and two epidural corticosteroid injections. The pain is described as a dull ache in the lumbosacral area with episodic aching in the posterior aspect of both thighs; it worsens with prolonged standing and sitting. He is concerned about losing his job, while at the same time worried that continuing to work could cause further pain. The results of a neurologic examination and a straight-leg–raising test are normal. Magnetic resonance imaging (MRI) shows evidence of moderate degenerative disk disease at the L4–L5 and L5–S1 levels and a small midline disk herniation at L5–S1 without frank nerve impingement. The patient wonders whether acupuncture would be beneficial and asks for a referral to a licensed acupuncturist.

Berman et al begins with a simple discussion of low back pain, which, as he correctly notes, is an incredibly common clinical problem. He also points out that most of the really bad causes of low back pain (tumors, infection, or inflammatory disorders) are seen relatively infrequently in common practice. The most common cause of low back pain is the dreaded “I” or “N” word: idiopathic or nonspecific, both of which basically mean that we don’t know what causes it. So far, fair enough. Berman et al even produce a fairly good discussion of the pathophysiology of low back pain, including the role of the central nervous system, behavioral elements, and musculoskeletal contributions, among others. Then, unfortunately, the authors go off the deep end:

Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians (Figure 1). Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.

They even include a figure of acupuncture points

It was at this point that I wondered whether I was reading the NEJM or a quackademic medical journal such as the Journal of Alternative and Complementary Medicine. Here was an actual discussion of qi as though it might actually exist and as though meridians and qi were anything other than the result of prescientific concepts about how the body works and disease develops. One wonders if, for its next trick, the NEJM will publish Clinical Therapeutics articles touting the wonders of the humoral theory of disease and how the four humors must be balanced. Or maybe the miasma theory. That was a good one, and quite in accord with the modern day obsession with contamination and “detoxification.”

My expectation to see greater woo appearing in the NEJM notwithstanding, as most CAM advocates do, Berman et al next try to justify acupuncture, starting with the belief that it works and then working backwards to cherry pick studies that they believe to support the hypothesis that acupuncture works for low back pain as anything other than a placebo effect. They begin with several inconclusive and conflicting animal studies, concluding by mentioning the study that I blogged so extensively about two months ago without noting that it didn’t show what the authors thought it showed, nor did it demonstrate that adenosine mediates the effects of acupuncture. As I pointed out, what really irritated me about the adenosine study was that it was relatively interesting science but it was yoked into the service of trying to justify acupuncture with an animal model that had very little to do with acupuncture.

Next, Berman et al decide to delve into the clinical evidence for acupuncture:

A number of clinical trials have evaluated the efficacy of acupuncture for chronic low back pain. A meta-analysis in 2008, which involved a total of 6359 patients,44 showed that real acupuncture treatments were no more effective than sham acupuncture treatments. There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.

At least Berman’s honest about this one in admitting that the meta-analysis showed that real acupuncture is no more effective than sham acupuncture, something that regular readers of this blog know. Then Berman tries to do what acupuncture apologists do every time they encounter studies that show that “true” acupuncture performs no better than the acupuncture control. Rather than simply admitting that acupuncture doesn’t work and that acupuncture effects are placebo effects, they try to spin the results by pointing out that both sham and “real” acupuncture “work” and therefore are useful! In other words, they argue for placebo medicine without calling it placebo medicine. They then do it again for a German trial. Unfortunately for them, it’s a study in which, as is the case with many acupuncture studies, the results didn’t mean what the authors claimed they mean. Once again, Berman tries to represent the finding that sham acupuncture was just as effective as “real” acupuncture. In any randomized clinical trial of a conventional therapy, such a result would lead to the conclusion that the therapy doesn’t work, but not in acupuncture. If both the placebo control and the treatment are indistinguishable from each other, then that means acupuncture must work.

The third study that Berman chooses is a so-called “pragmatic” trial. Basically, it’s a mixed randomized trial with a non-randomized cohort. Let me quote one small passage from the trial that demonstrates why it is an utterly useless study:

In this study, neither providers nor patients were blinded to treatment. Therefore, a bias due to unblinding cannot be ruled out.

