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Can we finally just say that acupuncture is nothing more than an elaborate placebo?

I realize that Steve blogged about this study earlier in the week, but since I also commented on this particular study as my not-so-super-secret alter ego, I figured it rated a place on SBM as well. I emphasized different aspects of the study and tried to quantify exactly why, under even the most charitable interpretation of the study possible, the effects are not clinically significant. Besides, if the level of comments and e-mails is any indication, there is sufficient interest in this particular study to rate a second post.

Not suprisingly, this study is about about acupuncture. Well, it’s not exactly a study, it’s a meta-analysis that aggregates a whole lot of acupuncture studies in which this most popular of woos is administered to patients with chronic pain from a variety of causes. It’s also being promoted all over the place with painfully credulous headlines like:

In deference to that last article, I was half-tempted to call this post Quackery: Acupuncture does not relieve pain. Then there were news reports like this:

And, of course, on accompanying the above news segment there was a story like this describing a patient with chronic pain:

In January 2009 she was referred to Dr. Jun Mao, a licensed physician and acupuncturist at the University of Pennsylvania.

“The only thing I had not tried was acupuncture,” Zierler said.

Now, a new review of research suggests that this ancient technique may truly hold benefits for those suffering from certain forms of chronic pain.

In a review of 29 previous well-designed studies, which together looked at almost 18,000 patients, researchers at Memorial Sloan-Kettering Cancer Center found that acupuncture does, indeed, work for treating four chronic pain conditions: back and neck pain, osteoarthritis, chronic headache and shoulder pain.

Even “placebo” acupuncture, where the practitioner only pretends to place the needle or places the needle in a random site, is effective at relieving pain, though true acupuncture works better.

And so was born the propaganda line for this particular study, namely that it’s huge; that it is the most compelling evidence thus far that acupuncture “works”; that all that stuff about “sham acupuncture” being as good as “real acupuncture” isn’t true. But is this study strong evidence of any of this? Let’s go to the tape, as I like to say.

The study itself is from a group called the Acupuncture Trialists’ Collaboration. I don’t know about you, but the very existence of something called the Acupuncture Trialists’ Collaboration is disturbing to me. Be that as it may, the study is Vickers et al, Acupuncture for Chronic Pain: Individual Patient Data Meta-Analysis. It was just published online in the Archives of Internal Medicine.

My first inclination when reading this was to apply a dictum to it that applies to all meta-analyses, no matter what the research question is; GIGO, Garbage In, Garbage Out, just like a meta-analysis of acupuncture to treat headache four years ago. On the other hand, on the surface, this meta-analysis looks like it’s a big deal. It uses patient level data instead of aggregated data, which allows for a better meta-analysis in most cases. It tries to restrict its included studies to those with the highest methodological quality (although that doesn’t completely inoculate it from the GIGO label, as you will see).

So what the authors did was to search MEDLINE, ClinicalTrials.gov, and the Cochrane Collaboration Central Register of Controlled Trials for studies testing acupuncture against chronic pain. They then winnowed the pile of studies they found using several criteria:

Randomized controlled trials were eligible for analysis if they included at least 1 group receiving acupuncture needling and 1 group receiving either sham (placebo) acupuncture or no-acupuncture control. The RCTs must have accrued patients with 1 of 4 indications—nonspecific back or neck pain, shoulder pain, chronic headache, or osteoarthritis—with the additional criterion that the current episode of pain must be of at least 4 weeks duration for musculoskeletal disorders. There was no restriction on the type of outcomemeasure, although we specified that the primary end point must be measured more than 4 weeks after the initial acupuncture treatment.

Do you see a problem yet? I do. It is not required that all studies included have a sham placebo group. That means some studies were acupuncture versus no acupuncture controls, the latter of which could include groups that got anywhere from nothing to regular care. That’s just one problem that I see, because mixing studies that compare acupuncture to no treatment, to sham treatment, or to sham treatment and no treatment are comparing apples and oranges in a way. Pooling such studies is inherently problematic.

