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Acupuncture Revisited

Believers in acupuncture claim it is supported by plenty of published scientific evidence. Critics disagree. Thousands of acupuncture studies have been done over the last several decades, with conflicting results. Even systematic reviews have disagreed with each other. The time had come to re-visit the entire body of acupuncture research and try to make sense out of it all. The indefatigable CAM researcher Edzard Ernst stepped up to the plate. He and his colleagues in Korea and Exeter did an exhaustive study that was published in the April 2011 issue of the medical journal Pain:   “Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews.” It is accompanied by an editorial commentary written by yours truly: “Acupuncture’s claims punctured: Not proven effective for pain, not harmless.” (The editorial is reproduced in full below.)

Ernst et al. systematically reviewed all the systematic reviews of acupuncture published in the last 10 years: 57 systematic reviews met the criteria they set for inclusion in their analysis. They found a mix of negative, positive, and inconclusive results. There were only four conditions for which more than one systematic review reached the same conclusions, and only one of the four was positive (neck pain). They explain how inconsistencies, biases, conflicting conclusions, and recent high quality studies throw doubt on even the most positive reviews.

They also demolished the “acupuncture is harmless” myth by reporting 95 published cases of serious adverse effects including infection, pneumothorax, and 5 deaths. Some but not all of these might have been avoided by better training in anatomy and infection control.

Their analysis does not prove that acupuncture doesn’t work (negatives are hard to prove) but it unquestionably sheds serious doubt on the claim that it does work. Overall the evidence is inconsistent, and the results tend to be negative among those studies judged to be of the highest quality. Where the results are positive, the reported benefits can be explained by the surrounding ritual, the beliefs and expectations of patient and practitioner, and other nonspecific effects of treatment. There is no evidence to support the vitalistic concept of qi or the prescientific mythology of acupuncture points and meridians; it doesn’t seem to matter where you put the needles or whether the skin is pierced. More modern science-based explanations like increased endorphin production are not convincing, since placebo pills can produce the same effects.

I was delighted when the editor of Pain asked me to write a commentary to accompany the article. It gave me a soapbox in a major medical journal to say all the things I thought needed to be said about acupuncture.

My commentary was edited, but it was a very different experience from the kind of editing I experienced with O,The Oprah Magazine. It was a pleasant collaborative process aimed only at improving the clarity of the writing and strengthening the impact of what I wanted to say.

The journal thought our articles were important enough to warrant a press release. Both Ernst’s article and my commentary immediately got some attention in the media: Science Daily, Medical News Today, e! Science News, and the American Council on Science and Health all reported on them.

Believers in acupuncture will not be pleased. I expect a hostile response and am wondering if Ernst and I should invest in needle-proof vests.

Here is the entire text of my commentary. Thank you to the publishers of Pain, the IASP and Elsevier, for their permission to reproduce it here.

Acupuncture’s claims punctured: Not proven
effective for pain, not harmless

Commentary from Hall H. Acupuncture’s claims punctured: Not proven effective for pain, not harmless. PAIN 2011 Apr; 152(4): 711-712

© 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. This article has been reproduced on ScienceBasedMedicine.org with permission of the International Association for the Study of Pain® (IASP®). The commentary may not be reproduced for any other purpose without permission. Permission to alter the article is not permitted. Permission to translate the article is not granted.

In this issue of Pain Ernst et al. [1], systematically reviewed a decade’s worth of systematic reviews of acupuncture. They found a mix of negative, positive, and inconclusive results. There were only four conditions for which more than one systematic review reached the same conclusions, and only one of the four was positive (neck pain). They explain how inconsistencies, biases, conflicting conclusions, and recent high quality studies throw doubt on even the most positive reviews. Ernst et al.’s analysis cannot prove that acupuncture does not work (negatives are hard to prove) but their study unquestionably sheds serious doubt on the claim that it does work. Overall the evidence is inconsistent, and among those studies judged to be of the highest quality, the results tend to be negative.

Acupuncture is based on pre-scientific concepts of a vitalistic entity (qi) and of meridians and acupuncture points unknown to anatomists. More scientific explanations have been offered as to how it might work, including a counterirritant effect or the gate control theory of pain. There is evidence that acupuncture can stimulate endogenous endorphin production, but there is evidence that placebo pills can do that as well. Importantly, when a treatment is truly effective, studies tend to produce more convincing results as time passes and the weight of evidence accumulates. When a treatment is extensively studied for decades and the evidence continues to be inconsistent, it becomes more and more likely that the treatment is not truly effective. This appears to be the case for acupuncture. In fact, taken as a whole, the published (and scientifically rigorous) evidence leads to the conclusion that acupuncture is no more effective than placebo.

Acupuncture research is inherently riddled with pitfalls. What constitutes an adequate control? People can usually tell whether or not you are sticking needles in them. Various controls have been devised, such as comparing ‘‘true’’ acupuncture points to ‘‘false’’ ones. The best control so far is an ingenious retractable needle similar to a stage dagger, where the needle just touches the skin and retracts into a sheath. Unfortunately, there is no way to blind the practitioner, so double blind studies are impossible.

The practice of acupuncture is also not sufficiently standardized, which makes it difficult, if not impossible to pin down reliably for objective study: there are various schools of acupuncture with different acupoints, and studies of acupuncture have included ‘‘electroacupuncture’’ (with or without needles), ear acupuncture, cupping, moxibustion, and other loosely related procedures. In their book, The Biology of Acupuncture, Ulett and Han [3] showed that transcutaneous electrical stimulation at a single arbitrary point on the wrist was just as effective as piercing the skin at traditional acupuncture points.

In more than one recent study, researchers have chosen not to use a sham acupuncture control group. Their reasoning? Since sham acupuncture has been shown to work as well as real acupuncture, then sham acupuncture must be an effective treatment too! Imagine applying this reasoning to a drug trial: if the drug and placebo got the same results, would you decide that the drug worked and that the placebo was just as therapeutic as the drug?

It does not make any difference where you put the needles or whether you use needles at all. Touching the skin with toothpicks works just as well. The crucial factor seems to be whether patients believe they are getting true acupuncture. It is becoming increasingly clear that the surrounding ritual, the beliefs of patient and practitioner, and the nonspecific effects of treatment are likely responsible for any reported benefits.

Is there really any need for more studies? Ernst et al. point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reasons, including bias and low prior probability [2]. More studies are not the answer. No matter how many studies showed negative results, they would not persuade true believers to give up their beliefs. There will always be ‘‘one more study’’ to try, but there should be a common-sense point at which researchers can agree to stop and divert research time and funds to areas more likely to produce useful results.

Of course, advocates of acupuncture have argued that it is worthwhile even if it only produces a placebo response; and that it is harmless, so it does not hurt to try it. Ernst et al. however, have shown that acupuncture is not harmless. While many of the reported adverse effects could be avoided by proper training in sterile precautions and anatomy, they correctly point out that even one avoidable adverse event is too many. With any treatment, we have to consider the risk/benefit ratio. If there is no benefit, any risk is too much. And there are other harms that they did not mention: time and money wasted, effective treatment delayed, unscientific thinking encouraged.

Placebos are unethical: our patients trust us not to prescribe them. With the current state of the evidence, I do not think we should be recommending acupuncture to our patients. On the other hand, if patients ask about it and want to try it, we should not try to stop them. We have a responsibility to educate them, but not to make decisions for them. We can tell them that although some patients believe it has helped them, the evidence does not show that it works any better than placebo, and there is a small risk of infection and other complications. With this information, they can then make their own informed decision.

In summary, Ernst et al. have shown that the evidence for efficacy of acupuncture for the treatment of pain is questionable, to say the least, and of particular concern is that its use can be dangerous. If the 57 systematic reviews they surveyed had been for a prescription drug and a similar list of serious adverse effects had been reported for that drug, we would hesitate to prescribe that drug. Is there any reason not to hold acupuncture to the same standards?

Conflict of interest statement

I have no conflicts of interest to report.

References

  1. Ernst E, Lee MS, Choi TY. Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain 2011;152:755–64.
  2. Ioannidis JP. Why most published research findings are false: author’s reply to Goodman and Greenland. PLoS Med 2007;4:e215.
  3. Ulett GA, Han SP. The biology of acupuncture. St. Louis, USA: Warren H. Green Inc.; 2002. 160p.

Posted in: Acupuncture

Leave a Comment (238) ↓

238 thoughts on “Acupuncture Revisited

  1. Jan Willem Nienhuys says:

    Very good! I already summarized your comment in a blog of my own :

    http://www.skepsis.nl/blog/2011/03/acupunctuur-tegen-pijn-dubieus-en-riskant/

    Even if you can’t read the Dutch, you may appreciate the pictures.

    I would like to take the opportunity to point out that Ernst et al. don’t mention 57 reviews, but 58. I checked all references mentioned in the beginning of section 3.1. There they give only 55 references, because they forget 67, 160, 161.

    For my blog I did some more counting:
    First the quality of the underlying studies:
    7 reviews: poor
    9 reviews: mostly poor
    32 reviews: variable
    10 reviws: good.

    For the reviews themselves:
    poor or moderate ones (23): 13 got a + , there were 4 times a +/- and 6 were -
    good or excellent (35): 12 +, 9 +/-, 14 –

    There were 6 reviews that were good, with underlying studies that were also good. Here the scores were 1 + , 4 +/- , 1 –

    In 1989 three Dutch researchers (Ter Riet, Kleijnen, Knipschild, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371348/ , http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021032/ ) examined acupuncture studies, not only for pain, but also addiction and asthma and so on, and they concluded that the number of positive trials decreases with increasing quality.

  2. drmarcelli says:

    Dear Harriet Hall.

    If I were the sole proprietor of the biggest oil company I should do all possible actions so that Los Angeles (the most “muscular” town in the USA) neither will ever have a public-private subway, nor electric, nor low fuel consumption cars.
    If I were the sole proprietary of the biggest fast-food company I should plan the transformation of all US children into very fat adults, few able or completely unable to think autonomously, but in compensation for it very specialized to eat junk-food and move their bodies no longer, except for the minimum enough to drive high fuel consumption cars.
    If I were the sole proprietary of the biggest drug company and I read the following very bad news for my company…

    — The Times Higher Education Supplement (27 July 2007) reports an 31.5% increase in applications for ‘university’ courses in complementary medicine. Compare this with 19 per cent fall in applications for places on anatomy, physiology and pathology courses, and a relatively low 6 per cent rise in applications for pharmacology, toxicology and pharmacy.—

    … I should engage the most intelligent medicine Professors, who are the ablest thinkers to transform the most innocent symptom of a patient into the heaviest imminent perception to be at death’s door.

    “And if I were a good man, I’d talk with you more often than I do. ” (Pink Floyd)

    Probably all CAMs are placebo medicines but MDs and all Well Trained people treating patients by them love children, nature and freedom.

    Best regards,

    Stefano Marcelli MD
    (not paid to generate fear and diseases)

  3. WilliamLawrenceUtridge says:

    …so Dr. Marcelli is arguing that Ernst was paid by drug companies to produce this negative result?

    You know what we should do? We should get Big Needle to conduct another meta-analysis to get positive results! That way, we can tell both sides of the story!!! WHAT A GREAT IDEA!!!!!

    Sweet Jebus, maybe acupuncture just doesn’t work and it’s not all a giant conspiracy.

  4. @ Stefano Marcelli:

    Are you in Italy? Are you advocating the purposeful use of placebos? If so, I wonder whether this is a more common point of view on the European continent. Here’s a French physician unabashedly arguing a similar point for homeopathy:

    It is doubtful that anyone would ever prescribe a compound with widely known placebo effects. Would any physician tell his patient he was prescribing something that, although not effective, might work? A compound is unlikely to act as a placebo when the recipient knows that its only effects are as such.

    I have been pursuing scientific activities for nearly three decades. I do not believe that there is anything active in homoeopathic pills. However, I feel that we have not yet assessed the potential usefulness of homoeopathic medication in the context of inappropriately prescribed allopathic medications or receipt of no medication at all. In such settings, the cost-effectiveness of homoeopathic therapy should be compared with that of allopathic medication.

    This strikes me as something that physicians in North America (I can’t speak for elsewhere) have, for better or worse but as part of a broader cultural change, repudiated in the past generation or so: old fashioned medical paternalism.

    No?

  5. windriven says:

    “There is evidence that acupuncture can stimulate endogenous endorphin production, but there is evidence that placebo pills can do that as well. ”

    The pharmaceutical armamentarium includes dozens of medications with proven abilities to fight pain quickly, effectively and safely. Even if acupuncture proves to be mildly effective, why go through the risk, time and ordeal when far better options are available?