That’s putting it mildly. Basically, the study is utterly worthless because it can’t account for the rather large placebo effect that is common in intervention studies for back pain. In fact, it’s fairly amazing that the peer reviewers at the NEJM let that pass. Be that as it may, Berman et al next write an amazing series of statements, beginning with:

Acupuncture is considered to be a form of alternative or complementary medicine, and as noted above, it has not been established to be superior to sham acupuncture for the relief of symptoms of low back pain.

In other words, acupuncture does not work. Even so:

However, since extensive clinical trials have suggested that acupuncture may be more effective than usual care, it is not unreasonable to consider acupuncture before or together with conventional treatments, such as physical therapy, pain medication, and exercise. Many pain specialists incorporate acupuncture into a multidisciplinary approach to the management of chronic low back pain.

In other words, even though acupuncture does not work, we should use it anyway because there are enough practitioners who believe it works and use it even though extensive clinical trials have shown that acupuncture is no better than sham acupuncture, and neither are better than placebo effects.

Even though:

As noted above, the most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.34,65 These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.

In other words, acupuncture does not work.

Let’s put it this way. Berman concedes that “true acupuncture” doesn’t work any better than sham acupuncture for low back pain. He concedes that it doesn’t matter where you stick the needles. It makes no difference; the effect is the same. He concedes that any perceived benefit from acupuncture in low back pain is due to nonspecific factors, in particular psychosocial factors, patient’s expectations, and the attention paid to the patient by the acupuncturist. What, I ask, do we call such a treatment, a treatment that is no better than placebo control and whose efficacy depends on beliefs and expectations, attention from the provider, and contextual factors.

We call it a placebo. A placebo.

That’s just what Berman is recommending to this patient in the clinical vignette that started out this post, a placebo intervention. We can argue about whether it’s ever ethical to use a placebo intervention, particularly for conditions that don’t respond well to conventional therapy and for which eschewing conventional therapy probably won’t cause harm, but we should be honest about the nature of the intervention. That’s the problem with CAM interventions like acupuncture. Its practitioners and advocates don’t acknowledge that they are placebos, and, whether they realize it or not, by failing to do so they are deceiving patients. In fact, Berman’s recommendation that the patient go to a licensed acupuncturist with “adequate training” doesn’t even jibe with his findings in his review article. After all, if it doesn’t mater where you place the needles, then it doesn’t matter if the acupuncturist is trained.

As Steve Novella points out, what Berman is doing in this article in the NEJM is the same thing that CAM advocates in general and acupuncture apologists in particular have a maddening tendency to do. They either cherry pick studies that appear to indicate that their favored woo works. When, as Berman et al were, they are forced to admit that well-designed studies with lots of patients show that their woo is no better than a valid placebo control, they then shift to embracing the placebo, to owning it, so to speak, all without actually calling it placebo.

What I find so disturbing about this NEJM article is not so much that Berman et al pulled these usual CAM tricks. I expect that. I see it all the time in CAM journals and sometimes in unsuspecting legitimate medical or scientific journals. What I find so disturbing about this NEJM article is that the peer reviewers did not spot the obvious CAM abuses of language designed to obscure the fact that acupuncture is no better than placebo. The editors of the NEJM should be ashamed of themselves. The peer reviewers who reviewed this article should be ashamed of themselves. Those of us who rely on the NEJM for evidence-based findings and assessments of various treatments should be afraid.

After all, if quackademic medicine can infiltrate the NEJM, there’s nowhere it can’t go.

Posted in: Acupuncture, Medical Academia

Leave a Comment (18) ↓

18 thoughts on “Credulity about acupuncture infiltrates the New England Journal of Medicine

  1. juryjone says:

    I think I got whiplash from the huge leap of logic in the sentence “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.” I wonder if acupuncture would help?

  2. windriven says:

    Or have I lost my way
    The path of least resistance
    Is catching up with me again today
    -Brandi Carlile, Again Today

    Critical thinking is difficult. Science is difficult. Blind faith is easy. The moon is yours for the asking if only you believe.

    Has mainstream medicine become so bankrupt, so indolent, that the most elite schools, journals and medical centers have fallen into the woolly embrace of woo without so much as a blush?