There are other problems, but let’s first discuss what the study showed. First, Vickers et al reported that patients who underwent acupuncture had less pain. That’s true. However, I find it very hard to be impressed by these results. Indeed, they were most…underwhelming. Basically, the study reported that “real” acupuncture resulted in pain scores that were 0.23, 0.16, and 0.15 standard deviations lower than sham controls and 0.55, 0.57, and 0.42 standard deviations lower than no-acupuncture controls for back and neck pain, osteoarthritis, and chronic headaches, respectively. What does this mean? The authors themselves try to put it into context:

To give an example of what these effect sizes mean in real terms, a baseline pain score on a 0 to 100 scale for a typical RCT might be 60. Given a standard deviation of 25, follow- up scores might be 43 in a no acupuncture group, 35 in a sham acupuncture group, and 30 in patients receiving true acupuncture. If response were defined in terms of a pain reduction of 50% or more, response rates would be approximately 30%, 42.5%, and 50%, respectively.

One notes that Vickers et al have chosen a rather dramatic example, with large numbers. For patients with chronic pain, it’s uncommon to have a 50% reduction in pain scores, and the standard deviation they chose was rather large. By their own argument, even if there weren’t any methodological issues with the meta-analysis and their conclusions were completely justified, Vickers et al have just unwittingly made the argument that the effect of acupuncture might be statistically significantly greater than placebo effects but that it’s almost certainly not clinically significant. What Vickers et al are arguing is that a change of 5 on a 0-100 pain scale (which would be a change of 0.5 on a 0-10 pain scale), a subjective scale, is noticeable by patients. It’s probably not. There is a concept referred to as “minimally clinically important difference” (MCID) defined as “the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate…a change in the patient’s management.” A recent review looking at minimal detectable and clinically relevant changes in pain scores in arthritis found a range in absolute terms between 6.8 and 19.9. Tubach et al assessed only the improvement aspect of the MCID and defined the minimal clinically important improvement (MCII) as the minimum improvement in the pain score reported by 75% of osteoarthritis patients ranking their response as “good” and reported that the MCII was -15.3 for hip osteoarthritis and -19.9 for knee osteoarthritis.

Here’s a hint: -5 (the difference between sham acupuncture and “real” acupuncture) is not clinically significant. The only way you can even approach clinical significance is to compare no-acupuncture controls versus acupuncture, in which case you’re adding placebo effects into any other effect observed, even if that effect is real (which I highly doubt it to be). Indeed, Vickers et al labor mightily to try to convince readers that this tiny effect, if it exists, is not just statistically significant, but clinically significant. They doth protest too much, methinks. In fact, I very much like how the grand master of the scientific analysis of “complementary and alternative medicine” (CAM), Edzard Ernst, put it:

Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, said the study “impressively and clearly” showed that the effects of acupuncture were mostly due to placebo. “The differences between the results obtained with real and sham acupuncture are small and not clinically relevant. Crucially, they are probably due to residual bias in these studies. Several investigations have shown that the verbal or non-verbal communication between the patient and the therapist is more important than the actual needling. If such factors would be accounted for, the effect of acupuncture on chronic pain might disappear completely.”

Which brings me to another major problem with this meta-analysis. It’s one that I noticed and one that Ernst also comments on. None of the studies included that I perused were double blind, which means that there was the potential for observational bias to creep into the study. While I concede that the authors did a pretty good job of making sure that studies in which there was a possibility of what is known in the biz as unconcealed allocation; i.e., failure to protect the randomization process to guarantee that the treatment to be allocated is not known before a subject is enrolled in the study (in studies with subjective outcomes, like pain, unclear allocation concealment is associated with bias towards beneficial effects), no attempt was made that I could identify to make sure included trials were double blind. In studies of subjective outcomes, blinding is almost certainly as important or more important than allocation concealment, and double blinding is essential. As Ernst put it so well, a trial is “either both patient and therapist-blind, or not blind at all.” The investigators appear to have only assessed the selected studies for whether patient blinding was adequate, looking for descriptions of questionnaires in which patients are asked to guess which group they were assigned to. Without double blinding, it’s hard to call any of these trials included in this meta-analysis “high quality.” And, yes, it is possible to double blind acupuncture studies, as much as acupuncture fans try to argue otherwise.

