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AFP Promotes Acupuncture

I subscribe to American Family Physician, the peer-reviewed journal of the American Academy of Family Physicians. It emphasizes evidence-based medicine and most articles include a table showing strength of evidence ratings for key recommendations for practice. Lately, its scientific rigor has been slipping. I have complained to the editor about several articles whose recommendations were not based on the best science, and I have been consistently ignored. 

Acupuncture for Chronic Low Back Pain 

A recent article on chronic low back pain recommended acupuncture and gave it an “A” rating corresponding to “consistent, good-quality patient-oriented evidence.” I wrote the following letter to the editor and to the author of the article: 

In the recent article on chronic low back pain http://www.aafp.org/afp/20090615/1067.html I was very disturbed to see acupuncture listed as beneficial with an evidence rating of “A.” That rating was supported by 4 references:

Reference 2 (Chou et al.), consisted of practice guidelines recommendations that lumped acupuncture with other nonpharmacologic interventions (intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation).” And labeled all of these as a “weak recommendation, moderate-quality evidence.”

Reference 22 (Sherman et al.) addressed current practices but did not comment on the efficacy of acupuncture.

Reference 23 (Furlan et al.) was a Cochrane review showing no evidence that acupuncture is effective for acute low back pain and commenting that the studies indicating its effectiveness in chronic low back pain were of “lower methodologic quality.”

Reference 24 (Witt et al.) only showed that adding acupuncture to routine care improved outcome and was cost-effective: it did not assess the effectiveness of acupuncture as a stand-alone treatment.

In contrast, this recent systematic analysis http://www.ncbi.nlm.nih.gov/pubmed/19250001?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum showed that true acupuncture is no more effective than sham acupuncture. Numerous studies with a retractable sham acupuncture needle (like a stage dagger) have shown that the sham procedure is equally effective (and at least in one study the sham procedure was more effective). Even toothpicks seem to work! http://www.time.com/time/health/article/0,8599,1897636,00.html

This study http://www.ncbi.nlm.nih.gov/pubmed/19433697?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum showed that it doesn’t matter where you put the needle or whether you penetrate the skin and commented “These findings raise questions about acupuncture’s purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.”

Acupuncture studies are all less than ideal in that double-blinding is impossible: the acupuncturist always knows whether he is administering a sham treatment.

Some studies have suggested that acupuncture releases endorphins in the brain, but studies also show that placebos elicit endorphin release.

All this evidence is compatible with the hypothesis that acupuncture is nothing more than an elaborate placebo.

If we had similar evidence that an analgesic drug was no better than a sham drug (a sugar pill), you would not be recommending it. How can you justify recommending acupuncture? How can you justify an “A” evidence rating?

I received no response from either the editor or the author. 

Acupuncture for Pain 

The current issue features an article “Acupuncture for Pain”  by Robert B. Kelly, a family physician who is associate director of a family medicine residency program and associate professor at Case Western Reserve University School of Medicine. He is also a member of the American Academy of Medical Acupuncture and a diplomate of the American Board of Medical Acupuncture. In the “author disclosures” this was not listed as a conflict of interest, but it should have been. 

The article claims

Based on published evidence, acupuncture is most likely to benefit patients with low back pain, neck pain, chronic idiopathic or tension headache, migraine, and knee osteoarthritis. Promising but less definitive data exist for shoulder pain, fibromyalgia, temporomandibular joint pain and postoperative pain.

It assigns “A” strength of evidence ratings (consistent good-quality patient-oriented evidence) to acupuncture for low back pain, neck pain, headache (chronic idiopathic), and headache (migraine). It assigns “B” ratings (inconsistent or limited quality patient-oriented evidence) to acupuncture for shoulder pain, knee osteoarthritis, fibromyalgia, temporomandibular joint pain, and postoperative pain. Note the inconsistency: knee osteoarthritis is listed among the conditions “most likely to benefit” but then is given only a “B” rating. 

It presents a biased picture of the published research.  For chronic low back pain, it cites these studies: 

  •  A systematic review of RCTs that found “There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.” In other words, acupuncture is no better than placebo, and using a placebo is better than doing nothing.
  • A randomized controlled trial showing that acupuncture was better than no treatment, but that the control (superficial needling at non-acupuncture points) was equally effective. In other words, acupuncture was no better than their placebo control.
  • A randomized controlled trial that concluded “Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.” There was no significant difference between “verum” acupuncture and the sham (placebo).
  • A pragmatic randomized trial that compared usual care to acupuncture. There was no attempt to control for possible placebo effects with a sham acupuncture control.
  • A pragmatic randomized trial that compared routine care with or without acupuncture. There was no attempt to control for possible placebo effects.
  • A Cochrane review that concluded  “The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.”
  • A meta-analysis that concluded “Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.” 

It does not cite these studies: 

  • A systematic review of RCTs that concluded “There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.” No significant difference between acupuncture and sham acupuncture means acupuncture is not better than placebo.
  • A Cochrane review that concluded  “The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.”
  • A systematic review of RCTs that concluded:   “Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain.”  

It does not cite the other studies I cited in my letter showing that acupuncture is no better than placebo and that it makes no difference where you put the needle or even whether you use a needle (toothpicks and retractable needles are equally effective).  

Other Kinds of Pain 

Kelly says “A systematic review on temporomandibular joint (TMJ) pain concluded that acupuncture significantly improved symptoms.” 

That’s not exactly what the review said. Its conclusion was: 

Overall, their results suggest that acupuncture might be an effective therapy for temporomandibular joint dysfunction. However, none of the studies was designed to control for a placebo effect. CONCLUSION: Even though all studies are in accordance with the notion that acupuncture is effective for temporomandibular joint dysfunction, this hypothesis requires confirmation through more rigorous investigations. [emphasis added] 

He also discusses the use of acupuncture for other painful conditions including neck and shoulder pain, headache, and arthritis. The evidence he cites is similarly unconvincing for those conditions. 

Excuses 

Kelly offers excuses and special pleading in an attempt to validate his recommendations. He suggests that “Western scientific methods” like RCTs do not lend themselves to the study of individualized treatment based on such things as pulse diagnosis, tongue diagnosis, herbal therapies, dietary modifications, ear, hand, or scalp acupuncture in addition to or instead of body acupuncture. He admits that there is no statistical difference between sham and actual acupuncture, but he doesn’t acknowledge the implications of that fact. 

Acupuncturists believe in what they are doing. Personal experience, patient gratitude, the natural course of illness, the placebo response and other factors conspire to impair judgment. This makes it difficult for them to be as objective as an outside observer.

This is a clear case of denial. To see why, substitute “drug” for acupuncture and “sugar pill” for sham acupuncture. When a controlled study shows that your treatment works no better than your placebo control, the only logical conclusion is that the treatment is no better than placebo. Imagine a drug company saying “Our drug works and the placebo works too.” Neither the drug nor the placebo would get past the FDA. 

There is only one science. The same standards apply to acupuncture as to drug therapies. A placebo by any other name is still a placebo.   

It is sad to see a journal I respected depart from rigorous science-based medicine and succumb to the CAM temptation, especially when it tries to justify its defection by misrepresenting the state of the evidence. It has been said that there is no such thing as alternative medicine: there is only medicine that works and medicine that doesn’t. When a treatment is shown to work, it is adopted by mainstream medicine and is no longer “alternative.” Acupuncture remains “alternative,” and even AFP recognizes that fact by listing this article as one in a series on “Alternative and Complementary Medicine.”