    Can anyone name a major mainstream medical organization that is fighting back, holding its members to the highest standards of science and practice, castigating those who stray into the weeds of wishful medicine?

  3. marcus welby says:

    The story of the treatment of low back pain contains a litany of placebo treatments. Much reconstructive surgery for low back pain has been all placebo.
    Around 1978 or so, Jerome Modell and associates at the U. of Fla. Dept. of Anesthesiology published an article in JAMA, I believe, in which acupuncture was compared to sham acupuncture or to random needle insertion for the treatment of chronic pain. As I recall, there was no difference in the benefit among the three treatment groups, and all had some short term benefit equivalent to placebo. Lasting pain relief was absent in all 3 treatment groups. The Chinese orthopedic surgeons with whom I have spoken indicate accupuncture has largely been abandoned in China.

  4. urodovic says:

    Although I am a urologist, besides reading my specialty journals I am also subscribed to the online versions of both the NEJM and The Lancet for general medical knowledge. I was of course surprised to read that article last week. The conclusions obviously raises the ethical issues of whether a physician should use well known placebo effects like sugar pills and in the case of the acupuncture for low back pain described in the article the mantra of “ancient traditional Chinese medicine woo” and not telling patients. I am afraid peer reviewers know this and are been sucked in by “the placebo won’t hurt the patient thingy”. Perhaps is the fact fact that most physicians, and even many journal peer reviewers are simply not trained to critically read and interpret, the information and studies submitted for publications in journals much of which is of poor quality. This should be a required course. Personally after 23 years in practice I am realizing this myself!

    Even today as I read an article in the August issue of the Journal of Urology the conclusion is worrisome: http://www.jurology.com/article/S0022-5347%2810%2903254-4/abstract

    “Briefly, our findings raise concern about the methodological quality of SRs published in the urological literature. While there is a strong trend across journals toward publishing an increasing number of SRs per year, there has been no notable improvement in quality”.

    “However, it is important for clinicians and other SR users in urology, such as guideline developers and policy decision makers, to look beyond study design alone and critically appraise methodological quality”

    They suggest requiring residents to take time to learn well the methodology as well as pitfalls of literature research by using educational aids like: A Users’ Guide to the Urological Literature Series

    http://evidence-based.urology.ufl.edu/publications_user.php

    Is EBM which the editors of SBM blog acknowledge has its limitations but is a start… at least for me.

  5. tmac57 says:

    I recall reading many years ago that there were large studies that showed that there was little correlation between disk degeneration in the spine, and back pain as had been assumed previously. Has that been borne out by serious research or was I snookered by some popular mythology of the time?

  6. SloFox says:

    I think this is GREAT news! I’m going to skip the costly extra acupuncture training and just start randomly poking my patients with 27G needles and bill for it. If it’s in NEJM it must be true.

    I hope the editors publish a retraction of apology but I’m not holding my breath.

  7. Carl Bartecchi says:

    Berman is at it again. He has moved up to the back after his unsuccessful attempts to tout acupuncture for the knee. His article in the Annals of Internal Medicine, 2004;141:901-910 was absolutely terrible as suggested by the “Rapid Responses” to the article. Unfortunately, the Annals chose not to publish the negative responses. Even worse was the fact that the ACP had a video showing a patient getting acupuncture for knee osteoarthritis. I supposed that it was made available for acupuncturists to show their patients – while pointing out that the video came from the ACP (how embarrassing). In any case, and fortunately, after the “Rapid Responses” the video was quickly removed, never to be found again.
    Berman’s article would lead one to believe that palpation of the radial artery and examination of the tongue has value. How could the reviewers have ever let that get by. The article also suggests that stimulation of the needle with moxibustion or heat has value. Why not ear acupuncture too? It probably is of equal effectiveness, though not so ancient?
    And yes, the need for patients to seek licensed acupuncturists – what about the practice of “grandfathering” such practitioners. And even worse, what about acupuncturists, even at our top medical centers, who have fraudulent credentials?
    I couldn’t be more disappointed with the NEJM. I only hope that they allow the publication of the negative letters that they will receive. Unfortunately, their letters are limited in the number of words allowed. I could only hope that the many outstanding individuals at the NEJM would be humble enough to admit that they had made a mistake in allowing the Berman article to be published.

