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Acupuncturist’s Unconvincing Attempt at Damage Control

Acupuncture has been in the news recently. A former President of South Korea had to undergo major surgery to remove an acupuncture needle that had somehow lodged in his lung.  A recent study in Pain compiled a list of 95 published reports of serious complications of acupuncture including 5 deaths. Meanwhile, acupuncturists continue to insist that their procedures are “safe.”

Edzard Ernst et al.’s article Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews was published in the journal Pain in April 2011. It had two parts: (1) it was a systematic review of 57 systematic reviews showing that there was “little truly convincing evidence that acupuncture is effective in reducing pain,” and (2) it tabulated published reports of 5 deaths and 90 other serious complications of acupuncture treatments. I wrote an accompanying commentary, “Acupuncture’s claims punctured: Not proven effective for pain, not harmless.”

William Morris chastised me for not declaring a conflict of interest (!?) in my commentary. Now, in Acupuncture Today, he has criticized the Ernst et al. study itself.

Morris’ first criticism is that the study

did not examine iatrogenic deaths due to conventional drugs, chemotherapy, radiotherapy and surgery. It was more focused on the safety and efficacy of acupuncture.

I laughed out loud when I read this. It was focused on the safety and efficacy of acupuncture because it was a study about the safety and efficacy of acupuncture. Duh!  A study of acupuncture for pain is not the appropriate place to examine iatrogenic deaths from four conventional treatment methods that are used for every disease from pneumonia to cancer. We need to know about acupuncture’s efficacy and safety (for pain) before we can even consider making any meaningful comparisons with other treatments (for pain). He says “it would be interesting to see results an [sic] in-depth ‘review of reviews’ on the safety and efficacy of conventional medicine and surgery.” Sure it would, but this is hardly the place.  He tries to forestall protests by insisting this is not a tu quoque argument; but it sure sounds like it, or like something worse.

Comparing iatrogenic deaths from different treatments would be a valid subject for a different article. But why does he single out conventional medicine instead of including deaths from all forms of alternative medicine? What about the risk of stroke from neck manipulation? Neck manipulation would be a particularly pertinent comparison to acupuncture because it is used by many chiropractors to treat pain as an alternative to both conventional medicine and acupuncture. And why single out deaths instead of looking at all serious adverse events? Most importantly, why not look at risks in the context of proven benefits?

Curiously, Morris does not address the results of the systematic review of acupuncture’s efficacy or attempt to counter its conclusions in any way. He only briefly criticizes its methodology, and then he focuses on the reports of adverse effects.

The Systematic Review of Systematic Reviews

He criticizes Ernst et al. for lack of detail in describing how they quantified the quality of the studies they included in their analysis. But they supplied a footnote to an article describing their method, indicating that they followed Oxman and Guyatt’s validated checklist. Does Morris think they should have reproduced the entire checklist and evidence for its validation in the text of their article? I can’t fault them for using a footnote to save space.

“For data on efficacy, it doesn’t provide information about how the studies were controlled.” He wants to know whether it was “acupuncture alone, skin penetrating, non-penetrating or adjacent to the point location.” This only highlights the imprecision of acupuncturists’ own definitions of what qualifies as acupuncture and what constitutes appropriate controls. In my commentary I pointed out:

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.

If he had any evidence that his preferred version of acupuncture was more effective or safer than other versions, or that one type of control is more appropriate than another, he could have presented it. He expresses doubts rather than offering data.

Safety

Morris criticizes Ernst et al. for including case reports where causality was uncertain, but each case report was listed individually and its causality categorized as certain or probable. The deaths were categorized as “certain” causality. Even if you eliminate the uncertain ones, the data show that acupuncture cannot be characterized as risk-free.

Bizarrely, he criticizes Ernst et al. for not including other complications such as fainting, vomiting, or bruising that are more common adverse effects. These are not “serious” risks, which is why they were not included in a study of “serious risks.” In essence, Morris seems to be arguing that acupuncture is even less safe than Ernst et al. depicted.

He says “Ernst and his colleagues do not reference previous studies showing acupuncture as safe,” citing a 2003 article by Lao and Berman published in an alternative medicine journal. That article’s conclusion included the authors’ opinion (a value judgment) that acupuncture is “a generally safe procedure”; but its text identified 202 adverse events, over twice as many as the Ernst et al. article. It included minor events like fainting and nausea, while the Ernst study was limited to serious events. I don’t have access to the full study. I wonder if it is exempt from the same criticisms: did its authors describe how they quantified the quality of the reports they included, did they assess the certainty of causation, and did they follow a validated checklist like Ernst et al. did?