Posted in: Acupuncture

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62 thoughts on “AFP Promotes Acupuncture

  1. OZDigger says:

    Interesting comments, Harriet. However, the “conventional medical alternatives” to acupuncture are not discussed by you. To be bio-ethically correct in your article you should really discuss the cost/benefit and risk/benefit ratio between the different courses of care for these conditions. Even if acupuncture achieves no results, it is better that the clinically toxic substances you recommend e.g. NSAIDS (for which you have always been reluctant to discuss in terms of risk and benefit)
    How many people has acupuncture killed in the U.S. in the last few years, compared to the clinically toxic and poisonous substances (NSAIDS) that you peddle and push. So if an acupuncturist is a sCAM merchant, what does that make you? A drug peddler….or worse?

  2. OZDigger says:

    You always seem to miss the most important issue in these debates.
    “What do patients want?”
    If you close your mind to patient autonomy and only advocate care from a very small bag of treatment modalities, that suit you paradigm of ignorance, then all you can expect is a large proportion of very unhappy patients.
    Patients want to be listened too. They want to be acknowledged for their concerns. They do not want to be brow-beaten by a narrow minded person, with a rigid, fixed comprehension of health, that existed when Marcus Welby was at Med. School and Dr. Kildare was just a first year intern. Listen to the patients, understand what they want, and provide good compassionate care, based upon what is considered appropriate for the time, place and patient. “Science”, what ever that is, will catch up.

  3. skepchick says:

    OZDigger:

    You don’t cite any references to back up your assertion that NSAIDS are “clinically toxic and poisonous” when used as prescribed.

  4. OZDigger says:

    Vioxx. 30,000 peoplle killed as a direct result of tasking Vioxx. Over 100,000 people maimed as a result.
    Look at references for the incidence of gastric problems from Ibubrufen and Diclophenac.

  5. OZDigger says:

    Harriet has all those references, if she is brave or honest enough to front up.

  6. OZDigger says:

    Harriet has all those references.

  7. Ben Kavoussi says:

    OZDigger, the fact that acupuncture has not killed anyone in the US does not make it an effective treatment for pain. How many people have died of prayer, yoga, meditation in the US? None. Do they help with pain? Many will say they do. Are we going to list them as pain management modalities? I don’t think so.

    There is a difference between the responsibility of a healthcare organization and people’s personal beliefs. If you or your healthcare provider think yoga, meditation, prayer or acupuncture are going to help you, you are free to use them. But the American Academy of Family Physicians has the duty to recommend modalities that are based on best practices, that work for everyone, and that are not based on patient’s personal beliefs.

    Acupuncture is not such a modality.

  8. Necandum says:

    In reply to OzDigger:

    –You always seem to miss the most important issue in these debates.
    “What do patients want?”–

    And if the patients want to jump off a cliff? Obviously not a good idea. Admittedly you do cover that base by saying:

    –”what is considered appropriate for the time, place and patient. “–

    I would say that acupuncture is not an appropriate treatment that a doctor should be recommending, unless the patient is made fully aware that it is a placebo. It doesn’t work, and doctor most definitely should not by lying to their patient.

    –”How many people has acupuncture killed in the U.S. in the last few years?”–

    Probably at least a couple. But the better question is: How many people has it cured? Not made ‘better’, but cured. My cat makes me feel better too, but he’s not going to cure anything anytime soon.

    –”Patients want to be listened too.”–
    Very true. Doctors, unfortunately, are not paid to listen. They have to see a certain number of patients per hour and simply wouldn’t have the time, no matter how much listening they might themselves want to do. That’s why the alternative are so attractive, not because they work, but because the patients get someone to listen and pay attention to them. Compassion might be nice, but if it is not backed up by a treatment that works..well…it ain’t pretty.
    Like this.

    –”and only advocate care from a very small bag of treatment modalities, that suit you paradigm of ignorance, “–
    An excellent description of a quack. Homeopathy, atrology, acupuncture, all covered. Quite good, really.

  9. OZDigger says:

    Vioxx could only be used as “prescribed”, as could lots of other drugs. Many have a wonderful benefit. Even Vioxx.!!!! But even recent “scientific based research” has found that this drug is no more clinically viable than the other, older NSAIDS that have been proven to work just as well.
    Harriet (who has no credentials in research, but reads a lot) will be able to give you a very good and well researched list of drugs that have had some catastrophic effects on patients, before being taken off the market. That is science for you!!!!!!!!!!!!!!

  10. Necandum says:

    In reply to OzDigger:

    –You always seem to miss the most important issue in these debates.
    “What do patients want?”–

    And if the patients want to jump off a cliff? Obviously not a good idea. Admittedly you do cover that base by saying:

    –”what is considered appropriate for the time, place and patient. “–

    I would say that acupuncture is not an appropriate treatment that a doctor should be recommending, unless the patient is made fully aware that it is a placebo. It doesn’t work, and doctor most definitely should not by lying to their patient.

    –”How many people has acupuncture killed in the U.S. in the last few years?”–

    Probably at least a couple. But the better question is: How many people has it cured? Not made ‘better’, but cured. My cat makes me feel better too, but he’s not going to cure back pain anytime soon.

    –”Patients want to be listened too.”–
    Very true. Doctors, unfortunately, are not paid to listen. They have to see a certain number of patients per hour and simply wouldn’t have the time, no matter how much listening they might themselves want to do. That’s why the alternative are so attractive, not because they work, but because the patients get someone to listen and pay attention to them. Compassion might be nice, but if it is not backed up by a treatment that works..well…it ain’t pretty.
    Like this.

    –”and only advocate care from a very small bag of treatment modalities, that suit you paradigm of ignorance, “–
    An excellent description of a quack. Homeopathy, atrology, acupuncture, all covered. Quite good, really.

    –”list of drugs that have had some catastrophic effects on patients, before being taken off the market. That is science for you!!!!!!!!eleven!!!11!!11″–

    Indeed. When ‘science’ finds a problematic drug, that drug is removed from the market. Maybe not as quickly as may be desired, but it does happen eventually. The same cannot be said for sCAM. Can you show me an instance where even one ‘treatment’ was retracted by a sCAM practitioner, voluntarily and before he/she/it could be thoroughly grilled for it, because of inefficiacy or harm caused? Think chelation, chemical castration, the Gonzlez protocol (the one linked above). Mountains of evidence they don’t work, but they are still being pushed as miracle cures. I’ll prefer the ‘science’, thank you very much.

    –But even recent “scientific based research” has found that this drug is no more clinically viable than the other, older NSAIDS that have been proven to work just as well.”–

    Reference required. Also, what’s your point? Is it that “Big Pharma” had a couple of patents run out and churned out a couple of new versions with enough small difference that they could be patented again? That’s business. Nothing to do with the scientific method.

    I don’t know if that’s what happened, just trying to understand what you’re saying, by the way.

  11. Deetee says:

    @Ozdigger.
    I echo the comments of necandum.

    In the last couple of decades, many hundreds of new biologically active drugs have been developed, tested, shown to have demonstrable efficacy, released onto the market and have proved to be very beneficial for patients.
    A tiny number of these (single figures) such as Vioxx have been recalled for the reasons you describe. So what does that mean? That we should therefore accept the use of completely unproven complementary therapies? There appears to be a bit of a logic gap in your argument here.