Finally, there’s the issue of heterogeneity in the trials. The authors report a lot of heterogeneity for most of the analyses that were performed but gave one of the sketchiest descriptions of how they actually calculated that heterogeneity that I’ve ever seen in a meta-analysis anywhere. One wonders what the reviewers were thinking. For supposedly ascribing to the PRISMA methodology for high quality meta-analyses, which specifies the calculation of a statistic (I2) for describing the heterogeneity of each meta-analysis comparison that is done, the authors don’t live up to its principles in at least this one respect. They don’t report that statistic. That strikes me as more sloppy than anything else, given that the authors concede considerable heterogeneity in their studies, making combining them problematic.

Finally, there’s the issue of publication bias. Publication bias, as most of my readers probably know, is the tendency for positive studies to be more likely to be published than negative studies. That’s because scientists don’t like publishing negative studies (they seem like “failures”) and journals don’t like publishing them either (because editors don’t consider them very interesting). That’s why, it’s essential that a meta-analysis include an analysis looking for publication bias. One very common way of doing this is a funnel plot. Yet there is no funnel plot included that I could find (I couldn’t get access to the supplemental material because I had to have someone e-mail the study to me and forgot to ask). Instead, they talk about looking at effect sizes in small studies and large studies and then calculate that “only if there were 47 unpublished RCTs with n = 100 patients showing an advantage to sham of 0.25SD would the difference between acupuncture and sham lose significance.” How they calculated this number is not described. I must say, I’ve never seen this sort of analysis in a meta-analysis before, which is why it stuck out like the proverbial sore thumb, as did the lack of a description of how this estimate was calculated. Modeling? Why 47 unpublished RCTs of 100 subjects and not a smaller number of larger RCTs? The whole thing looks like a number the authors pulled out of their nether regions and then plugged into their meta-analysis software in order to see if it would affect anything. In fact, I have a sneaking suspicion that they probably tried a lot of combinations in order to find the one that would make it look as though it would take a whole boatload of studies going the other way to eliminate the statistical significance of their results. Is that unfair to say so? Well, the authors have no one to blame but themselves, and if I missed the description of how that was calculated I’ll take my lumps.

In the end, I am less than impressed by this study, and it doesn’t surprise me at all that it was funded by the National Center for Complementary and Alternative Medicine (NCCAM) and the Samueli Institute.

In fact, I’m pretty much unimpressed at the whole study, although no doubt it will be touted by acupuncturists for years to come as “proof” that acupuncture really and truly works and isn’t just placebo medicine. It doesn’t, and it is. In fact, the study strongly suggests that any effect of acupuncture observed is almost certainly due to nonspecific and placebo effects and that the “positive” result is, as Ernst describes, likely due to small residual biases. Even if we concede that there might be the small effect of “true” acupuncture reported by Vickers et al, it is almost certainly a finding that is statistically significant but clinically insignificant or, as I like to put it because I like baseball analogies, a really long run for a really short slide. As they say, garbage in, garbage out. Can we finally just say that acupuncture is nothing more than an elaborate placebo?

Posted in: Acupuncture

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33 thoughts on “Can we finally just say that acupuncture is nothing more than an elaborate placebo?

  1. Jan Willem Nienhuys says:

    I am a little puzzled about the idea to express an advantage of a treatment in terms of SD.

    When one is planning research, one needs to know the SD, and also the size of the conjectured effect in terms of this SD, otherwise one doesn’t know how many patients to include to draw any kind of meaningful conclusion.

    But the SD refers to how much patients differ between themselves, and actually not even that: only the patients included in a particular investigation. But an individual patient doesn’t care much about how his or her discomfort or pain changes, compared to the range of discomfort seen in all patients of all doctors together. The pain of the individual patient goes up and down and possibly the patient will notice it when the decrease in pain is compared to the patient’s personal range.

    On the personal level I think that 0.25 SD is unnoticeable. If your pain decreases by 0.25 SD on top of the normal fluctuations, you’ll still be worse off in about 40% of the cases if the degree of pain is normally distributed, whereas without this 0.25 SD you’ll be worse off in 50% of cases.

    One can also express ’0.25 SD’ in the number of individual tests one must do to reject the null hypothesis with p=0.05, say. That number runs in the hundreds. Any effect that needs 17,922 experimental patients to establish, cannot be observed at all by a single patient, or even by a single doctor who carefully records what happens to all his or her patients.

    Just imagine that you have to tell a patient: ‘It is impossible to know whether this unpleasant procedure will help you, but it seems that if you and 10,000 people like you are averaged, one can see some kind of difference.’