  6. Thanks, Harriet Hall.

    If it’s not a medical prodedure or treatment, I don’t want my doctor performing or prescribing it.

    If the risk/benefit analysis is that acupuncture is a wash, we can allow acupuncture to be practiced. But that doesn’t mean I want to get it from my doctor.

    There are ways to reduce the risks of acupuncture. The one pmoran consistently proposes is to have it be offered under the supervision of a doctor. This is as unethical as doctors prescribing sugar pills — or even unindicated antibiotics — and cannot be considered an acceptable solution.

    Another way is to require anyone offering acupuncture to carry insurance and to have the insurance conditional on the acupuncturist respecting certain conditions (receive training in anatomy and sterile procedure and to limit practice to certain conditions). There are risks here as well — if acupuncurists must be licensed, then people are likely to believe it to be a legitimate medical prodedure — but those can be perhaps limited by requiring them to have a license and insurance that also apply to (say) tattoo artists and piercing studios.

  7. Ed Whitney says:

    To repeat from an earlier thread: the difference between acupuncture and sham acupuncture is small, probably too small to be clinically important. The difference between sham acupuncture and no acupuncture is moderate, probably large enough to be clinically important. You appear to be better off getting a fake acupuncture treatment than a fake steroid injection. Perhaps there is a difference between plain placebo and Extra Strength Placebo.

    But there is a larger set of questions not touched upon by Dr. Ernst in his review article (and beyond the scope of that article). It is very difficult to study pain and its treatment. Inferences from randomized clinical trials (RCTs) are not straightforward, even when the methods are well reported. This is because there are issues in the analysis of pain in which there is no general consensus as to the best method to follow.

    For example, it is usual and customary to analyze effect sizes in terms of changes in pain scores from baseline to various time intervals after the initiation of treatment. Generally this means taking some measure of central tendency (the mean) and its variance, and comparing these measurements between groups. However, it is likely that these comparisons miss at least some of the truth.

    In an article titled “Methodological issues in clinical trials of opioids for chronic pain” (Neurology 2005;65 Suppl 4:S32-S49) Nathaniel Katz discusses some problems related to difficulties in interpreting studies that show that opioids are no more effective than placebo for pain conditions. Heterogeneity among patients with respect to responsiveness, for example, can make the average pain response an imperfect measure of the effectiveness of the drug. Knowing which endpoint to measure (and how to measure it) is not an easy or settled matter, and it would be misleading to imply otherwise. If clinical trials fail to show that opioids are no more effective than placebo, does that mean that they should be abandoned (since they have dangerous side effects), or does it mean that the effects may be missed by some commonly used analytical methods?

    Similarly, how to handle missing data (which happen in all longitudinal trials) is not an easy issue to resolve. How you handle this (baseline observation carried forward, last observation carried forward, multiple imputation methods) can make a difference in what you conclude and what effect size you measure.

    Most pertinent to the present discussion, the greater the placebo response for any intervention, the harder it is to show a difference between placebo and the real thing. This happens for statistical reasons, and imposes difficulties of interpretation for all clinical trials.

    Dr. Ernst has done us a service in collecting reports of adverse effects of acupuncture; the 95 cases of serious adverse effects (5 fatalities) supports his conclusion that all acupuncturists should be trained adequately. However, the 95 cases are what is called numerator data; to interpret them properly, a denominator is needed. The number of patients treated with acupuncture would be the population at risk, and its magnitude is not reported and probably not known.

    So my point in all of this is that we must avoid the seduction of the straightforward interpretation. If anyone claims that the interpretation of clinical trials is clear-cut, we should regard that claim with the same horror we would if a nominee for Chief Justice of the United States sat in front of the Senate Judiciary Committee and said that applying the Constitution to specific cases is just like an umpire calling balls and strikes. Sometimes the posts and comments on this website give an impression that once the data have been presented, the conclusions are clear. This is probably an unduly optimistic view of how science works.

  8. windriven on human psychological quirks: “Even if acupuncture proves to be mildly effective, why go through the risk, time and ordeal when far better options are available?”

    Good question, but people do.

    I think it has to do with micheleinmichigan’s point that people are more likely to adhere to a treatment that they understand. Many people feel as though they have souls (I know I do) so presumably many people find it easy to extend that feeling to conceptualizing qi (which I do not do). Medicine is hard, and people are naturally suspicious of things they don’t understand. For people who feel that they understand qi and are suspicious of medicine, acupuncture may be “better” in that it is psychologically accessible to them.

    Limiting the harm of a second- or third-rate treatment may be a lesser evil.

    People do lots of things we don’t objectively think are good in themselves (drug and alcohol use, for instance) and some of the most effective responses of a pluralistic society appear to be harm-reduction in effect. (Welfare payments, union wages, subsidized daycare and the full participation of women in the workforce reduce the harm of alcoholism to families, making abolition less attractive. Needle-exchange programs are morally repugnant to many but appear to be objectively better from a utilitarian perspective than a war on drugs.)

    pmoran has a point in supporting harm-reduction measures with respect to unsupported parallel practices. I just don’t accept his proposal that acupuncture be incorporated into actual medical practice.

  9. LMAO says:

    On the other hand, if patients ask about it and want to try it, we should not try to stop them. We have a responsibility to educate them, but not to make decisions for them. We can tell them that although some patients believe it has helped them, the evidence does not show that it works any better than placebo, and there is a small risk of infection and other complications. With this information, they can then make their own informed decision.

    Why wouldn’t make that statement a bit more pointedly (sorry for the bad pun) by explaining them that the degree to which a patient truly believes that acupuncture will work seems to be the key factor in determining its efficacy?

  10. LMAO says:

    ^^^ ugh… sorry for the missing words… only one cuppa so far today :-/

  11. CarolM says:

    “if the drug and placebo got the same results, would you decide that the drug worked and that the placebo was just as therapeutic as the drug?”

    Isn’t this what happened with antidepressants? I read that a number of meh trial outcomes were suppressed by the pharma companies that conducted them.

    More conspiracy crap – ?

  12. drmarcelli says:

    >>WilliamLawrenceUtridgeon

    >>Dr. Marcelli is arguing that Ernst was paid by drug companies to produce this negative result?

    No! Dr. Marcelli cannot judge Ernst as a person, but as a “science’s citizen” he can judge his public position.
    So I must note that side effects of acupuncture compared to those of chemical (also herbal) drugs and radiations and surgical interventions are NOTHING. Consequently it’s not necessary to be Sherlock Holmes to think it’s a bit strange that Ernst – a university professor of CAMs – seems to go against his own specialty. What should you think about me as a cardiologist if I said OFTEN that my specialty is not only unuseful but also dangerous?
    I am both an acupuncturist and the first skeptic in regard to acupuncture. See here please: http://tinyurl.com/6bpvb9v. Beside the fact I am paid directly by patients consulting me privately (placebo or not), as an independent researcher I found enough observational reasons to continue to be confident in acupunture theory of meridians.

    BW

    Stefano

  13. Ed Whitney

    “The difference between sham acupuncture and no acupuncture is moderate, probably large enough to be clinically important”

    The difference in such an unblinded comparison cannot be considered clinically significant, except possibly for evaluating the strength of the placebo response.

    “Perhaps there is a difference between plain placebo and Extra Strength Placebo.”

    It’s a fairly well know fact that the more radical a treatment appears, the stronger the placebo response. (saline injection > sugar pill, etc.)

    It doesn’t change the fact that prescribing placebos is unethical and a violation of informed consent. Additionally, the use of inert treatments has the serious potential to crowd out/ replace active, effective treatments.

    “However, the 95 cases are what is called numerator data; to interpret them properly, a denominator is needed.”

    Not when the benefit is zero. ANY risk with zero benefit is unwarranted, no further math needed.

  14. WilliamLawrenceUtridge says:

    @Dr. Marcelli

    You’re not comparing the side effects of acupuncture to that of real treatment, that’s not a fair comparsion because real treatment has both placebo effects and real effects. You must compare the side effects of acupuncture to a similarly inert or placebo treatment such as homeopathy or reiki which have essentially no risks beyond the common, corrosive effect of such nonsense on critical thinking. The whole point of all these trials is to see if acupuncture has any actual effects beyond placebo. The suggested result is that acupuncture is an unusually effective placebo but one that causes harm. Therefore the appropriate choice is between acupuncture and all other placebos, picking the one that causes the least harm. Whether the benefits are worth the risk of real treatments depends on the intervention and the disease. Acupuncture is only an option when real treatment isn’t available – essentially it’s a needle-based emotional coping technique used to mark time while the symptoms regress on their own.

    Dr. Ernst did a great service by evaluating the scientific research behind acupuncture and arriving at an empirical conclusion. If you said you were a cardiologist who found their discipline unuseful and dangerous, I’d suspect you were incompetent. Ernst, who started his career in CAM and only became a skeptic when he realized how shallow the empirical basis is, is doing a truly great service to the world because unlike other CAM practitioners he is attempting to find out if the interventions are useful rather than assuming they are.

    The fact that you directly profit from what appears to be a placebo intervention, both in terms of money and the emotional gratification you must feel at “healing” your patients means I am far, far more likely to be suspicious of you than I am of Ernst. It’s a toss-up on who would be more likely to be intellectually dishonest, an acupuncturist or Big Pharma, because though the profits of Big Pharma are much greater, so is the oversight. You, on the other hand, have a direct motivation to lie to yourself and your patient because acupuncture is how you feed yourself. And your oversight is essentially zero. So don’t play the Big Pharma card as if it were a winning one, you’re applying an intellectually dishonest double-standard that you are apparently too blind to see. I’m not sure if this scares or angers me but either way I’m not happy.

  15. drmarcelli,

    Outside of twitter, there’s really no reason to use a URL shortener. I like to know where I am going before I click on a link.

    For anyone who wants to know before clicking, drmarcelli’s link is:

    http://www.geneticacupuncture.com/ifwetried.htm

  16. Josie says:

    Dr. Marcelli, As has been mentioned before, the side effect is not “nothing”. Risks of infection, delay in pursuit of rational treatments and wasting precious monetary resources on something that has no demonstrable benefit are all side effects.

    You make a few inappropriate comparisons between oil companies, fast food and Edzard Ernst.

    An example would be that oil companies don’t want anything but gas powered cars. Definitely not true –gasoline is but one product made from oil. Think of all the plastics other petrochemicals that are made during petroleum distillation. I believe we use plastic in our hybrid and EV cars no?

    Also, fast food companies surely did not start up with the intent to make people fat. Customers who die from obesity related illness do not buy any more hamburgers. If the fast food companies really wanted that outcome they would not make the effort to include more healthful choices on their menus.

    You call yourself an independent researcher. Does that mean you ‘research’ your own patients without any peer review? Dr. Ernst has his work strengthened by the process of critical review by fellow researchers. It is now out in the literature for the rest of us to critique and build upon –where is the fruit of your research so that we may take a critical look at it?

    Also, do you have an autoclave in your office?

  17. drmarcelli,

    “So I must note that side effects of acupuncture compared to those of chemical (also herbal) drugs and radiations and surgical interventions are NOTHING.”

    That’s the point, inert treatments can be expected to have zero side effects. Active treatments can have unintended side effects. It’s a matter of risk to benefit ration. If the benefit outweighs the risk, it’s generally worthwhile. Zero benefit requires zero risk.

    However acupuncture is not always truly inert, as the posts says. On rare occasions, infection, pneumothorax, and even death are side effects of acupuncture.

  18. Setting aside the ethical and other concerns…

    For anyone advocating acupuncture because of its nonspecific (placebo) effects, if you are going to recommend an inert treatment, go with the one with the least risks and complications. Sham acupuncture therefore trumps actual acupuncture.

  19. Harriet Hall says:

    @drmarcelli,
    “side effects of acupuncture compared to those of chemical (also herbal) drugs and radiations and surgical interventions are NOTHING.”
    I agree. But acupuncture advocates have claimed that it is completely harmless, and Ernst has shown that that is clearly not true.

    “I found enough observational reasons to continue to be confident in acupuncture theory of meridians.”

    As Mark Crislip has said, “In my experience” are the 3 most dangerous words in medicine. Medieval bloodletters were confident in their observational reasons as they continued to kill patients. That’s why we need science. You seem to reject the scientific method. What would you think of a doctor who practiced bloodletting today because he had found enough observational reasons to continue to be confident in the theory of the 4 humors?

  20. Mojo says:

    @drmarcelli: “it’s a bit strange that Ernst – a university professor of CAMs – seems to go against his own specialty.”

    You don’t seem to appreciate that there is a difference between studying a subject and uncritically promoting it.

    Ernst’s professorship was originally funded by Sir Maurice Laing, a CAM supporter, with a brief to conduct proper research into CAM. When the original endowment ran out after ten years, Sir Maurice provided further funding.