  12. Scott says:

    The risks of acupuncture are irrelevant. Since the evidence has consistently failed to demonstrate any benefit beyond placebo, the risk/benefit ratio is infinite no matter how small the risks are (so long as they are non-zero, which they are – there is always some chance of infection when the skin is broken, if nothing else).

    Since poking people with toothpicks provides the same benefits as acupuncture with less risk, acupuncture cannot be ethically provided by anyone to anyone.

    And since acupuncture is, based on the evidence, nothing more than a placebo, providing it with any claim of efficacy is lying. Which, of course, makes it lying in order to sell something which doesn’t work as advertised – or, in other words, fraud.

    The only way to perform “acupuncture” in an ethical, legal manner is to (a) openly admit that it is merely an elaborate placebo and (b) refrain from doing anything beyond poking with toothpicks.

    Of course, that would seem quite silly. So you might as well admit what the real mechanism of action is and just provide a friendly ear and a relaxing atmosphere. THEN you’re being ethical, legal, and sensible.

  13. OZdigger’s comments are a complete non sequitur. It’s a distraction.

    Good physicians do listen to their patients and do take into consideration what the patient’s want and need. But that does not justify using treatments that do not work. Our job is to provide them with ethical and science-based options, and let them make informed decisions. It is already part of standard medical ethics to respect patient autonomy.

    But what OZdigger is doing is standard CAM propaganda – attack a false issue (autonomy and respect for patients) as if it has anything to do with the question of whether or not a specific treatment works.

    The question of NSAIDS also has nothing to do with acupuncture – but the implication is that Harriet is not being consistent, but this is simply not fair. NSAIDS actually work, the question is how best to use them and how to maximize the benefit vs risk. No one claims they are without risk. Also, regulators made the decision to allow them to be used over the counter, which raises further issue of how to manage risk.

  14. Calli Arcale says:

    Harriet . . . will be able to give you a very good and well researched list of drugs that have had some catastrophic effects on patients, before being taken off the market. That is science for you!!!!!!!!!!!!!!

    Quite correct! With science-based medicine, we know when a therapy is dangerous, and stop giving it to people.

    The alternative, to practice without science, is to live in ignorance. Prescribe away — no one will know if it is better than existing, cheaper alternatives, much less whether or not it’s safe.

    One of the major problems with your logic is that you are on the one hand suggesting that Vioxx is horrible while on the other hand you are saying that doctors should be giving patients whatever they want. (Patient autonomy over all!) Patients were *screaming* for Vioxx. (Usually not literally, but you get the idea.) These include my grandparents, who were very upset when Vioxx was taken off the market. They wanted to keep using it, and were upset that their doctors told them “no, it’s not safe”.

    People keep holding up Vioxx as an example of what’s wrong with science-based medicine and the FDA. Yet if we didn’t use science and didn’t have the FDA enforcing things, [i]patients would never have learned of the risks associated with Vioxx, and it would still be on the market[/i].

  15. Diane Henry says:

    Like Calli said, I think Vioxx is an excellent example of the system working pretty well–it hurt some people, and was pulled off the market. When does alternative medicine ever give up a therapy?

    This has probably already been addressed multiple times elsewhere, but it seems to me one huge gaping flaw among many in alt med is the underlying belief that it doesn’t hurt anyone, ever. So their “science” never looks for it.

  16. Versus says:

    @OZ Digger
    “What do patients want?”
    I think they want to be told the truth. What patient would choose a treatment (1) that has no plausible basis, (2) that is no better than placebo, (3) whose effectiveness has not been demonstrated in any scienfitically reliable way, (4) whose risks have not been adequately studied, and (5) is expensive? Patients “want” acupuncture because they are being lied to about what it is and what it does. Does respect for patient autonomy include misrepresentation of the facts?
    If I consider taking a NSAID, at least I can look up the benefit v. risks, what it is made of, and how it works. Those facts are not easily available to the acupuncture patient, mainly because the acupuncturist must deliberately hide them — otherwise he would be out of business.

  17. Todd W. says:

    @Calli Arcale

    I’d just add that as far as Vioxx is concerned, it functions remarkably well as a pain reliever and, at least at the time it was pulled, was reasonably safe for short-term use for acute pain flare-ups. The danger really came out for long-term use, IIRC.

  18. MBoaz says:

    Thank you for another great article Dr. Hall. I’m really disturbed by this, and I’m sorry that responsible physicians such as yourself, who work so tirelessly to protect people from fraudulent health claims, are subjected to verbal abuse as thanks for their service. Sometimes it seems like the whole world is going insane.

  19. kausikdatta says:

    What people like OZDigger and CAM proponents in general shall willfully never understand are the parameters of safety and efficacy that go into drug development.

    Vioxx was an efficacious drug, it did what it was supposed to do (i.e. relieve pain), but it still had to be pulled from the market because of its lack of safety (increased cardiovascular events) in a subset of patients (at high risk for cardiovascular events) – although the COX-2 inhibitor Vioxx did have lower incidences of gastric ulceration, the traditional complaint with NSAIDs.

    These are established facts, quite aside from the controversy about Merck’s suppression of critical data and the NEJM editorial. But the CAM populace would, of course, jump on the criticism bandwagon without any understanding of the actual principle behind the drug.

    Given the physiological differences between human beings, there would always be concerns about adverse events in a certain subset of patients in case of any and all drugs – hence the Phase 4 post-marketing studies, the warning labels etc. The safety systems are in place. This is how drug discovery science works, and this is how the past 100 years we have got wonderful medicines saving the lives of countless people.

    When, OTOH, has CAM saved a life? When has a homeopathic ‘medicine’ been withdrawn from the market because it never worked? Oh, wait – CAM is not bothered by these considerations, I forget! CAM can only claim efficacy – and spread spurious stories and misinformation about the so-called efficacy – because there is no scientific evidence that they work. At all. CAM treatments have excellent safety profile because, as a matter of course, it has no effect, which is why placebo doesn’t kill anyone – unless that placebo is given in place of a life-saving drug for a serious condition.

  20. Todd W. says:

    @kausikdatta

    This is how drug discovery science works, and this is how the past 100 years we have got wonderful medicines saving the lives of countless people.

    And it is also why many, many more drugs than ever are approved are kept from making it to market. The process does a pretty good job of weeding out drugs that show no or inadequate efficacy or show an unreasonable risk compared to the benefits (e.g., drugs that look okay in animal models but prove fatal in Phase I human trials). In general, the dangerous products never even make it to Phase 2 or 3, let alone to market. All because of a rigorous system in place to screen them.

  21. superdave says:

    It is essentially impossible for any treatment to have only one effect. The conservative nature of evolution means that all our protiens and chemicals multitask, and therefore disrupting them in any way almost never yields solely the intended goal. The clam of CAM that there modalities have no side effects is therefore proof that they have no primary effects either.

  22. BKsea says:

    It seems that a broader question raised here is whether medicine should seek to harness placebo effects in the treatment of patients. It appears to me that these studies show that in pain management, placebos such as acupuncture can be highly effective at making patients feel better. Is it ethical to deny a patient the opportunity to feel better just because the “treatment” elicits a placebo effect? On the other hand is it ethical to lie to a patient, if that is necessary to get the optimal placebo effect? I am curious to hear the opinions on this subject.

    I would argue that the optimal medical therapy is one that maximizes both the mechanistic medical benefit (i.e. drugs, etc.) and the perceptual benefit (i.e. placebo). In the former, issues of risk/benefit come into play. In the latter, the considerations might be a zero-risk intervention and the need to consider individual patient characteristics and how they will respond. I think this is where the mumbo jumbo from the CAM world arises – They are arguing how to optimize placebo effects and the science-based medicine world is arguing how to optimize mechanistic effects. No wonder it is like talking to a wall.