  2. Thomas says:

    As a thought exercise: let’s examine this from an economic point of view. Medical care costs are high.

    A key aspect that is missing here is cost control. If one placebo, acupuncture, is only mildly better than other placebos, why not look for a less expensive and time consuming placebo that is equally effective?

    The next step, following the logic of this study, would be to compare acupuncture, M&Ms, and a massage chair in terms of pain relief. If M&Ms are as effective as the other treatments, then it would make sense in economic terms to replace all acupuncture “therapy” with M&Ms.

  3. Cornelioid says:

    Thanks (to both of you) for looking into this one. I was curious as soon as i read the piece in Futurity. The piece (Wood et al) on bias toward beneficial effects suggests what you’re saying — whatever the main design, to include with it (if not as it) an analysis using only those studies that account for unconcealed allocation and are double-blinded. (I’ll read it in full later; thanks also for linking to it.) While the authors split their analysis into acupuncture–no treatment and acupuncture–sham acupuncture, it seems that they did not include a high-quality-only analysis.

    Also:

    Publication bias, as most of my readers probably know, is the tendency for published studies to be more likely to be positive than studies that remain unpublished.

    Isn’t this description something of a p-value fallacy? That is, isn’t publication bias better described as the tendency for positive studies to be more likely to be published than negative studies? Pardon my pedantry.

  4. David Gorski says:

    I never pardon pedantry, as regular readers know. ;-)

    But seriously, pedantry is notorious for derailing discussion threads into arguments about little points that don’t have an effect on the main message. If that little pedantic issue of wording bothers you so much, I’ll change it to exactly your words.

    There, it’s done. Next topic.

  5. Cornelioid says:

    Ha ha! I’m sorry to have sounded accusatory. I was actually slightly worried that i might have the wrong idea and didn’t want to just tell myself it was a typo and move on. Thanks again. Next topic.

  6. Jan Willem Nienhuys says:

    M&Ms are as effective

    they may help against that kind of pain, but they increase dentist costs!

  7. Cymbe says:

    Acupuncture is more than a placebo. If you used toothpicks, you wouldn’t get the entire effect that acupuncture has on the human body. For example: http://www.cbsnews.com/8301-504763_162-57503549-10391704/swiss-healer-accused-of-intentionally-infecting-16-people-with-hiv-using-acupuncture-needles/

  8. Dr Rod says:

    Dr Gorski- were you aware that SESAP 14 has a question or 2 on acupuncture? It appears CAM woo has even crept into surgery! I believe it’s claimed to be effective for pain. It sort of embarrasses me as a surgeon and Fellow of the College. Your thoughts?

  9. BillyJoe says:

    Cymbe,

    Your link does not match your comment.

    “Acupuncture is more than a placebo. If you used toothpicks, you wouldn’t get the entire effect that acupuncture has on the human body. ”

    Acupuncture could just be a better placebo than toothpicks.
    However, if you blinded patients as to whether needles or toothpicks were used….

  10. Jan Willem Nienhuys says:

    BillyJoe, Cymbe was being sarcastic. With a placebo one can’t infect people that easily!

  11. Scott says:

    Yep, Cymbe’s link perfectly supports the comment – acupuncture had an effect which toothpicks would not. That effect was rather negative, but still it was an effect.

    An excellent illustration of why, even if one were to provide a placebo treatment for whatever reason, that treatment should NOT be acupuncture, because it carries very real risks that can be avoided by choosing a different placebo.

  12. David Gorski says:

    I am a little puzzled about the idea to express an advantage of a treatment in terms of SD.

    In retrospect, after having written this post, it occurs to me that I don’t recall ever having seen a meta-analysis that expressed its results in that manner. That bothered me. It stuck out like a sore thumb. At the time I didn’t quite know why.

  13. BillyJoe says:

    Better go easy on the birthday scotch :|

  14. Jan Willem Nienhuys says:

    I don’t recall ever having seen a meta-analysis that expressed its results in that manner.