    If you want acupuncture promoted, you should hire an advertising agency.

  21. windriven says:

    @drmarcelli

    “I found enough observational reasons to continue to be confident in acupuncture theory of meridians.”

    Would you care to share those with us?

  22. windriven says:

    @Alison

    “Limiting the harm of a second- or third-rate treatment may be a lesser evil. ”

    Indeed. I would never argue that someone should be prohibited from doing something to their own body so long as they are sane and have complete information available.

  23. Ben Kavoussi says:

    Excellent!

    Despite this overwhelming evidence, the proponents of acupuncture and Chinese medicine are using political pressure, lobbying and legislation to increase their scope of practice.

    For instance, in California, State Senator Leland Yee is proposing a new legislation (SB 628) to recognize the legitimacy of Traditional Chinese Medicine (TCM) because it is 5000 years old. SB 628 will change the name of the Acupuncture Board to the TCM Board.

    Furthermore, the proposed bill would allow acupuncturists to practice traumatology!

    If this bill passes, California TCM providers will be treating fractures, dislocations, Injury of muscle and tendon, internal traumatic syndrome, and “qi injury” (whatever that means!)

    Thins will be a blow to science and rationality in medicine!

    Anyone who lives in California, and is concerned with the public’s safet,y should contact their elected representatives, and ask them to oppose SB 628.

  24. CLK says:

    @Windriven and others wondering “why the expense and time and effort”? When there are so many clinically proven ways to treat problems.
    The first answer is that there aren’t always. Either for that particular individual with the problem who isn’t finding the conventional treatment helps, or sometimes for a chronic or rare disease that simply has no treatment. I guess the suggestion is that those of us who fall into one of these camps should just sit tight and hope for a science based solution to come along before the condition or our natural life span comes to an end. There is nothing irrational about thinking that way. It is also something that could only be felt by someone who hasn’t had the experience of daily chronic pain, fatigue or some other disabling symptom. This population are also very vulnerable to exploitation by CAM ideas and providers, so I am not sure what the answer is about regulation/ licensing. People should be able to exercise agency in trying whatever they want to see if it works, and when you are desperate enough it stops mattering how it works.

    Before you jump all over how ridiculous that sounds, consider that I inject, every day, a medication meant to slow the progression of my multiple sclerosis, and no one knows how it works or even where it goes once injected. They don’t know how your body excretes it. What they don’t know is more than what they do. What kind of crazy person takes something into their body every day when there is no scientific data explaining how it works (as per the company that makes it)? I take it because there is at least some data showing efficacy. And because it feels better than doing nothing at all to try and help myself. And because the alternatives are less desireable.

    I also go to acupuncture. I go not because I am under the delusion that it will cure my disease or even change the progression, I go because it helps the day to day symptoms- a lot. And I really don’t care why as long as I am able to hold a pencil, walk normally and experience fewer vertigo episodes. If I can accept a pharmaceutical intervention despite not knowing how it works or why, is it so crazy for me to accept acupuncture when I have no definitive answer as to why it works? With Copaxone, I have good studies showing long term results- it does nothing day to day to show me it’s working at all. With acupuncture, I have no studies proving anything, but day to day improvement in how I feel.

  25. Harriet Hall says:

    @CarolM

    “Isn’t this what happened with antidepressants? I read that a number of meh trial outcomes were suppressed by the pharma companies that conducted them.”

    I think you are referring to this study: http://www.nejm.org/doi/full/10.1056/NEJMsa065779

    I recently met the lead author of this study and he told me he is firmly convinced that antidepressants are effective and life-saving in major depression. He was concerned that selective publication would lead to unrealistic estimates of effectiveness, not that the drugs are ineffective.

  26. Ed Whitney says:

    For Karl Withakay: “ANY risk with zero benefit is unwarranted, no further math needed.”

    Maybe there are differences in orientation between sensation (emphasis on facts and their clear meaning) and intuition (emphasis on multiple potential meanings and possibilities for facts). This was all described by Carl Withasee Jung, but it is perhaps peripheral to this discussion. I am not so certain that the effect of acupuncture is proven to be zero, and therefore still need the denominator for the 95 cases in the numerator for serious adverse effects of acupuncture. Further math needed, as I see it. See below for the reason.

    For Harriet and the gang:

    Compare and contrast Ernst 2011 with Hopton A, MacPherson H
    Acupuncture for Chronic Pain: Is Acupuncture More than an Effective Placebo? A Systematic Review of Pooled Data from Meta-analyses
    Pain Practice, Volume 10, Issue 2, 2010 94–102

    One advantage of Hopton over Ernst is that Hopton gives a better accounting of what went into the quality assessment. Ernst cited criteria based on a 1991 article by Oxman and Guyatt in 1991 which have generally accepted things a good systematic review must do. It asks, for example, “Was the search comprehensive?” Hopton, like Ernst, uses Oxman and Guyatt, and also uses a more recently validated tool for systematic review quality, namely, AMSTAR, which is validated with a free link at: (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2131785/?tool=pubmed and at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1810543/?tool=pubmed ) .

    AMSTAR gives more specifics for how the criteria are to be decided upon; for the comprehensive literature search, AMSTAR, unlike Oxman and Guyatt, specifies that there must be at least two electronic sources (e.g., Central, EMBASE, MEDLINE) with key words and/or MESH terms stated, and the search strategy provided. One of my frustrations with Ernst was that he cited the Oxman and Guyatt criteria without details as to how they were applied. Advantage: Hopton.

    Now, Hopton and MacPherson restricted their analysis to systematic reviews which pooled data into meta-analyses. For short term results, they found acupuncture superior to sham acupuncture for low back pain, chronic osteoarthritis of the knee, and headache. In the longer term (6-12 months), the results were more uncertain and inconsistent; the effect sizes were small to moderate for knee and back pain.

    Hopton was probably published too late for Ernst to have had it for his review of reviews. I cannot proclaim that Hopton is right and Ernst is wrong; the only clear thing is that different methods led to different conclusions, and that the methods were more clearly described in Hopton.

    To sum up: It is a mistake to think that Ernst has provided conclusive evidence that the effect of acupuncture is zero. The conclusions giveth, but the methods taketh away, as they say.

  27. Harriet Hall says:

    @ CLK

    ” I go because it helps the day to day symptoms”

    If you feel better after acupuncture, you are certainly justified in continuing it. That is very different from claiming that it works.

  28. drmarcelli says:

    # windrivenon 29 Mar 2011 at 12:50 pm

    Would you care to share those with us?

    My observations are there: http://www.geneticacupuncture.com

    Thank you.
    Stefano M.

  29. Harriet Hall says:

    @Ed Whitney,
    “It is a mistake to think that Ernst has provided conclusive evidence that the effect of acupuncture is zero.”
    I didn’t say that. I said “Ernst et al. have shown that the evidence for efficacy of acupuncture for the treatment of pain is questionable.”

    The point is that after several decades of study, the evidence is still inconclusive. If acupuncture were truly effective we would expect the evidence to be clear by now. The published evidence is compatible with the hypothesis that acupuncture is nothing more than a compelling placebo system.

  30. Harriet Hall says:

    Here is one typical example of drmarcelli’s observations:
    http://www.geneticacupuncture.com/03.GBchannel&biliarytree.EN.htm

    He imagines similarities of shape between a diagram of “gallbladder”acupuncture meridians on the head and the anatomical relationships of liver and gallbladder. He thinks this validates acupuncture theory and shows that the liver controls the brain. Magical thinking at its best. Actually pretty funny.

  31. Mighty Amoeba says:

    It’s like someone had MS Paint, some pictures of human anatomy, and too much time on their hands.

  32. Ed Whitney says:

    @ Harriet Hall: You did not say that the effect of acupuncture was zero; Karl Withakay said so, and that therefore no further math was needed. I need more math for the reasons I specified, when it comes to the need for a denominator to go under the numerator of 95 serious complications.

    I agree that the data are compatible with the hypothesis that acupuncture is a compelling placebo system. Perhaps the data are compatible with the hypothesis that acupuncture is “nothing but” a compelling placebo system.

    The data are also compatible with the hypothesis that something about acupuncture requires that we may need to have a more subtle thought system to help us approach an even more subtle reality system. Comparing Hopton and Ernst could be a profitable exercise in this direction.

  33. WilliamLawrenceUtridge says:

    @CLK

    There’s a difference between your medication (don’t know how it works; validated that it does work) and acupuncture (don’t know how it works, don’t know whether it works).

    Medication also has going for it a set of high prior probabilities (we know the body is made of chemicals, we know chemicals interact, we know certain chemicals alter the function of receptors which in turn alters the function of the body).

    Further, if anyone has any condition where there’s truly no treatment, the use of low-cost, low-risk interventions to mitigate symptoms is reasonable and rational. I would never recommend acupuncture be made illegal, but I would recommend that the “magic” parts of it – qi, yin, yang, meridians, acupuncture points – be eliminated and the materials used be as safe as possible. No deep penetration, even use non-penetrating needles or simple pressure, sterile instruments and needle areas where the risk of harm is minimal (i.e. avoid the torso and ideally superficially needle over bones). But don’t call it a cure, don’t continue to invoke magic, discard the aspects that waste time, cost money and put patients at risk. Far more than any other part of acupuncture or TCM in general, that is what I reject – magic, waste, unnecessary training, the teaching of nonsense and the retention of worthless tradition. Anything the ancients did, we can certainly do better, faster, safer and for less money.

  34. Ed Whitney,

    RE: “I am not so certain that the effect of acupuncture is proven to be zero, and therefore still need the denominator for the 95 cases in the numerator for serious adverse effects of acupuncture. Further math needed, as I see it.”

    Were the below not your words?

    “To repeat from an earlier thread: the difference between acupuncture and sham acupuncture is small, probably too small to be clinically important.”

    If you dispute that sham acupuncture is equal to actual acupuncture, fine, present your case (as you subsequently did), but if acupuncture and sham acupuncture are equivalent, than there is no reason to recommend verum acupuncture over sham, as verum acupuncture has a non-zero risk.

    The fact that we can do study after study, review after review, and meta-analysis after meta-analysis and still get weak, inconsistent, and conflicting results (even if you don’t accept that the better controlled and blinded studies tend to be negative), would seem to indicate that the effects are weak and inconsistent at best and more likely just noise.

    >>>
    “For short term results, they found acupuncture superior to sham acupuncture for low back pain, chronic osteoarthritis of the knee, and headache. In the longer term (6-12 months), the results were more uncertain and inconsistent;”

    I would think that this is consistent with (though not necessarily indicative of) a placebo response. Likely either that or people can develop a tolerance of acupuncture.

  35. Ed Whitney

    “The data are also compatible with the hypothesis that something about acupuncture requires that we may need to have a more subtle thought system to help us approach an even more subtle reality system”

    The data are also consistent with my invisible, phase shifted, magic purple dragon choosing to empower the practice of acupuncture when and only when it feels like it, I suppose.

    Occam’s Razor baby, Occam’s Razor.

    I’m hoping you’re not invoking post modernism and different ways of knowing.

  36. drmarcelli says:

    >>>Harriet Hall

    That’s why we need science. You seem to reject the scientific method. What would you think of a doctor who practiced bloodletting today because he had found enough observational reasons to continue to be confident in the theory of the 4 humors?>>>

    I’m sorry, dear all friends, I answer only Harriet Hall because she is the article writer and I have not all the energy required to think and write more than one continual hour in English. :-)
    Ten years ago, were you skeptic as you are today? Pause…

    Did you act no medical behavior being not in accord to Science Based Medicine? Pause…

    And twenty years ago? Did you need science as you now need to recruit me to it? Pause…

    And before beginning medical studies? Long long pause…

    If science based behaviors are continuing to fail (i.e. see this last irrational war and Japanese atomic failure) is because many MDs like me are mentally children or apes or worms, evo-devo biologically speaking. There are degrees in nature. Maybe I’m arriving to where Prof. Ernst and you are now, maybe I will go also beyond.
    I dont reject scientific method, I need only to be recruited to skepticism. I am here to discuss with other MDs, to see things by other points of view.

    Sincerely,

    Stefano

  37. Ed Whitney says:

    For an example of how the placebo response rate can affect the contrast between true and sham procedures, see Peng B, Pang X, et al. A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain. Pain 2010;149:124-129.

    This study looked at 72 patients with discogenic low back pain at a military facility in Beijing. Patients had diseased discs (documented by discography), and were randomized to intradiscal injection of either methylene blue (MB, n=36) or saline (n=36). The outcomes were pain on the Numerical Rating Scale (NRS) and disability on the Oswestry Disability Index. The MB group had a large favorable response for both NRS and ODI, and the saline group had practically no response on either outcome scale. The randomization, allocation concealment, and blinding were reported to have been done, which controls the most important sources of bias. (The success of blinding was not so clearly reported, and perhaps that is a problem). But the quality of the study was pretty good, going by the criteria the Cochrane Collaboration uses to judge risk of bias.