  23. Calli Arcale says:

    Todd W:

    I’d just add that as far as Vioxx is concerned, it functions remarkably well as a pain reliever and, at least at the time it was pulled, was reasonably safe for short-term use for acute pain flare-ups. The danger really came out for long-term use, IIRC.

    I believe you are correct. I had mentioned my grandparents briefly in my last post; they loved Vioxx, and wanted to be able to take it constantly for their arthritis pain. Precisely the group that the FDA was concerned about.

    In many respects, it’s a pity Vioxx was just completely removed, because it was useful for short-term situations. Not as an arthritis treatment, since of course that’s something that doesn’t really go away. But it could’ve had its uses. I’m still a bit sad that Seldane had to go away; it was voluntarily pulled by the manufacturer (who came out with Allegra as a replacement; it’s just as effective, but more expensive) after studies showed that it can have lethal interactions with certain antibiotics in hospital settings (i.e. high intravenous doses). It wasn’t actually banned, and I think you can still get generic terfenadine. But the manufacturer knew nobody would touch it after that, and to be totally honest, I can’t really blame folks for not wanting Seldane after that.

  24. AusShane says:

    OzDigger illustrates some valuable points about how we look at the world of nature. Evidence based medicine means just that, there has to be some proof of an effect. It took a long time for civilization to develop a method for proving reality, and that method has stood us in good stead ever since. In recent times that model has been challenged to suit certain agendas. No longer does hard data become necessary, all we need are some feelings, anecdotes and a little indecipherable magic to convince people that a phenomena is real. If the rest of us require a bit more than that to be convinced then we are closed minded? Does anyone really think that if there were medicines that were 100% effective with zero side-effects that the evil ‘big pharmas’ wouldn’t be making squillions out of them? Science will never be able to ‘catch up’ to non existent truths. That is the power of this BS, it hooks into the individual psychology of the person and no amount of reality will change that. Contrary to popular belief these therapies do come with a significant mortality, that of misdiagnosis. Getting acupuncture for back pain might not kill you, but if your ‘therapist’ doesn’t recognise a spinal metastasis, nor understand the natural history of such disease processes, well you are just as dead. The older I get the more I am convinced that a significant portion of patients who present to General Practitioners have a psychosomatic illness. In which case the placebo effect, and the very act of listening to their problems will make them feel better regardless of the efficacy of the treatment. However it doesn’t matter how ‘good’ I feel about my condition if I have an undiagnosed cerebral anuerism no amount of placebo will cure me, and therein lies the real danger of CAM.

  25. Harriet Hall says:

    I made a mistake. I misidentified one of Dr. Kelly’s references. My original post read

    “A review of published methods of applying acupuncture. It concluded: For non-specific low back pain, treatment regimens of acupuncture differ by the types of reference sources, in terms of treatment frequency, the points chosen, number of points needled per session, duration and sessions, and co-interventions.” It said nothing about efficacy. One wonders if Kelly realized what this study was about or just noticed that it was a systematic review and included it without reading further.”

    I have corrected that section to read:

    “A systematic review of RCTs that found “There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief.” In other words, acupuncture is no better than placebo, and using a placebo is better than doing nothing.”

    My abject apologies to Dr. Kelly and to my readers.

  26. kausikdatta says:

    @Todd W.

    And it is also why many, many more drugs than ever are approved are kept from making it to market. The process does a pretty good job of weeding out drugs that show no or inadequate efficacy or show an unreasonable risk compared to the benefits (e.g., drugs that look okay in animal models but prove fatal in Phase I human trials). In general, the dangerous products never even make it to Phase 2 or 3, let alone to market. All because of a rigorous system in place to screen them.

    Absolutely. Thanks for pointing that out, Todd. Actually, a lot of the New Chemical Entities (fancy name for investigational molecules) get weeded out in preclinical testing, and those that pass may get stuck during PK/PD and toxicity testing in animal models. The phased trials come later. This is a pretty rigorous system in place, within the constraints of its one shortcoming – that it is impossible to predict one hundred per cent what effects a pharmacoactive agent will have in any given individual. Mankind has been reaping the benefits of this system for a long time (despite the tin-foil hats).

  27. kausikdatta says:

    @BKSea:

    It appears to me that these studies show that in pain management, placebos such as acupuncture can be highly effective at making patients feel better.

    I don’t want to make assumptions, but perhaps you are overstating the effects of placebo. There is no ‘efficacy of placebo’. Placebo is not a defined parameter whose efficacy you can judge by empirical or any other means. Placebo effect in a patient is a collection of random, probabilistic, ill-defined and unintended consequences.

    Let me emphasize this. It is random, a part of normal biological variations, meaning it can go either way, good or bad – and systems geared to show ‘efficacy of placebo’ – such as the CAM crowd – will more often than not cherry-pick the desirable effects and disregard the negative ones.

    That is the main reason why placebos that masquerade as therapy – such as acupuncture, reiki, crystal healing, magnet therapy, intercessory prayer, homeopathy and so forth, there’s no end to human craziness – don’t work in any randomized clinical trials, because their glaring lack of efficacy is revealed under any amount of scientific scrutiny.

    When you assume that the patients will feel better from being lied to (i.e. the false claims of CAM), you display an immense paternalistic hubris that science teaches us to avoid at all costs.

  28. Deetee says:

    “Does anyone really think that if there were medicines that were 100% effective with zero side-effects that the evil ‘big pharmas’ wouldn’t be making squillions out of them?”

    Good point.
    Someone is making squillions however. The turnover of Boiron, the foremost producer of homeopathy remedies in Europe is many billion euros each year. Not hard to see why: No R&D costs, no safety or efficacy trials required, negligible production costs (just a system for doing dilutions and bottling the resultant pure water/alcohol). Only major expense is marketing as far as I can see.

    Big Pharma is continually slated for trying to produce medically-effective medicines and heavily criticised (or sued) if any drug has side effects. Yet in terms of ethical practice they definitely have the morality high ground over the homeopathic producers who generate streams of useless junk and cream in vast profits, and hey, guess what? No one says their stuff made them worse or killed them or tries to sue them for billions. Its a win win for these charlatans.

  29. Harriet Hall says:

    Dr. Kelly, the author of the article in AFP, has given me permission to post this e-mail he wrote me:

    Thank you for correcting the error in your initial post. Apology accepted.

    Much of your criticism seems to boil down to something like this: if “real” acupuncture is not “significantly” (statistically) better than “sham” acupuncture, then “real” acupuncture is no better than placebo, and therefore cannot be recommended as an effective therapy. You would not be the first to make this type of statement.

    BTW, when “real” and “sham” acupuncture had the same results, or when “real” acupuncture had better results but was not significantly better than “sham”, or when “real” acupuncture significantly outperformed “sham”, I stated it as such in my AFP article.

    Here’s one dimension of the problem: “Sham acupuncture” is usually done by using needles in different points or in different ways than “real acupuncture”. It is not an inactive treatment but rather an active treatment that does not follow a TCM tradition. In RCTs, “real acupuncture” is usually done in a standard way, using the same points needled in the same way for each patient in the study. This approach risks underestimating the effects of acupuncture as it is usually practiced (individualized to each patient). Given these limitations of Western RCT research methodology, it is not surprising to me that the difference between “real” and “sham” acupuncture does not reach statistical significance in numerous studies. Improved methods may help – look at the Mayo Clinic study of acupuncture treatment for fibromyalgia (that I cited) for an example of excellent methods that I would recommend to future investigators.