    In other words, the meta-analyzer has been racking his brains for a way to make favorable sense of the data. If that is so, the question is: how many more methods he has tried in the seclusion of his office? Maybe it a case of ‘If you torture the data long enough, they will confess’ ascribed to Ronald Coase (Coase supposedly said ‘it will’ rather than ‘they will’).

    http://en.wikipedia.org/wiki/Ronald_Coase

  15. I had an incident as a child..5 or 6 years old, when my throat was closing because I slept in front of a fan on a hot summer night. My aunt and mom rushed me to her doctor, where he had me lay down, took off my shoe and sock, touched the bottom of my foot..for one slight instant, and my throat and congestion completely opened up and no more problem after! Is that a known problem..someone being congested by sleeping in front of a fan? To this day I cannot do it…I have to have air circulating me, but not pointed directly at me.

    As I understand it..it’s call ‘acupressure’ now… and how it relates to acupuncture..it’s along that line suppose. I know I’ve heard it’s oriental healing originally. But, isn’t it possible that one nerve in the foot affects something in the bronchial area..being connected, and so perhaps there is something to it? Anyway, that’s all I know, and have to say on the subject :)

  16. Acupressure is also known to cure DEATH!!!!

    Seriously, as a person of Chinese ethnicity, I find the Western reading of “Traditional Chinese Medicine,” acupuncture, “Ayurvedic medicine” and acupressure completely offensive, Orientalist (see Edward Said’s definition of the word) and essentialist. When I say Western reading, I am not referring to Western medicine, but the interpretation Western practitioners of those CAMs have of their practices.

    And just an FYI, RH, the Ming emperors actually banned acupuncture. And they are considered among the most intellectually inclined dynasties.

  17. Chris says:

    Exactly, Mr. Luong (I’m not adept at HTML to attempt the French letter in your first name)! It is offensive to claim “Western” versus “Eastern” on a planet that is close to being a sphere. I often tell those who claim that Western medicine is bad that means that the varicella vaccine and statins are good because they were developed in Japan. It is offensive to ignore the very real actual medical and science research that happens in Asia.

  18. I didn’t know that Francois. But, it did help me that day….anyway..interesting. I don’t go into it myself..just wondered..thanks for that info :)

  19. What helped you is something called the placebo effect, which makes you feel much better because you think something is being done to you. Which is also why snake oil have such a success in the free market.

  20. kscrimgeour says:

    How do you explain muscle twitches and the immediate relief of pain and increase in flexibility. Placebo? Your all double blind. Do you think all we do is just insert the needle and then pray. I guess the redness around the needle the light sweating and other skin changes are placebo. Also I like that you have to add in the elaborate placebo. At least it is better than just an M&M. Thanks for reminding us that you think we are either idiots or immoral a-holes. I love the pharmaceutical industry how they double blindly in random fashion seem to get away with all those side effects with a profit.

  21. kscrimgeour says:

    I especially like the story of the acupuncturist who spread aids. 1. he was a music teacher 2. the story stated they had no idea what tools he used to infect his students. Nice work love the research not biased at all. Science? more like old fashioned prejudice about another belief system. Seems like acupuncture is not much different than black people in the 50′s. Acupuncture should not have the same privileges as regular medicine.

  22. BillyJoe says:

    kscrimgeour:

    “Your all double blind. Do you think all we do is just insert the needle and then pray. I guess the redness around the needle the light sweating and other skin changes are placebo. Also I like that you have to add in the elaborate placebo. At least it is better than just an M&M. Thanks for reminding us that you think we are either idiots or immoral a-holes. I love the pharmaceutical industry how they double blindly in random fashion seem to get away with all those side effects with a profit…Science? more like old fashioned prejudice about another belief system. Seems like acupuncture is not much different than black people in the 50′s.”

    You may recognise yourself in this article:

    http://theness.com/neurologicablog/index.php/some-feedback-on-organic-farming/

    :D

  23. WilliamLawrenceUtridge says:

    Actually, the immediate pain relief can be a placebo effect – as soon as I swallow ibuprofen my headaches fade slightly, well before the medication has dissolved and reached any nociceptor. I was having breakfast with someone once who said they hadn’t had any coffee and their head hurt. I suggested it might be caffeine withdrawal. They took a sip of tea and immediately said their head felt better. So yeah, immediate pain relief can be placebo. There’s no question acupuncture has a physiological effect, the question is whether it is a new phenomenon (and for me, whether there is any benefit to training someone in anything besides sterility and avoiding organs). I certainly have no issue with “acupuncture” that doesn’t involve TCM, avoids elaborate (imaginary) diagnoses and uses thin needles that barely break the skin (or even better, toothpicks).