    It looks pretty good for MB, but I know no one who is taking this study at face value. The placebo response was suspiciously low; if an injection is supposed to have a large placebo effect, this study certainly does not prove it. Something is amiss, in my opinion, but until the study is replicated (as is in progress now), no one should believe a word of it.

    The reason to bring this up is that it is a sure thing that if enough people start injecting methylene blue into enough discs, some knucklehead sooner or later is bound to hit the thecal sac. Intrathecal MB can be very bad news; the adverse response rate would be very bad if it happens.

    So I agree with the conclusion of Ernst: acupuncture should not be done by knuckleheads. And even a well-reported randomized trial should be suspect if it just plain looks flaky.

    Methylene blue, as we know, does prove the truth of the law of similars in homeopathy. It is the treatment of choice for methemoglobinemia. You inject this blue medicine into that blue patient, and the patient turns pink! So there you go.

    For Karl: “Occam’s razor, baby, Occam’s razor.”
    Do you know what William of Occam died of?
    (It was multiple causes.)
    Also: I have met a postmodernist or two, and they were very literal when it came to the interpretation of the parts of their faculty contracts that dealt with fringe benefits.

  38. Harriet Hall says:

    drmarcelli,

    What would you think of a doctor who practiced bloodletting today because he had found enough observational reasons to continue to be confident in the theory of the 4 humors?

  39. WilliamLawrenceUtridge says:

    @drmarcelli

    Ten years ago I was far, far more credulous than I am today. However, a fair amount of reading on the sources of bias and the scientific method illustrated just how conceptually simple science really is, and just how powerful a tool it is for arriving at meaningful knowledge that can be used to improve lives. Even if in the past there were doctors and readers of this blog who were not applying the best knowledge and the best, science-based practice to the treatment of their patients – that doesn’t justify perpetuating the error. The whole point of science is to learn more and the whole point of being a science-based practitioner is being willing to change your mind in the face of convincing evidence. It is not a crime or a problem to make mistakes or operate under mistaken assumptions. But resolutely failing to change one’s mind irrespective the evidence, special-pleading with evidence to make it go away, willfully ignoring contrary evidence because you don’t want it to be true is harmful to patients and society.

    Wars are not scientific failures, the are political. Science can make wars more deadly (or less deadly) and one day may help make decisions about wars (See Sam Harris’ The Moral Landscape for a baby step in the right direction) but right now “war” isn’t a scientific decision (chances are if it were, the decision would be “don’t, that’s stupid”). Similarly, the events in Japan were due to a 9.0 earthquake, and dykes that were a meter too short. Science built a reactor that provided power to millions, and helped build the untimately inadequate defences against the tsunami – but I don’t think traditional chinese medicine has much to offer against a 9.0 earthquake either. Humans are indeed apes, which is why science is necessary to create research that improves lives.

  40. Today I ranted on SaveYourself.ca that the acupuncture debate

    will have to go on without me: I no longer consider acupuncture worth discussing. I haven’t heard an original or valid argument in its defense in years, and I haven’t seen any compelling evidence ever, because it doesn’t exist.

    So is my mind closed? Damn straight. That’s the point. It didn’t used to be about this — but it is now, and for many good reasons.

    “Should we keep an open mind about astrology, perpetual motion, alchemy, alien abduction, and sightings of Elvis Presley? No, and we are happy to confess that our minds have closed down on homeopathy acupuncture in the same way.” — Mike Baum, The dangers of complementary therapy, Breast Cancer Res. 2007; 9(Suppl 2): S10

  41. windriven says:

    @CLK

    Best wishes on managing your MS and hopes for early progress in arresting and reversing its effects.

    Part of Dr. Hall’s point, I think, is that acupuncture hangs in there because there are some who perceive benefits, illusory as those benefits might be.

  42. Ed Whitney says:

    But we return to the problems that arise with the study of pain and its response to treatment. Special study designs, such as enriched enrollment with randomized withdrawal, have been developed for the study of many pain medications. This involves enrolling all participants in an open-label run-in period, seeing how many respond to the drug with a meaningful (at least 30%) pain reduction, and then randomizing the responders to either continue with active medication or to placebo. It sounds weird, but it is a very common design nowadays, and is partly motivated by the idea that for certain interventions, analysis of the average pain response will obscure the fact that there is a subset of all participants for whom the drug is effective. There may eventually be genetic markers for this responsiveness, but for now there are none, and raw empiricism has to determine which patients will obtain pain relief. Nerve stabilizers like gabapentin and pregabalin have lots of such studies; even opioids have some of these study designs.

    There are some conditions for which a subset of patients do respond and others have no response; the average response can obscure the clinically important response of a subset. For breast cancer, Herceptin works only on women whose tumors have excess expression of HER2. This is about 25% of breast cancers; this minority has an important response, and that response could easily be missed if all cancers were analyzed together.

    So it is possible that there is some subset of patients who do respond to acupuncture, for reasons that are not known, and may someday become clear. It may be that CLK is perceiving a genuine effect of acupuncture, not an illusory one. We have to be careful not to deliver a message which could have a nocebo effect! It may be really working in CLK’s case. Acupuncture is not analogous to astrology or Elvis.

    The study of pain is difficult! Important basic questions about methodology do not yet have a general consensus among researchers. Way too much certainty on this blog thread!

  43. Harriet Hall says:

    “it is possible that there is some subset of patients who do respond to acupuncture”

    Sure, it is possible. But is there any evidence-based reason to think that it is probable? If more than a tiny minority of subjects responded, it should show up in the statistical analysis. And if it is only a tiny minority, would we want to recommend it to everyone knowing that most would not benefit? And would we want to apply the same reasoning to drugs and continue offering them to everyone when they failed controlled trials? It is possible that some subset of patients respond to homeopathy. Are we wrong to reject it? It is possible that some patients responded to bloodletting; were we wrong to reject that?

  44. drmarcelli says:

    >>>Harriet Hall

    What would you think of a doctor who practiced bloodletting today because he had found enough observational reasons to continue to be confident in the theory of the 4 humors?<<<

    I think that doctor lives and works in a theoretical dimension very different from that of MDs working in modern hospitals, though some of them are promoting the integration of EBM with CAMs. That doctor practices bloodletting or phlebotomy "off label" (intended not for hemochromatosis and polycythemia) for patients consulting him. In case there were a real danger the right authority can legally stop this practice, as recently happened in the USA. Anyway acupuncture is not "tout court" identifiable with bloodletting or phlebotomy and researches in this field continue, seen that Elsevier and Wiley journals continue to publish them.

  45. Harriet Hall says:

    drmarcelli,

    So, do you think any doctor should use any treatment that he believes is not dangerous? Would you condone a colleague who used bloodletting to balance the humors? If journals continued to publish bloodletting studies would that alone convince you that it was effective, even if the results were as inconsistent and questionable as the acupuncture studies?

    If a doctor “lives and works in a theoretical dimension very different from that of MDs working in modern hospitals” don’t you think truth in advertising should require that he identify himself as a practitioner of magic rather than letting patients assume he is practicing the kind of medicine MDs practice?

  46. pmoran says:

    Of course, advocates of acupuncture have argued that it is worthwhile even if it only produces a placebo response; and that it is harmless, so it does not hurt to try it. Ernst et al. however, have shown that acupuncture is not harmless. While many of the reported adverse effects could be avoided by proper training in sterile precautions and anatomy, they correctly point out that even one avoidable adverse event is too many. With any treatment, we have to consider the risk/benefit ratio. If there is no benefit, any risk is too much. And there are other harms that they did not mention: time and money wasted, effective treatment delayed, unscientific thinking encouraged.

    This paragraph assumes that we can know what benefits a placebo response can deliver in any given case. We have to know that before we can make the cost/risk/benefit calculation.

    We don’t. We cannot. None of the studies referenced are designed to fully elicit placebo responses, yet even so, as Ed, points out, there are indications of very acceptable overall effect sizes from sham versions of acupuncture as compared to “not acupuncture” groups.

    I agree that we don’t need further studies that essentially only tell us whether certain features of otherwise unsupportable Chinese medical theories are necessary to any “activity” of what can be quite complex ongoing “treatment” programs.

    Yet further questions need to be answered for the sake of a fuller understanding of medicine in all its glory.

    We need reassurance that the Newtonian “working better than placebo” yardstick is all we need to practice medicine with full effectiveness and humaneness, especially while our treatments are lacking in so many respects. We need also. I believe, need a better understanding of the role that CAM may be playing within medicine as it exists in the year 2011 before we decide upon policy and attitudes towards it.

  47. drmarcelli says:

    >>>WilliamLawrenceUtridgeon 29 Mar 2011 at 2:59 pm

    >>>Ten years ago I was far, far more credulous than I am today. It is not a crime or a problem to make mistakes or operate under mistaken assumptions.

    I thank and applaud you.

    >>>Wars are not scientific failures, they are political.

    About this point I disagree. Some geniuses, “a posteriori” penitent, among them Einstein and also the Italian physicist Fermi “presented” the atomic research’s results to the US Army for a Science Based World War. Also today part of science and most wars are based upon fear and circumstance rather than evidence and fraternity. IMHO, of course.

  48. drmarcelli says:

    >>> Harriet Hall

    If a doctor “lives and works in a theoretical dimension very different from that of MDs working in modern hospitals” don’t you think truth in advertising should require that he identify himself as a practitioner of magic rather than letting patients assume he is practicing the kind of medicine MDs practice?<<<

    Dear Harriet,
    you are right, I agree that doctor should identify himself as a practitioner of magic, also simply to be correct and honest toward his patients!!!

    Medicine is practiced at different positions with different degrees in freedom of therapy. For example:
    - University scholar and researchers don't inject IV vitamin C in cancer. They could not do it also if they believe it works.
    - Hospital MDs could inject IV vitamin C in cancer but generally they don't. When one "magically" believes it works can give vitamin C a shot.
    - GP can inject IV vitamin C – and other non evidence based (but anyway legally sold) drugs in cancer. Only few of them do it, the so called orthomolecular MDs for exemple, so researches on Vitamin C in cancer continue.
    But in this case the problem is not with Vitamin C or glutathione or possibly acupuncture, the problem is with cancer's complexity.

    The same instinctive-irrational medical behavior happened in the past for diabetes type I, before insulin were discovered. People suffering from diabetes (MDs did not know the word "hyperglycemia") needed however to be helped because of the may problems diabetes comported. Obviously "magic" therapies were the rule. But patients who received the raw dandelion felt a little bit better because (today we know why) dandelion contains pharmacologically active compounds that lower blood sugar and combat infections (all group B vitamins and C).

    I apologize for being a strongheaded MD. Now I go to sleep :-)
    29 Mar 2011 at 01:07 am in Italy

  49. Ed Whitney says:

    This thread is starting to get tapped out, but before it does, I continue to be curious about the implications for clinical practice in the management of chronic pain. I agree that a large percentage of patients with a meaningful difference between real and sham acupuncture should show up in the statistics, but the interesting thing still seems to me to be the difference between acupuncture and no acupuncture that does show up when a “no acupuncture” arm is included in the trials.

    I have not heard Harriet acknowledge the problems inherent in pain studies; the lack of a general consensus on how to approach some critically important methodological issues (e.g., how to handle missing data, which endpoints to use and when to measure them, what to do when recruiting participants to a trial becomes problematic) mean to me that dogmatism about methods is unwarranted. True, RCTs give you the best possible insurance against biased comparisons between randomized groups, but they are still very difficult to interpret and translate into practice.

    I think that many contributors to this thread think that the results of the acupuncture trials mean that physicians should tell their patients, “No, don’t even consider acupuncture; just keep taking your NSAIDs and going to PT. Just keep doing what you have been doing, because there is no difference between that and acupuncture. If you feel it has helped you, you are probably just responding to an illusion known as the placebo effect.” I do not think that the data warrant that interpretation.

    EBM should not mean that the old patriarchy of “Doctor knows best” should be replaced with a new patriarchy of “Cochrane knows best.” (Come to think of it, most of us have seen some pretty flaky Cochrane Reviews.) The patient’s perception of reality should have strong standing in the decision-making process. Sometimes those perceptions seem to fit poorly with the data in the literature. That means that there needs to be flexibility and subtlety on the part of the practitioner.

    Hell, if the interpretation of clinical trial data were unambiguous, there would be “an app for that,” and we could just do it all on our iPads.