    In my view, most “sham” acupuncture demonstrates what I would call a “nonspecific” effect: that the location(s) of the needles did not matter to produce the measured effect. When “real” acupuncture outperforms “sham” acupuncture, this demonstrates what I would call an additional “specific” effect; that the location(s) and/or stimulation of the needles in the particular study did matter. When “real” acupuncture does not outperform “sham”, it means that no additional specific effect of that method of “real” acupuncture was demonstrated. This could be because [1] there is no effective specific acupuncture treatment OR [2] that an ineffective or too-standardized “real” acupuncture treatment was chosen for the study.

    This is just one example of an issue that exists in acupuncture research. There are numerous other aspects, which I briefly touched on in my article in AFP. I would call your attention to the references I cited for a more thorough exposition of these research issues. However, even with these limitations, there is good evidence to support the option of a trial of acupuncture in numerous pain conditions – hence the statements made in my AFP article.

    I can’t resist adding the following comment: When patients feel better, they usually don’t care too much whether they are benefiting from a specific effect, a nonspecific effect, or a placebo effect.

  30. Scott says:

    I wonder how Dr. Kelly accounts for the various studies which utilized sham needles which don’t break the skin, or did tailor the acupuncture to individual patients, and still didn’t find any effect beyond placebo.

    But that doesn’t change the fact that the bottom line of his answer is “yes, it’s just an elaborate placebo, but that doesn’t matter.” One wonders whether he’d support giving patients sugar pills and telling them it’s a painkiller.

  31. squirrelelite says:

    Just a few comments.

    Scott –

    You hit the nail on the head. I had the same thought about risk to benefit ratio myself.

    Kausikdatta–

    The concept of placebo that I have gleaned from reading many postings on SBM and related blogs very much agrees with what you describe. Essentially, “placebo” is a careful and elaborate system to help us control for all the noise that is inherent in medical testing on humans and find out if there is a real signal in there somewhere.

    In other words, does what we are testing have a real effect and is it a benefit?

    I also remember a couple months ago when the results of this (I think) real acupuncture vs sham acupuncture study were discussed. I noticed that initially both the “real” and sham acupuncture seemed to show a benefit compared to the null procedure, but that after six months (when the data ended) that relative benefit was greatly reduced. Were the test subjects starting to realize that what was being done wasn’t really helping them???

    I also saw a news item a couple nights ago. There is a sort of competition going on to choose a site for a new center to treat returning military veterans with post combat traumatic stress disorder using “wellness based modalities” like massage therapy, yoga, and acupuncture. I could only shudder.

  32. BKsea says:

    @kausikdatta:
    “There is no ‘efficacy of placebo’. Placebo is not a defined parameter whose efficacy you can judge by empirical or any other means.”

    I disagree with both of these statements. While I agree there is no mechanistic efficacy of placebo, there is a mental effect. My point is that in pain management, mental effects, whether they are due to self-delusion or distraction, should be used if they honestly make the patient feel better. The question is how to best harness these mental effects?

    The answer is to test different approaches against one another. To illustrate, suppose that I propose having the physician chew gum at the end of a standard treatment as a way to remove the “aura of tension”. Obviously any effect of this “treatment” would be placebo in nature. We could, however, compare this placebo approach to acupuncture in a controlled (albeit unblinded) study. I suspect acupuncture would perform better and could be confirmed to be a better placebo than chewing gum. On the other hand, if chewing gum performed better, don’t you think a lot of physicians would start using this technique?

  33. BKsea says:

    I imagine the following question is addressed in a medical ethics class, but as a researcher, I missed that class. In response to Scott, I fail to see the moral imperative against “giving patients sugar pills and telling them it’s a painkiller.” Consider the following situation: Suppose you have 300 patients suffering from pain that is on best medical therapy, but still causes them to have trouble falling asleep. Now suppose you give 100 of them a sugar pill and tell them it will ease their pain and help them sleep. Give 100 the sugar pill and tell them it is a sugar pill. Finally, do nothing for the last 100. Then, see how long it takes them to fall asleep. I would be willing to bet that those getting sugar pills and being lied to would fall asleep sooner. In that case, we’d have a demonstrable improvement in patient quality of life “effected” by the sugar pill / lie. What is the ethical argument against using this tool? (Please don’t answer that they should be given sleep aids – I am looking for the philosophical argument against this concept in general).

  34. Todd W. says:

    @BKsea

    The problem with giving a placebo and telling them it is an active treatment outside of a clinical trial is that it violates a patient’s right to be informed of what treatment they are receiving so that they can make an informed decision about their personal health.

    In a clinical trial that uses a placebo control, part of the informed consent process is explaining that the patient might receive a placebo, what that means and that neither the patient nor the person administering the treatment (in double-blind studies) knows which is which. It is then up to the patient to decide if they want to take the risk of receiving an inactive treatment.

  35. kausikdatta says:

    @BKSea:

    While I agree there is no mechanistic efficacy of placebo, there is a mental effect.

    Do you have any evidence for that, or is it just that nebulous concept, ‘mental effect’, playing in your mind? Is there a demonstrable psychological or neurological effect that placebo produces? If you say, ‘yes, it does’, what kind of effect is that? How frequently and how reliably does it occur – one in one, in ten, in hundred occasions? How much of it is related to the amount of the placebo – less placebo (50 sugar pills instead of 100), less effect, more placebo, more effect?

    Answer all these questions (people in drug discovery business have to, every day) in the affirmative, and you have a ‘medicine’, that has a defined effect, and hence can be appropriately dosaged for the patient. If you answer ‘No’ to any of these questions, it is merely a placebo, it has no clinical use, it has no effect beyond what is a result of random, probabilistic chance.

    And as for your reply to Scott:

    …I would be willing to bet that those getting sugar pills and being lied to would fall asleep sooner…

    I maintain that it is your incredible, paternalistic hubris – that you ‘know what’s best’ for the patients – that is prompting you to think and feel this way. You are advocating therapy – however ineffectual – on a group of unsuspecting patients who are supposed to take your word on your authority, and undergo on faith a therapy (the said sugar pills) whose efficacy has absolutely no evidentiary support whatsoever. You would make a wonderful priest of ___ (insert your favorite religion here), I am sure, but as an ethical practitioner of medicine, it is a huge FAIL.

  36. Scott says:

    “What is the ethical argument against using this tool?”

    To put it a bit more briefly than Todd, the ethical problem is that you’re lying to them. Really, this simple observation ought to be plenty.

  37. BKsea says:

    @kuasikdatta:

    The proof for the existence of a “mental effect” of placebos is in the acupuncture studies quoted above themselves. They consistently show that people getting acupuncture (or sham acupuncture) report feeling significantly more pain improvement than those not getting it. We all agree that the effect is not due to a true physical mechanism. Then, if it is not in the patients’ minds where does the “effect” lie?

    To everyone else: I guess I will have to accept that a physician must never lie. Thinking about it a better argument would be that if one lie is ever exposed, it will permanently harm the credibility of the medical community. Better to forgo the short-term benefit (?) rather than risk the long term harm to all future patients. Thanks for weighing in.