    I love the pharmaceutical industry how they double blindly in random fashion seem to get away with all those side effects with a profit.

    I was under the impression that acupuncturists also charged for their services, at sufficient levels to surpass their fixed costs, thus achieving what most people would call “a profit”. The only “double” I see in your comments is a double standard – drugs must be proven safe and effective before being used, meanwhile acupuncture proponents are asking for a free pass on criticism or an evidence base. That seems like hypocrisy.

  24. Science? more like old fashioned prejudice about another belief system.

    You mean, like the Chinese government banning the practice of acupuncture in the 17th century?

  25. Harriet Hall says:

    “old fashioned prejudice about another belief system”?
    What about new fashioned prejudice in favor of exempting CAM from the standards of science?

  26. Narad says:

    Thanks for reminding us that you think we are either idiots or immoral a-holes.

    Remember, it’s not an either-or proposition.

  27. kscrimgeour says:

    Thanks for the replies. I can agree that avoiding organs and sterility is important and may be the most important. I question the theory when it comes to acupuncture and most agree the theory does not apply well to acupuncture but mainly for herbs. I have changed my practice to a more medical model and the results are better now I can agree.

    There are a few techniques that involve meridian theory that I still see working quite well. These involve palpation as well. The best understanding of acupuncture by most medical doctors who practice is that it is actually stimulating the fascia which is found to contain a high concentration of nerve endings and is responsible for our ability to touch our nose with our eyes closed. This is bringing new light to how the early folk understanding came about.

    I think the traditional theory might also be a bit much as well. And yes an number of emperors banned acupuncture but all where because the acupuncturist would not listen. The most historic was Hua tuo who treated an enemy soldier while working as the emperors main physician. All the acupuncturists who knew him were ordered to be beheaded. It was not because the emperor thought it didn’t work but more anyone who was an acupuncturist had one of Hua tuo’s books or so it seemed and would be deemed guilty by association.

    There are a number of responses that occur during acupuncture and the client has a right to stop treatment at any time. This means if you do not get results quickly then they will and do stop coming. Some do get great results in fact many. Also realize most people are like yourselves they think it is bunk and do not want to try unless it is a last resort only. Usually after trying drugs surgery and physio to no avail. It saves money for many for the cost of acupuncture is far cheaper than seeing a specialist again who has already stated they will just have to continue with their pain meds and wait for it to get bad enough for surgury.

    I want to share this article and I invite criticism.

    http://well.blogs.nytimes.com/2012/09/11/acupuncture-provides-true-pain-relief-in-study/?smid=fb-share

  28. kscrimgeour says:

    Thanks Billy Joe for the reminder to tone down the rhetoric and tune up the logic fallacy theory. I don’t think I used any profanity and it was quite clear the article quoted as a proof of the dangers of acupuncture was perhaps closer to the article you referenced for me to read. It had NO SUBSTANTIATED facts what so ever about acupuncture. It was sort of an inside joke at an old boys club was my impression considering this is an evidence based forum.

    I apologize for my perspectives on pharmaceuticals I work in detox so I see quite a few fresh faces every week addicted to pills they were given by their doctor and pharmacist. They took them as prescribed and now they need more resources to get off them. Up to a year for benzos this is very expensive for everyone. Nor T does this lead me to see antidepressants as very safe. Useful but safe that is a stretch but better than being depressed they are over prescribed and this is clear and evidence based.

    Also I read a study that counted upwards of 300 000 deaths from properly prescribed medications in a ten year period I beleive it was 1995 to 2005. Considering you can count deaths from acupuncture on your hand my logic places acupuncture as a better first option considering the risk alone. Am I wrong?

    Trying a harmless and very well documented as effective doesn’t it make sense to have it part of the system. If it avoids the risk of harm from medication and they are harmful and the safety is only statistical like driving. Acupucture you can be 100% sure with today’s standards no harm will come. The first premise of medicine is “Do No Harm.”

    So Acupuncture can save the system money and to use it safely people need to see their MD and their acupuncturist. The result will be less over prescription less unnecessary surgeries. Considering a surgery at a basic cost is $10 000 or more that is about 200 acupuncture treatments. My guess is at least one of those 200 would benefit enough to realize they don not need a surgery even if it was placebo. This is guess work but with numbers so large if you hit 200 golf balls one of them will be on the fairway just by distribution logic.