  50. daedalus2u says:

    Ed, I think what most contributors to this thread and those who understand SBM would not abandon is science and rational thought. RTCs are not difficult to interpret. The RTCs of acupuncture clearly show that real needles are not better than sham needles.

    Substitution of “Doctor knows best” with “Quack with pre-scientific magical thinking knows best” is not an improvement.

    If a patient with chronic pain is unsatisfied with treatments that have been tried so far, that patient should discuss treatment options with their doctor. Good and ethical doctors don’t prescribe placebos. Good and ethical doctors don’t lie to their patients. Good doctors don’t lie to themselves and pretend they know things for which there is no evidence.

  51. Harriet Hall says:

    @Ed Whitney,

    “I have not heard Harriet acknowledge the problems inherent in pain studies”

    I do acknowledge the problems inherent in pain studies, but I don’t think that is an excuse to ignore studies and go by beliefs rather than by evidence. I am certainly not a worshiper of Cochrane: on the contrary, I tried to explain that the existing body of acupuncture RCTs is unconvincing because of many factors including the problems inherent in pain studies. But RCTs, properly designed and properly interpreted, are still the best tool we have to avoid error.

    “The patient’s perception of reality should have strong standing in the decision-making process.” Have you considered the full implications of that idea? If a patient is out of contact with reality, should the doctor participate in or encourage his delusions?

    If you merely mean the patient’s perception of what seems to help, I can go along with that. I have no objection to people using acupuncture or anything else that they perceive as helping their symptoms. It would be cruel to confront them and say it doesn’t work. I only object to doctors who misrepresent the evidence and recommend placebos.

  52. Ed Whitney says:

    To be explained: Real acupuncture and sham acupuncture are the same, but sham acupuncture is better than none.

    One interpretation: the trials with two arms, real and sham acupuncture, have been comparing two active interventions; the differences have been too small to bother with. Trials with three arms, one of which is “usual care,” show differences in which usual care is less effective.

    Imagine that you were conducting a series of trials of SSRIs for depression, and in each of the trials, you compared two different SSRIs; perhaps you used Celexa as the drug you were investigating and you gave Prozac to the control group. After numerous trials, which were pooled with the best meta-analysis methods available, you conclude that Celexa does not work, since it is no better than sham Celexa. Unwittingly, you would be comparing two active interventions with small differences between them.

    The descriptions of sham acupuncture require special scrutiny. Often, the sham acupuncture is done by acupuncturists who simulate many aspects of the real acupuncture (see Cherkin et al Arch Intern Med. 2009;169(9):858-866 for an example). The problem of imperfect placebos has been recognized as one of those damn persistent difficulties in pain literature. The sham acupuncture may have enough characteristics of the real thing to constitute an active intervention in itself.

    No, the interpretation of these trials is not easy. The placebo which is not a placebo may be an active treatment. Sounds Taoist, doesn’t it: the placebo-not-placebo!

    I meant, Harriet, that the patient who says that an intervention helped is to be believed; the patient is the final judge of what alleviated pain. The doctor should trust but verify. For example, the patient should be requesting fewer refills on meds, and should be up and about and doing things rather than lying in front of the TV. Forget about it being “cruel” to tell them that the intervention had not worked; it would be inaccurate.

    RCTs are, as I said, the best way to avoid biased comparisons between groups; this is the one error against which they protecct us. They leave us open to all too many other errors of inference.

  53. pmoran says:

    EdI meant, Harriet, that the patient who says that an intervention helped is to be believed; the patient is the final judge of what alleviated pain.

    I can’t go along with this. We should nearly always accept the patient’s observation that the pain is better now. We are under no obligation to accept the patient’s understanding of why it is better.

    Although, as Harriet says, we don’t necessarily have to treat a patient’s statement as we might a serious scientific contention.

  54. Harriet Hall says:

    @ Ed Whitney,

    “the patient is the final judge of what alleviated pain”

    No, the patient is only the final judge that the pain has been alleviated. The patient is not the final judge of what alleviated the the pain because he can’t rule out post hoc ergo propter hoc errors.

    The Prozac/Celexa example is a false analogy, but if it were valid, then the sham/verum acupuncture trials would still show that acupuncture doesn’t work, since the sham procedures don’t involve the things that acupuncture theory rests on (meridians, acupoints, skin penetration, de qi sensations, etc.). The most parsimonious explanation is that a placebo response is being elicited by both verum and sham procedures. They both “work” in the sense that placebos “work.” If the sham procedures really “worked” beyond placebo, that would only prove that none of the rigamarole of acupuncture is necessary.

  55. peterdeadman says:

    We have posted a response to Ernst et al on The Journal of Chinese Medicine’s website (http://www.jcm.co.uk/drum-tower-archive/article/a-response-to-acupuncture-does-it-alleviate-pain-and-are-there-serious-risks-a-review-of-reviews-by-e-ernst-myeong-soo-lee-and-tae-young-choi-pain-r-volume-152-issue-4-april-2011-1606/).
    It is written by Mark Bovey, Research Co-Oridinator of the Acupuncture Research Resource Centre. He reports major problems with Ernst’s paper (“inadequate methodology that at times crosses the border into misrepresentation”) that clearly call its conclusions into question.

  56. Ed Whitney says:

    I was careless: the patient is the sole judge that the pain is better, not in attributing the relief to a specific cause. Big problem with vertebroplasty, where the effects are often as dramatic as effects get: the patient with a very painful fracture has the procedure, feels better almost immediately, and attributes the improvement to the procedure. This is a different topic, having to do with such things as patient selection, but it illustrates a major current dilemma for spine practice.

    I almost immediately thought better of the Celexa/Prozac analogy. Maybe testing an SSRI with a MAOI as the control would be closer to the case. The MAOI does not selectively inhibit norepinephrine reuptake, and therefore does not involve the mechanism upon which the SSRI theory rests. MAOI would still be an imperfect placebo which could mask the truth, unless there were a third treatment arm with no treatment at all, which would probably show a difference with the third group coming off the worst. The acupuncture studies with two arms and the studies with three treatment arms seem to follow this pattern.

    We need not speculate back and forth about the imperfect placebo problem. It seems that it is testable. Perhaps it has already been tested; I am not all that acquainted with the literature. But here we go: group A is randomized to acupuncture by a trained acupuncturist, who is told to place the needles according to usual practice standards. Group B is randomized to placebo acupuncture by the file clerk who is given an equal number of needles and told to poke the patient in several places with no further instruction. This would be a real placebo. You predict that group A and group B will have the same degree of pain relief. I predict that group A will do better than group B. If acupuncture is pure pseudoscience, the file clerk or maintenance man should do just as well as the acupuncturist.

    Trouble will be getting the IRB to sign off on the design. No sense of adventure with those guys.

  57. daedalus2u says:

    Ed, as I understand that trial has been done, but even more rigorously. They used trained acupuncturists for the sham leg so they would not put needles in the acupuncture points. There was no apparent difference in outcome.

    Real needles in the right places, real needles in the wrong places, fake needles; they all give the same results. If needles are not necessary and the right places are not necessary, what is “necessary” about acupuncture?

  58. Skeptosaurus says:

    On the same Journal of Chinese Medicine website I can conveniently purchase ear candles and gua sha products (skin-scraping, toxin- removing ‘therapy’) . Here are some interesting links on these two products:

    http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/ear-oreille-eng.php

    http://youtubeskeptic.wordpress.com/2008/05/15/gua-sha/

    http://www.cmjournal.org/content/5/1/5

    The first link states …”both Canada and the United States have issued directives that ban the importing of ear candles.” (Health Canada)

    Gua sha is, at best, a crude exfoliator and, at worst, a recipe for severe bruising.

    Peter Deadman – credibility on a science blog is hard to attain, even harder if you are peddling quackery.

  59. Mojo says:

    “They used trained acupuncturists for the sham leg…”

    I can’t avoid picturing a highly ingenious placebo intervention here. Real needles and real acupuncturists, but a sham leg.

  60. Jan Willem Nienhuys says:

    If you could prove that the place of the needles is irrelevant a lot would be gained. A test which would specifically test this (double blind) would go as follows.

    The licenced acupuncturist (LA) indicates for the complaint several places, only one of which is correct, and the others are not even on known acupuncture points. S/he marks and numbers ten places with a circle. There is no talking and the circles are drawn in a random order. The LA leaves.

    The test supervisor selects randomly a number from 1…10. An assistent who is properly instructed how to stick acupuncture needles in people, but with no knowledge about acupuncture points, enters the room, and puts the needle in the center of the randomly chosen circle and leaves only after the needle is taken out and all circles are erased.

    Of course many variants of this scheme are possible. Another possibility is that one hundred true and one hundred false points are preselected, the LA selects from the one hundred true points a few treatment points, and unbeknownst to the LA a similar selection is made from the false points. Then the assistant gets after randomisation either the instruction to put needles in the correct points or in the falsle point. In this manner the LA doesn have to see the patient at al to mark the puncture sites.

    When it has been established that the location of the points doesn’t matter, the training of acupuncturists can be simplified to a short course (four half days, would that be enough for someone with a knowledge of anatomy?) where only needs to be explained where you can’t stick the needles. All ‘Colleges for acupuncture’ and diplomas can be abolished. We don’t have colleges for bicycle riding either. Or do we (here in the Netherlands we don’t)?

  61. WilliamLawrenceUtridge says:

    Essentially what is off the table is all the “theory” accompanying acupuncture. What is still on the table is whether sticking people with needles has specific effects. The toothpick trial suggests that puncturing the skin is unnecessary. The dramatic ritual trial suggests any effect that might exist is enhanced by elaborate ritual. Therefore the best option seems to be nonpenetrating but pointy stimuli on safe locations with some sort of elaborate setup. Perhaps substitute the qi nonsense with some sort of pre-poking relaxation, or an accompanying gentle massage. That seems to be what the best evidence says – train people not to injure their patients (which would be much shorter and cheaper than the current program with it’s unnecessary vitalistic nonsense), make it a time-consuming and relaxing ritual (but one that doesn’t invoke magic and it’s accompanying corrosive effect on critical thinking and nonsense criticisms of real medicine) and make sure the equipment is safe to use (pointy enough to feel like something, blunt enough that it does not penetrate the skin).

    That’s what the scientific understanding of acupuncture appears to distill down to currently.

  62. Ed Whitney says:

    It seems that we need to resort to some philosophy to advance this discussion, since the placebo concept is so much at the heart of the matter. Clearly, “placebo” is a noun, but it does not necessarily follow that placebos are things. Alfred North Whitehead discussed “the fallacy of misplaced concreteness” in Science and the Modern World. (It has been about 40 years since I read this book, so bear with me, but Whitehead intended it as a precaution against mistaking the abstract for the concrete.)

    The discussion of placebo acupuncture has been proceeding as if it were analogous to a placebo in pharmacologic research. In those studies, placebos are things; they have mass and extension in space and they displace air when sitting in a room. Furthermore, you can have confidence that they are truly inert: a gelatin capsule has no remotely plausible mechanism of action in the body. They are perfect placebos. No problem with misplaced concreteness with them.

    With “placebo” acupuncture, the analysis needs to be done on a different logical level. One must make do with imperfect placebos; the placebo in this case is not a thing but a complex interaction between the practitioner, the instruments, and the patient. You cannot count on anything in the equation being absolutely inert. Calling it a placebo does not make it analogous to a gelatin capsule.

    The problem is this: these RCTs may be comparing two active interventions with competing (or similar) mechanisms of action. Acupuncture may yet have a mechanism of action, with placebo acupuncture having a distinct but physiologically real mechanism of action. The gate control theory comes to mind; this is a pretty elastic theory and comes up constantly in discussions like this. Whatever the phenomenon is, if you can’t explain it with the “gate control theory,” shoot, you just aren’t trying.

    If sham acupuncture has a biological mechanism of action, using it for a “control” is not problematic in any way; using it as a “placebo” is full of problems. Just as an MAOI used as a control for an SSRI could obscure the effect of the latter through having a competing mechanism of action, sham acupuncture could obscure the effect of real acupuncture through a competing mechanism of action.

    Richard Owen wrote a commentary in JAMA back in 1982 (vol. 247(18): 2533-4) on “Reader Bias.” He talks about things like “personal habit bias,” overrating or underrating a study that supports the reader’s habits. If we read that chocolate and red wine may be good for us, are we going to get all huffy and say, “Well, correlation is not causation” ? Hell no! We will say, “Very interesting study!”

    There is “do something bias,” which favors a study which demonstrates effectiveness (common among clinicians, according to Owen), and its converse, “do nothing bias,” common among academics. I am personally inclined to favor the final one, “I am an epidemiologist bias,” which means repudiating any study containing any flaw in its design, analysis, or interpretation. Not having any dogs in this particular fight, I do not feel any temptation to “bankbook bias” or “territory bias.”