  38. squirrelelite says:

    Since I referred to a specific study about the relative benefits of “real” and sham acupuncture, which I thought came out “a couple months ago” and that continues to be a primary line of discussion for this blog post, I decided to see if I could find the data I thought I remembered.

    Actually, it was in May 2009 when Steven Novella wrote a 2 part discussion of those results:

    http://www.sciencebasedmedicine.org/?p=492

    http://www.sciencebasedmedicine.org/?p=500

    The PubMed reference for Cherkin DC et al is here:

    http://www.ncbi.nlm.nih.gov/pubmed/19433697?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    In summary, 638 adults … were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists.

    “They were scored according to back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale).

    Outcomes were assessed at baseline and after 8, 26, and 52 weeks. RESULTS: At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P < .001). "

    In other words, individualized acupuncture practiced by experienced acupuncturists is slightly worse than standardized acupuncture and equivalent to simulated acupuncture. So, if individualized acupuncture is really better than standardized or simulated acupuncture, then it needs to be defined in a way that can be taught to "experienced acupuncturists" and shown to produce "clinically meaningful improvements".

    Keep in mind that (as Steven Novella points out) all groups continued to receive their "usual care", in other words pain medication.

    So, what made the difference was whether the patients knew they were getting stuck.

    "Participants receiving real or simulated acupuncture were more likely than those receiving usual care to experience clinically meaningful improvements on the dysfunction scale (60% vs 39%; P < .001). Symptoms improved by 1.6 to 1.9 points in the treatment groups compared with 0.7 points in the usual care group (P .05).”

    So, the participants receiving “usual care” continued to improve while the three acupuncture groups stayed about the same.

    60% —> 59-65%

    Half the difference between acupuncture (sham or real) plus pain medication and just pain medication has gone away.

    Steven does cite the article to report that participants in the three acupuncture groups took less of their pain medications at the end of the study than those in the “usual care” group.

    Perhaps that is why their symptoms did not improve.

    At any rate, I think the onus is on anyone who claims a benefit from some drug, herb, treatment regimen, or whatever to define it in a way so that the benefit can shine through the fog of the placebo effect.

  39. tmac57 says:

    I don’t think this debate will ever be settled for the following reason: Every time that I try to explain to someone with no medical background why acupuncture, homeopathy, reiki etc, doesn’t work, I get this general response ” Well, whats the difference if it makes people feel better?”
    As long as you have people willing for others to be fooled into feeling better, and they constitute a substantial segment of the population (and they do apparently), then we have a defacto societal contract (for some) that says ” I don’t want to know if this is real, just make me feel better”. A kind of don’t ask, don’t tell form of ‘medicine’.

  40. ”Patients want to be listened too.”–
    Sure. I agree. But let’s be honest, and not fool ourselves and anybody else. In psychotherapy, we would technically, officially call this “supportive therapy,” or informally, amongst colleagues, hire-a-friend.”

    Empiricism: if it works, and the benefits are not outweighed by harms, and if pt. is informed, then go ahead: let’s listen to patients as an intervention. Studies have been done on this for pts. with “medically unexplained symptoms,” with high utilizers of medical care, etc.

    In practice, it really doesn’t go well to say: “hey this is all in your head – I am gonna refer you to a counselor.” But you can do this: “hey – along with medical treatment for [fill in the blank with the diagnosis du jour, recognized by its characteristic symptoms of: low energy, fatigue, difficulty concentrating, diffuse aches and pains, dizziness, etc.] – we know that lifestyle has a great impact on how a disease impacts your life – We need a holistic interevntion – I want to refer you to our health psychologist [or whomever] who trains people in how to manage chronic illness — stress management, wellness things like exercise, diet, and sleep, and things like that – I am going to refer you, and follow up to see how this works for you.”

    Figure out someone somewhere to do this for you. Figure out how to bill for it. Follow an evidence-based chronic illness management program such as Kate Lorig’s, and make sure to let the counselor know that they have liberty to add a healthy dose of “listening” PRN.

    Along with the empirical evidence, I have done the counseling part myself. One pt had terrible arthritis – you could see the swollen knuckles. Once we started talking, she skipped the pain mgmt agenda I had prepared, and she just went on to talk about: alcoholic boyfriend, lazy irresponsible young adult son, money management problems, etc. Across a couple months, her pain from arthritis disappeared from her agenda — use of pain meds decreased, sleep interference from pain decreased, etc., — pain relief disappeared from her list of “what the patient wants;” she wanted someone to listen, plus she needed to learn basic assertiveness and a few psycho-ed type skills like that.

    So, if what the pt wants is someone to listen — in a certain salubrious way – let’s do it; and let’s not carry on the charade of ineffective interventions (acupuncture, chakra re-alignment, magnetic therapy, tuning fork therapy, etc.).

  41. Harriet Hall says:

    Dr. Kelly said “When patients feel better, they usually don’t care too much whether they are benefiting from a specific effect, a nonspecific effect, or a placebo effect.”

    No, patients don’t care, but doctors should care. Ethical doctors do not lie to their patients. Doctors have a responsibility to choose effective treatments for their patients and not to deceive them with placebos.

    If he really believes this, does he extend his philosophy to drugs? Does he prescribe drugs that have been tested and shown not to be any better than placebo? I submit that he probably does not, and that he is using a double standard. He wants to believe acupuncture works and he is willing to accept a level of evidence that he would not accept for a pharmaceutical.

  42. BKsea says:

    The last several posts really hit the nail on the head regarding this issue. As tmac57 states you get a general response of “Well, what’s the difference if it makes people feel better?” I posted several provocative questions earlier exactly because I did not feel I had a reasonable answer to this question. One of my central issues is that there seemed to be a slippery slope in the argument that acupuncture is bad merely because it is a placebo. As MedsVsTherapy seems to argue, it would be better to send the patient to psychotherapy or counsel the patient yourself. However, where is the evidence that this works? Yes, there are studies (e.g. see Cochrane review of April 2009) that suggest some benefit of psychotherapy to control pain. However, these studies completely lack blinding and proper placebo control (sham psychotherapy?) Why might physicians argue against acupuncture, but have an easier time accepting psychotherapy?

    The answer is this. You can recommend psychotherapy without lying to the patient. Paraphrasing MedsVsTherapy, you can simply state that “in addition to medication, some people find that talking to a therapist helps improve their lives.” You could also state the same thing about acupuncture, i.e. “in addition to medication, some people find that acupuncture helps improve their lives.” However, this contains an implicit lie because acupuncture is based on the concept of qi. To recommend acupuncture is to endorse qi on some level. I think that is what does not sit well with physicians.

    So a recommendation to Dr. Hall: Perhaps you need to expand your argument to get through. The fact that acupuncture is a placebo is only part of the story. The bigger problem in the journal American Family Physician permitting an article that suggests that acupuncture is appropriate for pain management is that it implies to the physician that he/she should either believe in qi or allow the patient to believe that the physician believes in qi. You might get more traction with your argument if you asked the editors, “So, are you asking me to lie to my patients?”

  43. Scott says:

    There are other problems, too. The “helps improve their lives” approach still strikes me as somewhat deceitful even without considering qi, since to me it tends to imply that it’s the acupuncture part that helps.

    I would also strongly suspect that providing a sympathetic ear in a relaxing environment could be done much more cheaply than what acupuncturists charge – a very significant point given what health care costs these days. Paying a premium for what is, in the end, just so much window dressing seems exceedingly questionable.