    So when you look at the big picture it only makes sense to save money by using a safe technique in conjunction with medical supervision and tests. The best thing for acupuncture is for it to be included as a CAM because it saves money and statistically it does not kill or harm at all.

  29. weing says:

    “The best thing for acupuncture is for it to be included as a CAM because it saves money and statistically it does not kill or harm at all.”

    Neither does doing nothing, when nothing needs to be done. How is it better than that?

  30. WilliamLawrenceUtridge says:

    The history of acupuncture does not justify its use, only its proven results. To date, those results support only the use of acupuncture to reduce pain and nausea for the short term, and no impact on specific conditions. I don’t really have a problem with these indications, provided it’s practiced with minimal risk, and no association with magical thinking.

    Though I am familiar with the theory that acupuncture meridians are related to connective tissue planes or fascia, I am unaware of any proof for that theory. Further, wouldn’t a better approach be to abandon the historical acupuncture meridians and points, or at best test them to see if there are any specific associations? Rather than defending traditional practice, a science-based approach involves testing and discarding the useless parts – like diagnosis, qi, meridians and herbs.

    The cost of acupuncture is a pure drain on the economy and individuals if it is ineffective. If acupuncture is a pure placebo, it’s questionable whether it’s worth reimbursing through insurance schemes and it’s definitely not worth spending a large amount of time and money on it. If acupuncture is as cheap as $5 for a brief treatment (which is all that is supported now considering it’s effects are short-term at best), that’s fine. But if it involves a lengthy consultation, a long treatment, and is accompanied by denigration of real (i.e. proven) medicine it is not worth the cost.

    In addition, your invocation of a false dilemma (i.e. if drugs cause harm, acupuncture works) raises questions about your true understanding of medicine, science and the application of skepticism. No authors here believe drugs are without risks or that pharmaceutical firms are angels, and there are many posts on this subject. They merely apply the same standards for CAM – which generally lacks evidence of being effective beyond placebo. I question any treatment that is marketed with minimal evidence of efficacy, under the rubric “it’s safer than drugs so it must work”. You wouldn’t support a new drug that was supported by little more than Pfizer’s CEO saying “this is based on a thousand years of history and in my experience it works really well” – why should the same standard not apply to acupuncture.

    I understand that as a (probable) acupuncturist, you want to believe and you have a strong economic motivation to find it effective (i.e. the conflict of interest you find so abhorent in Big Pharma). However painful it might be, from an ethical (and certainly a scientific) perspective, it is worth questioning the true efficacy of your profession rather than blindly and blandly accepting the rhetoric and inaccurate claims spoon-fed to the world about acupuncture. May I suggest you switch to a lower-cost, lower-risk model involving sympathy, guide tubes and toothpicks rather than elaborate prescientific diagnoses and skin-penetrating needles? You might be surprised that you can offer the same benefits with less risk. And if you are careful in recording the results, you might be able to publish and contribute to the scientific discourse rather than attacking it with double-standards.

  31. Scott says:

    WLU pretty well covered it, but I think this particular paragraph calls for a more detailed discussion:

    Also I read a study that counted upwards of 300 000 deaths from properly prescribed medications in a ten year period I beleive it was 1995 to 2005. Considering you can count deaths from acupuncture on your hand my logic places acupuncture as a better first option considering the risk alone. Am I wrong?

    Yes, your conclusion is wrong. This is because “considering the risk alone” is inappropriate. We must consider both the risk and the benefit, as the acceptable level of risk depends on how much benefit will be gained from taking the risk. As an extreme example, a 50% chance of death is entirely unacceptable if the benefit is minor pain relief, but acceptable if the benefit is avoiding a 100% chance of death.

    Accordingly, we also must consider the benefits of medication (large) and the benefits of acupuncture (none beyond placebo convincingly demonstrated, and well-demonstrated to not be large).

    Therefore, we see that the benefits of medication are larger than the risks, and therefore condone the use of pharmaceuticals. (This is of course a massive simplification, as each individual medication must be evaluated – and for each individual using it. But for our purposes here, it will suffice.) However, the risks of acupuncture (small but non-zero) are larger than the benefits (zero) and hence we cannot condone the use of acupuncture.

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