    We bring our biases to the interpretation of studies. If you have long believed that acupuncture is bogus, the Ernst study nails it, so to speak. If you believe that there is something fascinating about acupuncture which has yet to be discovered, the study raises more questions than answers. If you are a true believer in acupuncture, you may see the study as missing the point, so to speak.

  63. Scott says:

    So, Ed essentially admits that there’s not specific effect of acupuncture and it’s all a sham to produce a placebo effect. Yet somehow avoids the conclusion that it’s therefore unjustifiable to practice…

  64. Scott,

    Whether it’s “justifiable” to practice is irrelevant: people do practice it.

    There are other relevant questions though.

    Whether it’s justifiable to offer acupuncture as a medical treatment in a medical context or by a medical doctor.

    Whether it’s justifable to make acupuncture illegal.

    Whether it’s justifiable to regulate acupuncture in some way, and if so, how.

  65. daedalus2u says:

    Ed, what is your definition of “placebo”? The definition that I like is “a treatment that has positive health effects where those health effects are not mediated through pharmacology, surgery or other physical means”.

    By my definition, psychotherapy is a placebo because it is a treatment that has positive effects where the effects are not mediated through pharmacology or physical means. The positive effects are mediated through communication with the psychotherapist.

    Psychotherapy is an ethical placebo because the therapist is not lying to themselves or to the patient and patients do get better and psychotherapy is recognized as being effective under a standard of care.

    Acupuncture is an unethical placebo because acupuncturists are lying to themselves and to the patients and it entails risks of infection not compensated for by actual therapeutic effects and acupuncture is not recognized as being effective under a standard of care.

  66. Alison Cummins “Whether it’s justifiable to regulate acupuncture in some way, and if so, how.”

    I’d vote for regulations requiring licenses and certification that requires safety and infection control education. This should include Government inspections that are paid for by acupuncture license fees. Insurance to cover customer injuries should also be required.

    I believe this would be similar to tattoo, piercing salons, hair salons, cosmetology, etc.

    I guess I was thinking that was the current situation in the U.S. But, I’ve never checked into it.

    Doesn’t make sense to make it illegal. Consenting adults and all that.

  67. Scott says:

    Proper regulation of acupuncture must also include barring false claims. In particular, claiming that it has any specific effect, or that qi/meridians exist, or that the needles are relevant.

  68. WilliamLawrenceUtridge says:

    Placebo is relative to the hypothesis.

    * Hypothesis = acupuncture points/meridians exist; placebo = points on the body that are not “true” acupuncture points for a condition
    * Hypothesis = skin penetration is necessary; placebo = nonpenetrating needles; toothpicks
    * Hypothesis = needling is inert; placebo = an inert or comparable treatment that has an equivalent dramatic intensity, attention from the practitioner, ritual and “exoticness” (all of which are known to enhance the placebo effect)

    Each requires a different test, a different placebo, a different analysis. When people say “acupuncture doesn’t work”, they could be saying acupuncture points don’t exist, needling doesn’t manipulate qi, acupuncture doesn’t reduce acute pain, acupuncture doesn’t reduce chronic pain or acupuncture’s effectiveness is based solely on nonspecific effects. Part of the problem is the lack of distinction between acupuncture’s theory (qi, points and meridians), it’s practice (the very act of needling) and the nonspecific effects of practitioners (their bedside manner, the time and attention paid to patients, their nonverbal behaviour).

    I believe the British Medical Acupuncture Association has adopted acupuncture (in the sense of using solid needles for the treatment of symptoms) and dropped the “theory” (http://www.medical-acupuncture.co.uk/Portals/0/Public%20Docs/BMASCodeofPracticev9Dec2009.pdf). Their emphasis is on scientific knowledge rather than tradition, and their training courses are only four days long.

    Rather entertainingly, they appear to be headquartered at one of the British homeopathic hospitals.

  69. Ed Whitney says:

    For daedalus2u:

    Ed, what is your definition of “placebo”? The definition that I like is “a treatment that has positive health effects where those health effects are not mediated through pharmacology, surgery or other physical means.”

    The physical means, while interesting, are of secondary importance in my understanding of what EBM tries to do. I am mostly interested in interpreting comparisons between groups with different exposures or different levels of the same exposure. Many purported biological mechanisms, even if confirmed, are less important than clinically meaningful endpoints.

    The most plausible alternative to the “acupuncture sucks” interpretation of most sham-controlled RCTs is the one I have tried to put forward: the studies are comparing active interventions with different mechanisms of action. Now, I may read about acupuncture enhancing generation of nitric oxide in a randomized double-blind crossover study (Tsuchiya et al, Anesth Analg 2007;104:301-7) and read that NO generation increased in the true but not the sham acupuncture intervention. What do I do with this? Do I interpret it as saying, “See! Acupuncture works after all! Told you so!” Not perzackly.

    Rather, I look at their data and say, “Hmmm. Interesting. This may be a mechanism of beneficial effect, or it may be an artifact, or it may be a physiological response which has no clinical meaning.” Having a measureable physiological mechanism gives us one of those old Bradford Hill considerations for causality, namely biological plausibility. I am more concerned with strength of association (effect size) and with the factors that can obscure the association. Having a comparison intervention with an established mechanism of action (gate control theory), making it highly likely that it is an active intervention, is one of those factors that can cloud an association I am interested in.

    For Scott: “Ed essentially admits that there’s not specific effect of acupuncture and it’s all a sham to produce a placebo effect. Yet somehow avoids the conclusion that it’s therefore unjustifiable to practice.”

    What I essentially admit is that the specific effect of acupuncture is unproven. Plausible mechanisms exist, but I am not convinced of their relevance to any therapeutic effect of acupuncture. Does acupuncture increase NO synthase activity? Jolly good! Does that constitute proof of its clinical mechanism of action? See above for discussion.

  70. Scott says:

    When “the specific effect of acupuncture is unproven,” and as much effort has been put into looking for it as there has been, the correct conclusion (albeit provisional as in all of science) is that there is no meaningful specific effect.

    “But… but… there MIGHT be!!!” is unavailing. And talking about “plausible mechanisms” for an effect where the evidence against said effect existing is so strong is the worst sort of Tooth Fairy science.

    These are the statements of someone ideologically invested in the proposition that it works, and unwilling to consider facts and evidence that demonstrate that it does not.

  71. seorsa says:

    I have just joined the Skeptics, and have been intrigued by your writing. I was drawn to your refutation of “Why we get fat” but found it to be flawed, and actually agree with a couple of commentators that you may not have read the book.

    On accupuncture I think you are being fair in reviewing the study of the studies (what we used to call “meta-analytical”). I am a regular user of acupunture, and have a positive view of its efficacy. I really like your crack about needle proof vests. I think there are huge hurdles to overcome before acupuncture can be studied, and only a few of them are the limits of the western scientific method as it has developed. The incredible variety among practitioners, training and treatment methods etc. contributes more that the lack of understanding of the priciples of acupuncture that I have found in the very few studies I have read.

    There is one glaring error in yout work that I feel I must comment on. I also hope that you will indulge me in reading further and letting me share an anectdote about acupuncture with you as well. So, to the error:
    “In summary, Ernst et al. have shown that the evidence for efficacy of acupuncture for the treatment of pain is questionable, to say the least, and of particular concern is that its use can be dangerous. If the 57 systematic reviews they surveyed had been for a prescription drug and a similar list of serious adverse effects had been reported for that drug, we would hesitate to prescribe that drug. Is there any reason not to hold acupuncture to the same standards?”

    I think this is a bit niave. I remember reading an article last year about the FDA approving a new and dangerous drug. The FDA said that although the drug fared slightly worse than the placebo effect, it would be wrong to deny the drug to the small portion it would help. When you mentioned in the paragraph above that one that placebo’s were un-ethical it reminded me of a study that showed the placebo effect still occured even when patients were told they were getting a placebo! So yes, there is a lot that science can’t (yet) exlplain about medicine. Or about space for that matter.

    If you have bourne with me this long I hope you will tolerate an anecdote. I fitst went to acupuncture for foot pain, and my acupuncture wanted to know why I wasn’t as concerned about my blood pressure and my asthma ( a life threatening condition, especially in the wilderness!). In discussing this with my sister she mentioned that she too had her running curtailed by pain. When my acupuncturist examined her he told her that her knee pain was being caused by a severley inflamed galbladder, and that she should see her physician right away, there was nothing he could do.

    My sister called the doctor that Friday, and her doctor laughed. He told her that he would love to see her just to prove the acupuncturist wrong. He scheduled her for an ultrasound two weeks out. That Sunday she spent the night in the ER due to a severly inflamed galbladder. It was so bad that the only treatment option they offered her was surgery, done about 48 hours later. That is moving pretty quickly for our HMO!

    I appreciate your writing, and would love to write as well as you do.

  72. Scott “Proper regulation of acupuncture must also include barring false claims. In particular, claiming that it has any specific effect, or that qi/meridians exist, or that the needles are relevant.”

    Clearly, I’m not a lawyer, but I would guess that you could handle it somewhat like the FDA does with a statement similar to “this is not proven to have any benefit” required.

    I don’t see how you could make claiming that qi exists off limits, when it’s easy enough to offer the defense “I was speaking metaphorically, about a mental process or visualization process, etc”

    but what do I know.

  73. daedalus2u says:

    Ed, you brought up nitric oxide, not me. ;)

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    The physiology of the placebo effect is mediated through neurogenic production of nitric oxide.

    It is the neurogenic triggering of the end of the “fight or flight” state. It tells physiology to re-allocate resources to healing and tissue repair and away from keeping them ready for “fight or flight”.

    If you don’t have a clear understanding of what a placebo is, just say so. If you do have a clear understanding then you should be able to define it, and your definition needs to be consistent.

    If something is equivalent to a placebo, then it is a placebo. Real therapies can have placebo-type effects. Part of the therapeutic response to a treatment is due to the placebo effect. That is why “real” therapies are tested against placebos or against known effective treatments. If a treatment only has therapeutic effects through the placebo effect, then it will have therapeutic effects no better than a good placebo.

    What I want to do is invoke the “placebo effect” pharmacologically by raising the NO/NOx status of people. Invoking the placebo effect via pharmacology will work better than any ritual.

  74. Scott says:

    Michele,

    I should have been more precise, and instead of “claiming that qi/meridians exist”, referred to the more exact “claiming that inserting needles into specific points along meridians improves the flow of qi, thereby producing beneficial effects.”

  75. Ed Whitney says:

    For daedalus2u:

    I am not much good at interpreting studies with surrogate endpoints like NO synthase activation, and usually ignore them, following the GRADE Initiative’s approach to evidence, in which the “indirectness” of an outcome results in its being downgraded in support of an intervention. Therefore I cannot interpret why that Tsuchiya study found NO increased in the acupuncture plasma but not the sham acupuncture plasma. When is a placebo not a placebo?

    Personally, I never had acupuncture (don’t much believe in it). When I fell recently and had excruciating low back pain, I did not bother with placebo pills or needles. I used placebo Feldenkrais exercises, with lasting beneficial effect. This was due to a bias that Owen in his JAMA paper did not mention, namely “cheapskate bias.” Also, I never take large, oblong, chalky placebos; they do absolutely nothing. I take only small, round, colored placebos (red works best).

    One of the puzzling things about the Ernst article was his puzzlement over acupuncture working for some conditions but not for others. This is only a problem under an assumed “panacea” model of acupuncture. I am unaware of any intervention of proved effectiveness that is good for what ails you. The point of studying an intervention is to figure out what, specifically, it is good for.

    It so happens that the conditions I am most interested in, namely low back pain, neck pain, and osteoarthritis, showed overall superiority of acupuncture over placebo acupuncture; other conditions, including rheumatoid arthritis, cancer pain, fibromyalgia, and shoulder pain, were not shown to respond to acupuncture over placebo. The stuff I need to worry about was on balance either inconclusive or positive for the comparison between the real and the sham interventions. Table 1, ignoring the poor quality systematic reviews, had conclusions like “effectively relives ( I am sure hoping this is a typo for ‘relieves’) back pain,” “limited evidence to support,” and “sham-controlled trials show statistically significant benefit.” The latter was in one of the ‘excellent” systematic reviews of 16 trials for peripheral joint osteoarthritis, one of the conditions I have to focus on.

    For Scott:

    The time has come: I gotta ask you whether you have actually read the Ernst article. I have been wrestling with it for a couple of days (it was just published), and I do not interpret it the way most of this thread seems to be interpreting it. For the conditions mentioned above, there seems to be no reason to deprecate acupuncture.