Morris quotes a researcher who says “acupuncture is seen as an extremely safe therapeutic system whose complications are very rare and are easily avoided or rectified.”  This is not at all in conflict with the findings of the Pain study. Ernst et al. found a number of complications that was quite small in relation to the large number of acupuncture treatments, and they called for better training of acupuncturists to minimize the chance of complications. The real point is that there is no reason to accept any degree of risk, no matter how little, if there is no benefit to the treatment. Safety by itself is no recommendation: homeopathy is probably the safest treatment going.

Conflict of Interest

Morris criticized me for not declaring a conflict of interest in my commentary.  I have no conflict of interest: it makes no difference to me whether acupuncture works or not; I would follow the evidence wherever it led and write about it.  He, on the other hand, has a clear interest in defending his occupation, and I don’t see any declaration of his conflict of interest in his Acupuncture Today article. The Ernst et al. study is solid: it shows that there is little evidence that acupuncture is truly effective in reducing pain. Taken as a whole, a rigorous evaluation of the published evidence leads to the conclusion that acupuncture is no more effective than placebo, and it is not risk free.  Morris doesn’t want to accept this. He is biased in favor of acupuncture and is doing whatever he can to limit the damage from the Pain study. He can’t do much: his efforts are unconvincing and rather sad.


 

Posted in: Acupuncture

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20 thoughts on “Acupuncturist’s Unconvincing Attempt at Damage Control

  1. windriven says:

    “Curiously, Morris does not address the results of the systematic review of acupuncture’s efficacy … he focuses on the reports of adverse effects.”

    And why would he address efficacy? There is an existing population who use acupuncture, believe in acupuncture, proselytize for acupuncture and defend its benefits regardless of scientific evidence to the contrary. These will always find an audience among the chaotic of mind who follow fashion rather than fact.

    Ah, but adverse effects are another matter. Too many reports of acupuncture needles being surgically removed from various organs, drug resistant infections from poor or absent sterile technique, and other icky eventualities will drive Buffy and Jody away from acupuncture and into the loving arms of Reiki.

  2. It’s so weird that the alt.med. people, some of whom seem to be fairly well-versed in argument, don’t see that a modality like acupuncture is a house built on a paper foundation. Eventually it’s going to collapse.

    The twin powers of ignorance and denial are formidable foes for reason and education.

    Oh, and as a side note, I’d say that reiki is the “safest” alt.med. modality. You’re not even touching the client, just allowing them to nap to soft music and glowing candles while their disease eats them alive from the inside.

  3. qetzal says:

    @BigHeathenMike

    I figure remote healing must be even safer than reiki. With reiki, there’s still a chance of getting in an accident on the way to the reiki grifter’s office, or being exposed to some pathogen left behind by the last patient to lie on the couch.

  4. DevoutCatalyst says:

    @qetzal

    Yes, and the remote stuff can be automated and made free to all the world as an open source alt med, with the harm written out of the script.

  5. “…while their disease eats them alive from the inside.” Yikes Funny! But yikes.

    Please don’t forget financial harm. The safest ineffective treatment would risk nothing … not even the patient’s hard-earned dollars. By that criterion, it’s nearly impossible to find a truly harmless snake oil.

  6. daedalus2u says:

    There are some treatments that are safer than doing nothing. For example what is the “risk” associated with a healthy diet, sufficient sleep, or moderate exercise. If those were considered to be “interventions”, they would have a safety profile better than doing nothing.

    If someone is dehydrated, the “intervention” of drinking more water is safer than maintaining a dehydrated state.

    This is also how I think about a biofilm of my bacteria. If the normal physiological state is with a biofilm of ammonia oxidizing bacteria, having such a biofilm might have a better safety profile than not having one. The “normal” gut has normal flora in it. Removing the “normal” flora does have an adverse safety profile. Many gut problems occur after systemic antibiotics that remove the normal flora. Why should flora on the skin be different?

  7. tmac57 says:

    daedalus2u-I have been meaning to ask you for some time,how can a person deal with personal hygiene functions,and still maintain their skin flora?

    Oh,and so as to not be totally off topic…

    http://www.xtranormal.com/watch/8213859/dale-darlins-pick-n-poke-toothpick-acupuncture-clinic

  8. @ qetzal et al – Yeah, I stand corrected. Aside from the not-incedental financial harm, being the “patient” of a remote healer would be the least harmful of the nonsense-pile with which we regularly deal.

  9. vicki says:

    daedalus2u: A healthy diet is almost definitionally not risky (unless you get hit by a car on the way to the market). But there isn’t a single healthy diet. For example, I can reasonably get a significant portion of my protein from dairy and nuts; some people are allergic to one or both of these.

    Similarly, “moderate exercise” sounds great, but again has to be somewhat tailored to the individual and any preexisting problems.

  10. qetzal says:

    I suppose we could eliminate the financial harm, as well as potential harm from eschewing beneficial treatments, by performing covert remote healing. That is, don’t even tell the patient it’s being done!