    And while there may not be placebo-controlled studies demonstrating that such sympathy and relaxation are actively beneficial (though in one light, all the acupuncture vs. standard care studies could be so construed), that’s not much of a problem since that’s not presented (explicitly or implicitly) as if it has any specific effect.

    Anyway, given that the question such a study would ask is simply “does it feel good” I think that anecdote, prior plausibility, and personal experience are actually enough to answer confidently in the affirmative. Not EVERYTHING needs to be rigorously tested.

  44. qiwiz says:

    To quote Dr. Hall about me: “he is using a double standard. He wants to believe acupuncture works and he is willing to accept a level of evidence that he would not accept for a pharmaceutical”. I could say that Dr. Hall believes that acupuncture does not work, but since I don’t actually know what she believes, I would not go that far. Maybe she wants to believe that acupuncture works, but is not yet convinced that the evidence is strong enough.

    Many of those who post to this site are quick to criticize, perhaps with incomplete understanding of what they are criticizing. In my own practice of acupuncture, I treat people every day who have not had their symptom patterns (pain or non-pain or both) improved with standard “Western” medical evaluation and treatment. Some don’t respond to acupuncture, some respond minimally, some respond moderately, and some respond completely. Those that respond well are very happy that they are feeling much improved, are able to do more, function better, etc. They don’t care if we “scientists” would describe them as having a “placebo” effect or a nonspecific or specific effect of acupuncture. That is my point. To offer a trial of acupuncture to patients that request it, in the hope that it improves symptoms, quality of life, or functional status is not lying to them. If they get better, I’m never sure exactly why, though they will usually credit the acupuncture treatment. If they don’t get better, all I know is that what I did was not helpful.

    I don’t have the time to go into the issue of sham acupuncture in great detail, but suffice to say, the best sham (in my opinion) would be that no needle actually picured the skin anywhere, but also that the patient could not tell one way or the other (ie., effective patient blinding as to treatment status, “real” vs “sham”). I would refer you to the 2007 Mayo Clinic study of acupuncture treatment for fibromyalgia in which this type of blinding was effectively accomplished. In this study, despite using a standardized protocol rather than individualized treatment, “real” acupuncture did outperform “sham” acupuncture with statistical significance, using a standard fibromyalgia symptom score that has been used in other studies of fibromyalgia treatment.

    Robert Kelly MD

  45. Scott says:

    Would you like to reply to the particular questions that have been raised? In particular:

    I wonder how Dr. Kelly accounts for the various studies which utilized sham needles which don’t break the skin, or did tailor the acupuncture to individual patients, and still didn’t find any effect beyond placebo.

    For example:

    http://www.ncbi.nlm.nih.gov/pubmed/19433697?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    Discussed in this post:

    http://www.sciencebasedmedicine.org/?p=492

    And particularly:

    One wonders whether he’d support giving patients sugar pills and telling them it’s a painkiller.

    Or if you prefer, telling them it may make them feel better.

  46. Harriet Hall says:

    Dr. Kelly says he doesn’t know what I believe. I try not to “believe” anything but to reach a provisional conclusion based on the best available evidence. He “believes” acupuncture works. I looked at the evidence and concluded that the evidence is compatible with the hypothesis that acupuncture is nothing but an elaborate placebo.

    He says some patients respond to acupuncture, but some patients respond to every kind of quackery. I, for one, would like to know which my patients are responding to.

    He argues that individualized acupuncture might be better, but does not comment on the trial cited above that showed that individualized treatment was not better.

    In response to the trial he cites in his last comment, I offer R. Barker Bausell’s trial described in “Snake Oil Science” where the only factor correlating with success of real or sham acupuncture was whether the patient believed he had received the real thing. Those who got the real thing and believed it was the sham treatment were less likely to respond; those who got the sham treatment and thought it was the real thing were more likely to respond.

    I can condone telling a patient that other patients have thought acupuncture helped them, but I would preface it with the statement that scientific testing had not shown it to be effective, and that the apparent effects were compatible with placebo response.

    Dr. Kelly has still not told us whether he would prescribe a medication that had not been shown to be superior to a placebo.

  47. Harriet Hall says:

    Dr. Kelly sent me an e-mail saying “Most “sham” acupuncture as used in research studies is not the same as “placebo”, but rather is a nonspecific type of acupuncture. The typical study is therefore comparing nonspecific acupuncture with a standard non-individualized acupuncture. This is one reason that “real” acupuncture is often better than, but not significantly better than, “sham” acupuncture. I’m confident that we will continue to disagree, and I can live with that. Be well.”

    So why haven’t acupuncture researchers been able to come up with a control that they think is a placebo?? When you use the “stage dagger” retractable needles and there is no penetration of the skin, and the patient can’t tell if it was a real or sham needle, how can you call that “nonspecific acupuncture”? If you want to define any skin stimulation anywhere on the surface of the body as “acupuncture” the whole concept of acupuncture becomes meaningless. If you think nonspecific acupuncture is effective, why bother with all the rigamarole about acupuncture points and meridians? Maybe stroking the skin or giving a massage is equally effective?

    To get back to the medication analogy, would you argue that the sugar pill might really be effective?

  48. “If you want to define any skin stimulation anywhere on the surface of the body as “acupuncture” the whole concept of acupuncture becomes meaningless. If you think nonspecific acupuncture is effective, why bother with all the rigamarole about acupuncture points and meridians?”

    If “non-specific” acupuncture works as well as “traditional &/or individualized” acupuncture then the underlying principles and understanding of acupuncture are all invalid, and the Chinese have been mistaken for “thousands of years” about how acupuncture “works”.

    The claim that “non-specific” acupuncture works actually overlaps the actual science of acupuncture a bit: Meridians are BS, chi doesn’t exist, and all you need to do is randomly poke yourself with toothpicks; why pay someone else to do it if all their expertise in unnecessary? I guess it helps to sell the placebo if you have a convincing showman doing the performance.

    No one’s denying that there was a quarter under you pillow when you woke up in the morning, we just say there’s no evidence or reason to believe that the tooth fairly put it there.

  49. OZDigger says:

    “Around three-quarters of New Zealand doctors who completed the survey reported having administered or prescribed a placebo, around half of respondents had done so in the previous year and 1 in 7 had done so more than 10 times in the previous year”.
    Journal of the New Zealand Medical Association, 03-July-2009, Vol 122 No 1298
    I wonder how many of the New Zealand doctors who responded to this survey would like to be called “liars and cheats”, when all they are doing is trying to manage their patients in such a way, to be safe and efficacious.
    They main problem I see in this blog, is that so many of the contributors have not seen a patient in “general practice” for such a long time, that they forget what it is like to manage the patients who do not quite fit in the box.

  50. OZDigger says:

    The the issue will be, “What is a safe placebo?.
    Water (homeopathy), needles (acupuncture), Spinal Manual Therapy (Chiropractic, physical therapy or osteopathy), of Clinical Toxicology (Prescribed medication).

    Any of you techo-pseudo-scientist got any bright ideas on what is going on in primary health?

  51. BKsea says:

    To OZDiggger: the New Zealand doctors who responded affirmatively to prescribing the placebos ARE liars, unless they told the patients they were being given placebos. I don’t think they were cheats in that they most likely thought they were acting in the patients’ interests. I think the point that has been made in these comments is that it is unethical for a physician to lie to a patient in any circumstances. It harms the patient-doctor relationship and calls into question the credibility of the medical community. If you institutionalize lying to the patients, why would a patient believe anything a doctor says? In that regard, there is no such thing as a safe placebo.