    Ernst does say that most of the serious adverse effects came from Asia, where (1) acupuncture is widely practiced, and (2) Asian therapists may be poorly trained in Western stuff like sterile technique. I still look very seriously at adverse events, and, as previously stipulated, think that it should never be practiced by dummkopfen.

  76. pmoran says:

    .”The toothpick trial suggests that puncturing the skin is unnecessary.

    Toothpicks might not work as well in practice, and not only through the introduction of a banal element into acupuncture proceedings.

    If the endorphin release is a major part of the action of acupuncture, it is quite likely that the thought that needles are going to be inserted into the skin will be an adequate trigger. If so, the toothpick studies may actually be comparing like with like.

    The soothing effects of the endorphins and possibly other neurotransmitters may trigger a cascade of other responses leading to a reevaluation of pain levels or reducing pain perception though other mechanisms.

    Now, I don’t know how valid this will prove, but neither does anyone else. We have to factor the possibility in to some degree or other.

    Ernst seems to embrace “”classical medical skepticism” (of which I was a founding member), for whom a toothpick study is seen as somehow completely discrediting the whole field of acupuncture including any claimed benefits. It is thought that the most rigorous levels of scientific inquiry are being applied, but biases are leaking through, nevertheless.

  77. daedalus2u says:

    The toothpick result only confirms that acupuncture has equivalent therapeutic effects to toothpicks.

    To continue to accept acupuncture, you have to change your physiology paradigm such that whatever the unknown physiological mechanism of acupuncture is, toothpicks activate it and needles in random places activate it and that activation occurs in ways that are indistinguishable from the activation by acupuncture.

    This result does not provide evidence for qi flowing in channels underneath the skin because the stimulation works where the channels are not supposed to be, and works without breaking the skin. The toothpicks and random places demonstrates that affecting the flow of qi in channels cannot be the mechanism by which acupuncture works because toothpicks can’t affect qi (unless qi is even more magical than has been supposed).

    That toothpicks and random spots are just now found to be equivalent to standard acupuncture, implies that all prior acupuncture “experts” didn’t know that they were equivalent, and all the “theory” that they developed to justify and predict differences is simply wrong. Acupuncture isn’t based on any “wisdom of the ancients”, it is based on the “foolishness of the ancients” and the “Emperor’s new clothes effect” on every “expert” who passed down that “wisdom” without testing it.

    The alternative is to acknowledge that since acupuncture works the same as a placebo, acupuncture is a placebo. If you have nothing better to offer someone, say you are stranded on Gilligan’s Island and need to treat someone for a broken leg, maybe a placebo would be ok. I would opt for kind words and gentle hand-holding myself.

  78. Ed Whitney says:

    But the studies with three arms (not only two), with usual care as the comparison–the sham acupuncture should not be better than usual care. Let’s say that usual care means NSAIDS, physical therapy, maybe a nerve stabilizer or a tricyclic, not an uncommon mix of things for many kinds of chronic pain. Shouldn’t all those things have a placebo effect, too? A study with three treatment groups, all of them with placebo effects, ought to be equal in outcome, assuming that a placebo is a placebo is a placebo. Why should the placebo effect of acupuncture or sham acupuncture out-perform the placebo effect of usual care? If acupuncture is a placebo, why isn’t usual care just as good a placebo?

    For the conditions of back pain, neck pain, and osteoarthritis, the available data in Ernst 2011 support acupuncture having more than a placebo effect. Hopton 2010 (cited here yesterday), having reached similar but not identical conclusions as Ernst, has a most pertinent question: “is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?” Then questions such as, “Do acupuncture patients start to reduce their opioid consumption?” are worth exploring, and are quite practical–the kinds of question Hopton probably has in mind.

    Harriet mentioned that RCTs are our best protection against error; I repeat that they are our best protection against one kind of error: biased comparison of group outcomes. They do not protect us from the error of asking the wrong questions, or from neglecting to ask the right questions.

  79. nybgrus says:

    If the endorphin release is a major part of the action of acupuncture, it is quite likely that the thought that needles are going to be inserted into the skin will be an adequate trigger. If so, the toothpick studies may actually be comparing like with like.

    “Comparing like with like” insofar as that the endorphin cascade you speak of would be the same between the two modalities. However, you seem to be asserting that “sticking a needle in someone” is the same as “not sticking a needle in someone” – and that is patently false.

    Now, I don’t know how valid this will prove, but neither does anyone else. We have to factor the possibility in to some degree or other.

    The fact that you don’t know “how valid this will prove” is exactly the problem. I know how valid it will prove – invalid! This does in fact show us that acupuncture does not work.

    To try and assert we are comparing “like with like” here is just asinine. Just as you may tense up and have a catecholamine rush at someone throwing a very convincing punch at your face, but stopping just short as well as if they actually connected and decked you, I think you might agree that there is a distinct difference between getting punched in the face or not. But by your logic my “punch you in the face” versus “almost punch you in the face” treatment would be comparing “like with like” since the cascade of catecholamines would be the same and indeed it would be the anticipation and expectation causing said cascade. But if you would like to assert that this is still a “comparing like with like” scenario perhaps you’d like to sign up for a randomized trial of the two “equivalent” face-punching modalities.

    It is thought that the most rigorous levels of scientific inquiry are being applied, but biases are leaking through, nevertheless.

    Yes, but it is your biases, not Ernst nor ours that are leaking through.

  80. nybgrus says:

    Why should the placebo effect of acupuncture or sham acupuncture out-perform the placebo effect of usual care? If acupuncture is a placebo, why isn’t usual care just as good a placebo?

    A good question… answered by:

    They do not protect us from the error of asking the wrong questions, or from neglecting to ask the right questions.

    Based upon the mountain of equivocal data the question should be “Why is there a lack of additional placebo effect in the “usual care” treatment arm.”

    The fact of the matter is there are myriad answers: different placebos affect people differently, perhaps the people seeking acupuncture also used some usual care, perhaps the “usual care” isn’t actually very good, and of course, since we are asserting that the placebo effect of acupuncture is mediated through the ritualistic interaction, one could expect that to have a higher placebo effect than the “usual” prescription of some pills. Also, you must remember expectation people with chronic pain have been using “usual care” with limited success… then they hear about “something new” and give it a go. The expectation is that it may work, especially with such equivocal results being given credulity. If you notice, most of the studies show the effects wane after time. If you look at studies that look at objective measures of function there is no change, despite reported decreases in pain. And there is that well known fact that patients will often tell their practitioner what they think the practitioner wants to hear.

    But the best part? None of that matters! The point is when you have a treatment, whose very premise is that needles inserted into meridians modify chi flow and thus generates an effect, and you have no evidence (or even plausibility!!) that meridians or chi exist in the first place (and indeed historical evidence to offer an explanation for their location and existence without invoking the magical thinking of TCM) and a mountain of data that shows equivocal results, AND studies showing that the very core premise of needle insertion AND specific meridian points is nonsensical (the sham acupuncture) you are done! Wham, bam, thank you ma’am – it is clear that there is no (remotely significant) effect beyond placebo to acupuncture.

    Think about it – I give you aspirin to swallow and tell you that it will relieve your pain and thin your blood by inhibiting COX which will then inhibit synthesis of pain mediating prostaglandins and thromboxane, which is necessary for platelet adhesion. So you take it and have more effect than, say, bloodletting which has been the “usual care.” Then, along comes a molecular biologist and finds out that COX doesn’t exist, that prostaglandins don’t mediate pain, and that thromboxane isn’t necessary for platelet aggregation. Then, we do studies and show that whether you ingest the aspirin or if I just wave a fistful of pills over you, the effect is the same – but both have more effect than “usual care.” And further study shows us that all the results with aspirin have been equivocal with only a couple showing some odd mildly positive results. And on top of that, someone like Ben Kavoussi shows us the history of it all and demonstrates that the original purveyors of aspirin actually called it an offering to the COX god and that the “prostaglandins” and “thromboxane” were just permutations of old understanding of simple anatomy superimposed on it (meridian lines and veins).

    But wait! There is more effect than “usual care!” We should clearly keep trying to find out how aspirin works!

    Can anyone say “Tooth Fairy Science?”

  81. pmoran says:

    — assuming that a placebo is a placebo is a placebo

    Not tenable. Plenty of evidence to the contrary — that the strangth of placebo responses are influenced by both characteristics of the placebo treatments and other aspects of the therapeutic interaction.

  82. nybgrus says:

    is that an argument? I even clearly stated that not all placebos are created equal. Ben Goldacre has a lot to say on that as well. What is your point pmoran? You seem to be lacking one (no pun intended).

    Are you trying to advocate for the intentional use of placebo since one placebo may be better than another placebo? Ever heard of “medical ethics?”

  83. pmoran says:

    Pay attention, Nybgrus! That was a response to the quotation from Ed, as you should have recognised, having responded to it yourself in a similar way, in an overlapping post.

  84. nybgrus says:

    apologies then, pmoran.

  85. Isn’t “acupuncture” a distraction here?

    If the point is to induce an objectively greater placebo response, then shouldn’t any further medical research be invested in how to induce that heightened response safely and ethically? (Massage, for instance?)

    I haven’t read any of the papers, so please correct me where I’m wrong. If the heightened placebo response induced by [sham] acupuncture is restricted to temporarily reducing reported pain and does not actually improve functional outcomes, then a parsimonious explanation is that hope that the pain will end makes pain more bearable. When it turns out that a treatment isn’t working, hope is dashed and pain tolerance drops again.

    For a doctor to string patients along by offering them false hope would be unethical.

    For chronic pain patients to flit from one practitioner to another in hopes that maybe this will help… No? Then maybe that… That’s understandable, and perhaps a doctor should stand back and not interfere. But to lie to a patient that “this will help” because hope feels good (until it is proven unfounded) is not ethical and I would be very distressed to think that medical professional organizations endorsed this practice.

  86. Scott says:

    The time has come: I gotta ask you whether you have actually read the Ernst article. I have been wrestling with it for a couple of days (it was just published), and I do not interpret it the way most of this thread seems to be interpreting it. For the conditions mentioned above, there seems to be no reason to deprecate acupuncture.

    Don’t have access, but any single article is irrelevant. The overall evidence base was overwhelming years ago.

    Remember, any completely ineffective treatment, if tried enough times, will produce some positive results. Check out Ionnidis’ work; it applies perfectly to the acupuncture literature.

  87. GLaDOS says:

    Eh it’s the S&M play that makes a lot of people feel better for a time thanks to some medical interaction. The more intense the adversive, the more trust and surrender for the bottom. At some point the bottom dissociates, which is like getting a hit of morphine. The pain is still there but it seems distant and less intense.

    I can’t quote anything from PubMed, but I’ve talked to people involved with alternative lifestyles.

    I’ve also watched little kids play doctor and hypnotize-U (“you are now under my power”), and WWII movies. White coats and black uniforms can become discriminative stimuli or fetishes that trigger the dissociative state.

    Most humans are fascists in their deepest darkest hearts. We, the old farts, really hate fascism because of what our grandparents lived through. But the next generation is clueless. They’ve no idea of the addictive power of social rank or grades. They’ve no idea what happens when mysticism –a shared representation of an idealized human mind– is combined with political power.

    The traumatized dissociate and therefore long for guidance. The worst thing you can do, IMHO, is to take on the role of shaman for these people. That’s what they want. But it’s not good for them. It simply reinforces their habit of tripping out all the time.

  88. Ed Whitney says:

    My reason for asking if people had read the Ernst article was that it is being taken as saying that acupuncture is bogus when it does not say that acupuncture is bogus.

    Ernst reported that acupuncture was superior to placebo for low back pain and osteoarthritis, but not for other conditions, including sciatica, cancer pain, and shoulder pain.

    These “contradictions and doubts” are puzzling to Ernst because “there is no plausible reason why acupuncture should reduce pain in some conditions while failing to work in many others.”

    They are puzzling to me as well, but perhaps not as deeply. It is a bit puzzling that NSAIDS should work well for most kinds of pain but not very well for neuropathic pain. It is not very realistic to expect any intervention to work for everything. Sometimes you can construct a plausible reason for different effects in different pain situations: why epidural steroids could be effective for sciatica but not so much for back pain, as an example. Sometimes you can’t. Often the explanations are constructed after the fact, which does not make them bogus; it only means that they have an element of speculation and may not be completely correct. Nature does the darndest things.

    About the ethics of placebos: some national practice guidelines formalize distinctions that are made intuitively by clinicians in daily practice: there are recommendations, suggestions, and options. You would recommend smoking cessation to everyone, suggest water aerobics for others, and be willing to discuss acupuncture as an option with others. The circumstances of the patient would have a small impact on recommendations, a moderate impact on suggestions, and a large impact on options. The level of certainty about the effectiveness of the intervention also plays a role; the more certain the effect, the more it moves from option to suggestion to recommendation. It may be ethically questionable to recommend something with a large placebo effect, defensible to suggest it, and justifiable to discuss it as an option.