    I guess someone has to pay the secret remote healers, though. I’m sure Harkin et al. will happily write that into the health law.

    Would it violate the principle of informed consent if you don’t tell a patient that you’re performing a “treatment” that has no effect whatsoever?

  11. daedalus2u says:

    tmac, with a biofilm of ammonia oxidizing bactera, heterotrophic bacteria are suppressed. How do wild animals deal with skin hygiene?

  12. pmoran says:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001416/?tool=pmcentrez

    Essential reading. Points out that effect sizes from the non-specific “effects” of acupuncture-like treatment rituals are well within the ranges found with many pharmaceuticals.

    From the conclusion.

    We believe that there has to be a discussion involving scientists, decision makers, health care providers and patients whether and when the evidence for clinically relevant total effects from nonblinded comparisons is sufficient to consider a treatment effective, even if specific effects due to the postulated mechanism of action might be minor or even nonexistent.

    I think so too. We are over-preoccupied with peripheral matters: the overweening pretentiousness of some CAM providers, their biased misrepresentations of the mainstream, their rear-guard attempts at muddying up the science relevant to the theory, even as their somewhat less batty elements are close to explicitly allowing that they are mainly exploiting psychological aspects of patient-doctor-”treatment” interactions (this is the true, subliminal message of the Atlantic discussion).
    .
    This is where healthfraud was always heading. When I first entered this field some decades ago CAM practitioners were already saying “what does ti matter if it is only placebo, so long as it ‘works’?”.

    And in those days the placebo was a very dirty word. It has been somewhat rehabilitated, but not to the extent that we may not one day wish we had a more neutral or positive term for all the non-specific beneficial influences within medical care.

  13. tmac57 says:

    d2u-”How do wild animals deal with skin hygiene?”
    Well,my dogs seem to prefer rolling in the dirt.I haven’t tried that yet.It looks a little uncomfortable.

  14. JPZ says:

    @Harriet

    Once again, a well-structured, thoughtful discussion of someone else’s poorly thought out, dogmatic discussion about acupuncture. Your posts are very educational!

    I’ll admit a little trepidation at pointing this out to somone so careful with their argumentation, but I think a distinction needs to be made been between two points you may have treated as equivalent.

    Stating, “Meanwhile, acupuncturists continue to insist that their procedures are ‘safe.’” is not the same as “Taken as a whole, a rigorous evaluation of the published evidence leads to the conclusion that acupuncture is no more effective than placebo, and it is not risk free.” Both could be true, but unrelated. One group of acupunturists could look at the AE and death profile and respond that better training and more careful procedures would have avoided most or all of these AEs/deaths, i.e. acupuncture is as safe as any minor medical procedures that require manual skill and attention to protocols (but I do note and agree with your statement that an ineffective treatment should have zero risk). The later statement draws the line at “risk-free” and is verified by the Ernst review. Thus, “safe” and “risk free” are not equivalent, and the former can be supported (conditionally) even in light of the Ernst review.

  15. Harriet Hall says:

    @JPZ,

    Point well taken. I had thought about mentioning the subjectiveness of “safe,” but that didn’t make it into my post. I agree that acupuncture is “safe” compared to any minor medical procedure. Of course, minor medical procedures usually have proven benefits, so their risk/benefit ratio is more defensible. In saying “risk free” I was reacting to the many times I have encountered the assumption that acupuncture was a risk-free treatment.

  16. daedalus2u says:

    tmac, this is SBM. Just because something looks uncomforatable you are ready to not even consider it? We need data to make conclusions about anything.

  17. Calli Arcale says:

    qetzal:

    I suppose we could eliminate the financial harm, as well as potential harm from eschewing beneficial treatments, by performing covert remote healing. That is, don’t even tell the patient it’s being done!

    This is already done, in the form of prayer groups who, out of the goodness of their hearts, pray for the healing of strangers who will never even know they’re being prayed for.

    In my opinion, the main value is that the participants feel less guilty that they can’t actually do anything for the person, feel a bit nobler, and are at least sparing some thought for those less fortunate; in theory, at least, it’ll increase their compassion for others. In theory. In practice, it can have the opposite effect, by reinforcing the praying person’s prejudices, depending on what exactly they’re praying. But it’s harmless to the subject of the prayer, since it has no effect whatsoever on them.

  18. hbuchtel says:

    Another ‘unconvincing attempt at damage control’:

    http://tinyurl.com/3wfaant

    (Journal of Chinese Medicine)

  19. tmac57 says:

    Calli-

    But it’s harmless to the subject of the prayer, since it has no effect whatsoever on them.

    It may actually be a good thing. There may be the beneficial effect of the afflicted NOT being in physical contact with people who might be harboring harmful bacterial or viruses. Please keep those do-gooders out of my hospital room!

  20. tmac57 says:

    D2u- Are you saying that maybe I should try some ‘dirty dancing’?

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