  52. OZDigger says:

    I would estimate that the prescribing habits of M.D.’s between Australia and New Zealand to be very similar. They are probably similar to those prescribing habits of the U.K., Germany (St.Johns Wort is used instead of anti-depressants in mils and moderate depression), France and Canada.
    Thus, I believe that stats for M.D.’s in the U.S.A. using prescription medication as placebos would probably be very similar to New Zealand and other members of the British Commonwealth.
    Unless you can prove to me otherwise, then we can presume this to be a fact.
    No one is advocating lying to ones patients. However, to be blind to the fact that this is occurring is naive.
    The question is, which you are all very reluctant to answer is, “Why”?

  53. tmac57 says:

    For the acupuncture proponents out there, is this a good idea?
    “Childrens Hospital Los Angeles Offers Pediatric Acupuncture Program to Help Children Manage Chronic Pain”
    “LOS ANGELES – The Pain Management Clinic at Childrens Hospital Los Angeles is collaborating with Yo San University of Traditional Chinese Medicine to create a pediatric acupuncture program to help children manage chronic pain, according to Jeffrey I. Gold, Ph.D., director of the Pediatric Pain Management Clinic, and assistant professor of clinical anesthesiology and pediatrics at the Keck School of Medicine of the University of Southern California.”
    …”The collaboration provides an opportunity for Yo San University students to obtain clinical experience at Childrens Hospital Los Angeles, which is a teaching hospital with more than 575 medical students, 83 residents and 86 fellows.”
    See the whole press release here: http://www.childrenshospitalla.org/site/apps/nlnet/content2.aspx?c=ipINKTOAJsG&b=5207503&ct=6710963

  54. nobs says:

    From Harriet’s AFP/CE on Chronic Lowback Pain–

    ……”Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are effective in certain clinical situations.”

    From this, Harriet declares: “AFP PROMOTES ACUPUNCTURE”
    It is impossible(to an objective, unbiased reader) to conclude(per AFP above) that Harriet’s reference “PROMOTES” acupuncture.

    Instead, it is balanced in it’s approach to chronic low back pain- a condition for which allopathic treatment has a dismal record. The AFP/CE article suggests and acknowledges that acupuncture may be effective “in certain clinical situations” Evidence supports that AFP assertion.

    Harriet’s elevation of this statement to “promotion” is a disengenuous exaggeration.

  55. Harriet Hall says:

    nobs,

    My point was that AFP gave acupuncture an “A” strength of evidence rating for low back pain, neck pain, headache (chronic idiopathic), and headache (migraine) corresponding to “consistent, good-quality patient-oriented evidence.” I do not think that is accurate. The evidence for acupuncture is consistent with the hypothesis that it works no better than placebo. This looks to me like a double standard: if they looked at a drug that was not consistently better than placebo, they would not give it an A rating.

    In fact, different publications of the AAFP have given different opinions. The FP Essentials Home Study module #359 on headache, April 2009 reads “A Cochrane review of acupuncture in migraine headache supported the value of true acupuncture compared with sham acupuncture. However, many of the 26 studies had methodologic flaws, and the reviewers concluded the evidence was insufficient.”

    If the evidence is insufficient, it does not deserve an A rating.

  56. Joe says:

    Harriet Hall on 18 Sep 2009 at 9:21 pm “… In fact, different publications of the AAFP have given different opinions. The FP Essentials Home Study module #359 on headache, April 2009 reads “A Cochrane review of acupuncture in migraine headache supported the value of true acupuncture compared with sham acupuncture. However, many of the 26 studies had methodologic flaws, and the reviewers concluded the evidence was insufficient.””

    I have my doubts about Cochrane reviews these days. Edzard Ernst commented on one questionable review on his blog http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4123523&c=1 (free registration). He suggested the review (of Chinese herbs for endometriosis) was to good to be true.

    My response was that several years ago I saw a list of some Cochrane reviewers and some had bogus credentials (e.g., naturopathy; sorry, I lost track of that link). Ernst responded that limiting who may participate in the reviews was not “PC.”

  57. OZDigger says:

    Please Harriet, watch your blood pressure when you read this, especially the bit about placebos and antidepressants.

    Social support and beliefs affect a patient’s ability to rebound from illness, Dr. McDiarmid added, pointing out that over half of the people who respond to antidepressants do so because of the placebo effect.

    http://www.nytimes.com/2009/09/20/us/20shaman.html?_r=1&em

  58. coleman22 says:

    You guys are retarted. I have seen acupuncture work day in and day out for the last five years.
    Especially for pain.
    You waste time trying to “prove” its effect with “science”
    Acupuncture is not rooted in science you jackass.
    Acupuncture is rooted in Taoism. It’s rooted in the Chinese concepts of yin and yang. It’s rooted in the ART of observation.
    Open your fucking eyes. Western medicine kills people every goddamn day.
    It’s what, the 4th leading cause of death in this country. “Iatrogenic”. Ever heard of it.
    People are waking up to this fucked up profit based “science” as you call it, where every one is squeezing every last cent out of th system that they can.
    You Herriet, are a sham. You and that dick wad over at quackwatch are serving very little useful purpose to the people.
    What you call placebo, I call healing. Just because you cant explain it doesnt matter to the person who doesnt have cancer anymore, does it? you think that person gives a shit about how it happened?
    Healing is possible. Prevention is now in the hands of what you call “alternative” medicine. I call it simply… medicine. It is traditional. It has been used for centuries, and there is wisdom in it.
    This medical establishment has lost the trust of the people in this country and it is because of naysayers like your self who push drugs and fuck people up. Sometimes they die. 4th leading cause of death.
    go fuck yourself

  59. Scott says:

    Yeah, all that profanity is a really good way to get people to listen to you.

    YI have seen acupuncture work day in and day out for the last five years.

    You mean you *think* you have seen it work. Humans are far too fallible for that to be reliable.

    You waste time trying to “prove” its effect with “science”
    Acupuncture is not rooted in science you jackass.
    Acupuncture is rooted in Taoism. It’s rooted in the Chinese concepts of yin and yang. It’s rooted in the ART of observation.

    Utterly irrelevant, and not even wrong. If it has an observable effect (which would include subjective pain relief!) then it can be studied scientifically.

    Open your eyes. Western medicine kills people every day.
    It’s what, the 4th leading cause of death in this country. “Iatrogenic”. Ever heard of it.

    Even more irrelevant; the failings of medicine don’t have any bearing at all on the efficacy of quackery.

    People are waking up to this up profit based “science” as you call it, where every one is squeezing every last cent out of th system that they can.

    Just like acupuncturists, chiropractors, naturopaths, homeopaths, etc. Your point? Except perhaps that real doctors generally work ethically, instead of scamming people out of their money while providing no benefit.

    What you call placebo, I call healing. Just because you cant explain it doesnt matter to the person who doesnt have cancer anymore, does it?

    Now see, you’re assuming that it works. When the evidence is quite to the contrary. Whereas if acupuncture has actually cured cancer, it should be a simple matter for you to prove it. But you won’t, of course, provide any actual evidence.

    The “proof by vigorous assertion” and “proof by profanity” don’t actually prove anything at all.

    Healing is possible. Prevention is now in the hands of what you call “alternative” medicine. I call it simply… medicine. It is traditional. It has been used for centuries, and there is wisdom in it.

    Traditional, used for centuries, and enthusiastically endorsed – yep, just like slavery.

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