    There are potent modifiers of the placebo effect, assuming that this is related to an alignment of the patient’s expectations and conflict-free goals. Many RCTs do not enroll patients if they have pending litigation for personal injury or disability compensation. Why? Well, part of the reason is that placebos do not work for them; getting all well can create a conflict of interest when there is a lawyer standing by working on a contingency basis for a large settlement. It would be foolish to discuss acupuncture as an option in such circumstances. If, on the other hand, the patient’s daughter is getting married in a month and he wants to walk her down the aisle, and has been suffering from back pain that has been responding poorly to usual care, and if he heard that his wife’s hairdresser’s astrologer tried acupuncture with success, and wonders if it may work for him, that is a different situation and a different response could be appropriate.

    1. Harriet Hall says:

      @Ed Whitney,

      ” It is a bit puzzling that NSAIDS should work well for most kinds of pain but not very well for neuropathic pain.”

      It is far more puzzling that acupuncture would work for musculoskeletal pain in one part of the body but not in another. If the studies on NSAIDS were as inconsistent as the acupuncture studies and showed that they relieved musculoskeletal neck pain but not musculoskeletal shoulder pain, wouldn’t you start to wonder whether they really worked at all?

  89. Scott says:

    Keep in mind the problem of multiple comparisons! When you try something for enough indications, it will seem to work for some of them. Going from there to try and figure out why it works, instead of considering that those are statistical anomalies, is wrong-headed.

  90. Harriet Hall says:

    seorsa,

    ” I was drawn to your refutation of “Why we get fat” but found it to be flawed, and actually agree with a couple of commentators that you may not have read the book.”

    For crying out loud! That’s an outright insult. I read the book! I couldn’t have commented on its details the way I did if I hadn’t read it. And if you found my analysis flawed, you should have commented on that thread and explained what you thought the flaws were.

    “The FDA said that although the drug fared slightly worse than the placebo effect, it would be wrong to deny the drug to the small portion it would help.”

    I don’t know what drug you’re talking about, but the FDA could not have said that unless it had solid evidence that the drug was effective for a subset of patients. Evidence much more credible than the acupuncture evidence. Do you have any evidence that some subset of people can be identified who benefit from acupuncture?

    Yes, sometimes people get a placebo response even after being told they are getting a placebo, but that doesn’t change the fact that placebos are unethical. Your comment about “science doesn’t know everything” is a truism that doesn’t contribute anything to the discussion.

  91. Ed Whitney says:

    @ Harriet:

    Continuing the battle of the analogies, I would indeed expect that NSAIDS should work on any musculoskeletal pain sharing similar pathophysiology. NSAIDS, being systemically absorbed, ought to go to every part of the body.

    Acupuncture may have a general relaxing effect in the hands of a good practitioner, but the action (by whatever mechanism) may be more local than systemic. I, like most contributors to this thread, do not buy into models of “meridians” and “qi” that classical acupuncture uses as its explanatory principles. However, investigations into relationships between “meridians” and connective tissue planes, neurovascular bundles, and the like, are beyond my ability to assess critically, but at least they are based on general principles in which I have some familiarity, even if the details are long forgotten.

    If the mechanism of action is more local than systemic, then it would be surprising, but not quite shocking, to find that different musculoskeletal conditions responded differently to acupuncture interventions. It would, in any case, be less shocking than if NSAIDS acted only in some parts of the body and not in others for similar kinds of pain.

    I actually doubt that you and I are all that far apart on acupuncture; I did think that your editorial was more negative on acupuncture than the Ernst meta-meta- analysis concluded. Acupuncture seems to have a limited, secondary role (not a first-line choice) for some common musculoskeletal pain conditions. There are contrasting points of view between people who emphasize efficacy (with specificity of mechanisms and strict control of experimental conditions) and effectiveness (with emphasis on what works for patients in the unstructured settings of community practice). I say contrasting, not contradictory; the differences are more of emphasis than substance. Most contributors to this thread are oriented to efficacy, as a perusal of the thread will confirm.

    Adverse effects, naturally, are of concern, but the risks of acupuncture are not all that great in a country where aseptic technique is nearly universal and training requirements meet some good standards. (There is a case report in press in Spine in which a cervical hematoma from dry needling resulted in quadriparesis; that was reported in Korea but could happen here.) Your editorial emphasized the numerator of 95 adverse events; I wanted the denominator as well as the potential confounding factors (setting and training of practitioners).

    Bottom line: I do not think that acupuncture has been shown to be just a placebo, and I am certain that it has been shown not to be a panacea. It can be good, but not good for what ails you.

  92. Harriet Hall says:

    Ed Whitney said “I do not think that acupuncture has been shown to be just a placebo.”

    I don’t either. I just think it has not been shown to be more than a placebo. And the longer we go without such evidence, the less likely that it will be found. As Scott commented above: “But… but… there MIGHT be!!!” is unavailing.”

  93. @Ed Whitney,

    “I actually doubt that you and I are all that far apart on acupuncture;”

    It is said that the devil is in the details.

    Methanol and ethanol are not all that far apart in chemical structure, but they have radically different outcomes if you drink them.

  94. nybgrus says:

    Bottom line: I do not think that acupuncture has been shown to be just a placebo, and I am certain that it has been shown not to be a panacea. It can be good, but not good for what ails you.

    Dr. Hall beat me to it.

    If the mechanism of action is more local than systemic, then it would be surprising, but not quite shocking, to find that different musculoskeletal conditions responded differently to acupuncture interventions. It would, in any case, be less shocking than if NSAIDS acted only in some parts of the body and not in others for similar kinds of pain.

    Swing and a miss. The point of Dr. Hall’s analogy was that pain arising from your calf muscle, neck muscle, bicep, etc should all respond to the same analgesia since there is no difference between the mechanisms for pain perception based on location. Neuropathic pain is different because it does not involve the same mechanism for generation and perception of pain as muscular pain. This is why when an NSAID works for MSK pain but not neuropathic pain, we aren’t surprised. You miss the point entirely when you compare the “systemic” effect of NSAIDs vs the “local” effect of acupuncture. If you injected an NSAID locally into a muscle it would work in any MSK pain to which it was localized. The fact that acupuncture works for MSK pain only in certain locations of the bodies is extremely surprising surprising enough that it makes it very, very likely that those positive results are false.

    Your editorial emphasized the numerator of 95 adverse events; I wanted the denominator as well as the potential confounding factors (setting and training of practitioners).

    You also miss the basic point of medical ethics vis-a-vis risk/benefit analysis. If you have a treatment with a definable, measurable, and mechanistically explained benefit then you would look at the number of adverse events divided by the number treated (and the number helped). If that ratio becomes too high, then even though the treatment is actually beneficial it is no longer given. However, when you have a treatment that shows nothing better than palcebo, has essentially no definable or mechanistically explainable benefit then the denominator becomes pointless. Any adverse event, even just one, tips the scale. You may think “95 events if the denominator is 100,000 people being treated with acupuncture means .095% of people have an adverse event. That’s vastly better than aspirin! This is a great treatment” But the real calculation is “that is 95 events with a placebo – that is unacceptable.” Try and think about this – if I had two pills, one sugar and one drug X. And I did a study where drug X had the exact same effect as the sugar pill (real vs. sham acupuncture) but drug X had a .095% adverse effect rate (including a death and maybe some quadriplegia) but the sugar pill had exactly 0 adverse events, would you still give drug X? If you are a patient and knew this, would you want me as a physician to give you drug X? If you answer yes to either of these questions, you are truly lost on the topic.

  95. Ed Whitney says:

    @ Karlwithakay

    Methanol and ethanol differ by one letter…reminds me of the sixth grade when us kids went around the playground at recess singing, “We never stagger, we never fall, we sober up on wood alcohol…” We didn’t know what it was, but it had been handed down by the big kids and that was good enough for us.

    @ Harriet et al.

    Hopton 2010 concluded that the accumulating evidence from recent reviews suggests that acupuncture is “more than a placebo” for commonly occurring chronic pain conditions. And Ernst 2011 says a most interesting thing in his discussion, namely, “The majority of the early reviews arrived at negative conclusions, while the majority of the 57 recent reviews were positive.”

    That last sentence sounds almost innocuous, but this is a rather remarkable state of affairs. Almost at the same time that John Ioannidis published his widely quoted 2005 article on why most published research findings are false, he published a paper on contradicted and initially stronger effects in widely cited clinical research. This paper discussed a now widely appreciated phenomenon: studies that show large treatment effects tend to get published early, while later studies show smaller treatment effects. Carotid endarterectomy, immediate angioplasty, coronary artery stents, showed large reductions in morbidity and mortality when first published; later studies eroded the initial effects and led to considerable erosion of the early estimates of treatment effect.

    So it is highly interesting to see the trend in acupuncture going in the other direction. Early studies tending to be negative, more recent studies trending positive…what in the world could be going on?

    Ernst 2011 is not the final nail in the coffin that will bury acupuncture once and for all. Many are tempted to conclude the discussion, close the books on acupuncture, and move on. But just as premature closure of the epiphyses stunts growth, premature closure of the acupuncture question stunts progress in pain research.

  96. Harriet Hall says:

    @Ed Whitney,

    After the “early studies negative/later studies positive” comment, Ernst et al. go on to say

    “These findings should be seen in the light of recent results from
    high-quality randomized controlled trials.” with a fuller explanation later in that paragraph about exactly “what in the world could be going on.”

    The article will not spell the end of acupuncture because of people like you who keep saying “But… but… there MIGHT be!!!” We are not dealing with a straightforward question of pain research, but with a belief system amounting almost to a religion. If acupuncture were a new drug that people had no emotional investment in, it would have been given up by now.

  97. @Ed Whitney

    Ethanol and methanol differ by a little bit more than just one letter.

    CH3–CH2–OH vs CH3-OH There’s an entire added methylene (CH2) group in ethanol, so three letters or two letters and a number.

    “we sober up on wood alcohol”

    Permanent blindness would be somewhat sobering.

    The jury came in on acupuncture some time ago. It’s not pining for the fjords; it’s dead. If people wouldn’t keep nailing it to the perch, it’d be pushing up the daises.

    Ernst 2011 is not the final nail on the coffin; it’s not even the icing on the cake. It’s the aperitif your drink after you finish the cake and the flowers you put on the grave of the buried coffin.

    However no amount of negative research will convince some people that it is an un-parrot.

    Jonathan Swift said, “It is useless to attempt to reason a man out of a thing he was never reasoned into”

  98. Jan Willem Nienhuys says:

    Jonathan Swift said, “It is useless to attempt to reason a man out of a thing he was never reasoned into”

    Is this actually from ‘Letter to a young clergyman’,
    http://www.readprint.com/chapter-49128/Writings-on-Religion-and-the-Church-Vol-I-Jonathan-Swift/14 ?

  99. pmoran says:

    Harriet : The article will not spell the end of acupuncture because of people like you who keep saying “But… but… there MIGHT be!!!”

    That’s not quite true. While I also disagree with Ed’s interpretation of the evidence, acupuncture will persist because a lot of people think that it helps them and because there is no clear practical medical significance to the phrase “works no better than sham/placebo”, with more complex interventions like acupuncture.

    A simple example: why would not stimulation at that mystical P5 acupuncture point distract some patients from that growing feeling of nausea after surgery, sufficient to have a useful effect on post-op nausea? Why should that ever be regarded as a bad thing, and not something not worth trying in preference to adding on more drugs?

    Why would a cotton wool plug in the left ear (an example I provided previously) not distract some people from their sea sickness, and quicker than any pill?

    If a method like acupuncture has distractant, and counter-irritant potential, along with enabling periods of enforced relaxation, and opportunities for ongoing socio-medical interactions, as well as perhaps being a good provoker of endorphin release, why would it be dismissed as “only ” a placebo? WTF does that mean for practical medicine?

    I don’t want to get into the tricky business of defining just what “placebo” means in all possible settings. I would like to draw attention to a problem in communication, with there not being a sufficiently well differentiated vocabulary for these matters.

    “Placebo” has a negative taint that is difficult to shake off. Once something acquires that label it is automatically ignored by the “scientific” skeptic, even when it has plausible medical potential and the sham versions i.e. those that have been merely divorced from TCM theory have quite significant effect sizes within clinical studies.

  100. Harriet Hall says:

    pmoran,

    I agree that placebos have plausible medical potential. I’d love to find a way to take advantage of that potential without lying to patients. Can you suggest a way to do that?

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