  8. wertys says:

    Like you Dr Gorski I was simply flabbergasted by the chutzpah of these authors. They simply say that no evidence shows it to be effective, but then act as if they hadn’t said it. If the CAM racket is so easy that you get away with this sort of stunt in the serious literature then I’m for handing in my license and imposing my own special brand of stupidity tax on unsuspecting sick people.

  9. David Gorski says:

    I couldn’t be more disappointed with the NEJM. I only hope that they allow the publication of the negative letters that they will receive. Unfortunately, their letters are limited in the number of words allowed. I could only hope that the many outstanding individuals at the NEJM would be humble enough to admit that they had made a mistake in allowing the Berman article to be published.

    Having tried to write a letter to the NEJM before, I found its word limitations to be utterly ridiculous. What substantive criticisms can be made in 175 words or less. Not many. Still, we should try.

  10. LindaRosaRN says:

    I note that CME credit is available for reading this NEJM paper on acupuncture. Damn.

    http://www.nejm.org/continuing-medical-education/

  11. Anarres says:

    I emailed the link to NEJM

    to: comments@nejm.org

    (Subject)

    Credulity about acupuncture infiltrates the New England Journal of Medicine

    “Please read this:

    http://www.sciencebasedmedicine.org/?p=6381

    Thanks,”

  12. Draal says:

    Having tried to write a letter to the NEJM before, I found its word limitations to be utterly ridiculous. What substantive criticisms can be made in 175 words or less. Not many. Still, we should try.

    Crazy thought but why don’t you contact one of the editors, like the editor-in-chief?

    Jeffrey M. Drazen
    Department of Environmental Health
    10 Shattuck Street
    Boston, MA 02115
    Phone: 617.734.7870
    email: jdrazen at nejm.org

  13. BillyJoe says:

    “I’m going to skip the costly extra acupuncture training and just start randomly poking my patients with 27G needles”

    A box of toothpicks will do ;)

  14. Dr Benway says:

    Reading this article makes me feel like Richard Dawkins at an Intelligent Design conference, sponsored by the Oxford biology department.

  15. Dr Benway says:

    Thanks, Draal.

    Google tells me that Dr. Jeffrey M. Drazen is a good person who likely will sympathize with our reaction to this accupuncture article. Maybe he was on vacation when someone gave it the green light for publication.

    Here Dr. Drazen warns about supplement manufacturers overstating the evidence for their products and using links to NEJM articles to imply endorsement.

    Curiously, such warnings may have little impact. On the woo side I often read articles that begin with, “we still don’t know…. the research is in its infancy” but end with, “to buy our unproven product or service which *might* prevent cancer, call the number below.”

    The marketing people understand that our right brains are blind to grammar but will link concepts repeated together often enough. Dodgy products can be made to seem respectable if “NEJM” is frequently noted in the footnotes.

    Oh look, here’s a site promoting expensive genetic testing to patients while referencing one of Dr. Drazen’s cautions against premature use of such tests.

    LOL.

  16. BillyJoe says:

    David Gorski,

    “What substantive criticisms can be made in 175 words or less. Not many. Still, we should try.”

    Steven Novella, maybe.
    But, David, you don’t have a chance in hell :D

  17. David Gorski says:

    Don’t be so sure. I’ve written one and two page grant proposals that got good scores.

  18. Jurjen S. says:

    [...] it is not unreasonable to consider acupuncture before or together with conventional treatments, such as physical therapy, pain medication, and exercise. Many pain specialists incorporate acupuncture into a multidisciplinary approach to the management of chronic low back pain.

    And “Sugar Bombs are part of this balanced and nutritious breakfast,” never mind that the breakfast pictured would have been quite “balanced and nutritious” (indeed, significantly more so) without the Sugar Bombs.

    Though it has to be pointed out that this far from the first time the NEJM has published studies in which the conclusions were not supported by the research. In 1991 and 1993, it published studies by John Sloan and Arthur Kellermann, respectively, in which the lead researchers (having had earlier studies thoroughly savaged for the junk science they were) insulated themselves from criticism by the simple expedient of refusing to deposit their research data with the journal. Why the reviewers even deigned to look at the material in those circumstances continues to be beyond me.

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