Mar 03 2010
Acupuncture for Depression
One of the basic principles of science-based medicine is that a single study rarely tells us much about any complex topic. Reliable conclusions are derived from an assessment of basic science (i.e prior probability or plausibility) and a pattern of effects across multiple clinical trials. However the mainstream media generally report each study as if it is a breakthrough or the definitive answer to the question at hand. If the many e-mails I receive asking me about such studies are representative, the general public takes a similar approach, perhaps due in part to the media coverage.
I generally do not plan to report on each study that comes out as that would be an endless and ultimately pointless exercise. But occasionally focusing on a specific study is educational, especially if that study is garnering a significant amount of media attention. And so I turn my attention this week to a recent study looking at acupuncture in major depression during pregnancy. The study concludes:
The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy.
Plausibility
The study compared acupuncture designed specifically to treat depression, and in fact tailored to the individual patient, according to principles of Traditional Chinese Medicine (TCM). This was compared to two control groups – a control acupuncture that was not specific to depression and massage. The comparison to massage was obviously not blinded and therefore, in my opinion, of very little value as depression is highly susceptible to non-specific therapeutic effects and both interventions – acupuncture and massage – would be likely to create such non-specific effects.
The interesting aspect of this study is the comparison between treatment acupuncture (targeted for depression) and control acupuncture (not targeted for depression). The purpose of the study was to control, as much as possible, for any other variables so as to determine if the underlying TCM principles have any validity – does it matter where the needles are placed?
We can really only put this study into context if we first consider the prior probability of this claim. I would argue that there is already a large body of acupuncture research that collectively shows needle placement as a variable has no effect on clinical outcome. This one study does little to alter the balance of that evidence.
Further, from a basic science point of view, the TCM principles have essentially no plausibility. The underlying theory is that there is an undetected life force (chi) that is partly responsible for health and illness, that acupuncture needles placed in specific acupuncture points alters the flow and strength of this energy, resulting in a clinical outcome. Chi has no existence in science, however. Vitalistic philosophies such as chi were discarded over a century ago as both unnecessary and without any empirical foundation.
Any modern attempts to explain acupuncture effects with known physiological phenomena might explain non-specific needling effects, but cannot explain any differences due to needle placement, and do not provide any explanation for the location of alleged acupuncture points.
Therefore, given the extremely low prior probability of the claims of this study, nothing short of a large rigorous and replicated study would alter our assessment of validity of acupuncture as a specific intervention.
The Current Study
This new study, published in the Obstetrics and Gynecology, is not of sufficient quality to justify the conclusions of the authors. The authors did do a decent job of trying to rigorously control the comparison between the two acupuncture groups. Subjects were blinded to which group they were in, as were those evaluating the outcome. Standard depressions scales were used. They even made a reasonable attempt to blind the acupuncturists, using a novel method (to my knowledge).
They had experienced acupuncturists design a treatment and control acupuncture regimen for each subject, and then had a “junior acupuncturist” (less than two years experience) perform the treatment without being told which one they were giving.
This, in my opinion, in the crux of the methodology – were the treating acupuncturists properly blinded. The study authors took the very useful step of assessing the degree of blinding of the acupuncturists and the subjects. Unfortunately for the validity of the study, they found that the treating acupuncturists were significantly more likely to have positive expectations for the treatment group than the control group – so their blinding methods failed with respect to the treating acupuncturists. The study was therefore, at best, single blinded. Test subjects did not have any significant difference in expectations.
Because depression is so amenable to non-specific therapeutic effects, the expectations of the treating acupuncturist can plausibly have had a significant effect on the final outcomes. This is the primary weakness of the study – but there are other worth mentioning.
The author also, for some reason, did not stratify the test subject according to race, and there turned out to be significantly more African Americans in the control acupuncture group than the treatment group. Cultural beliefs can have a significant effect on responses to different kinds of placebos, particularly needles. This is therefore a potential, if unknown, confounder.
The results were also not impressive. The study used the Hamilton Rating Scale for depression:
Interpretation of Hamilton Rating Scale for Depression scores is as follows: less than 7, nondepressed; 8–13, mild depression; 14–18, moderate depression; 19–22, severe depression; more than 23, very severe depression.
At 8 weeks the control acupuncture groups has about a 9 point drop in the scale, while the treatment acupuncture group dropped 11.5 points. On this scale that is a modest clinical effect. There was also no difference in remission rates among the three groups. In addition this was a relatively small study (141 treated in total, divided among the three groups) with a 23% drop out rate.
Conclusion
Therefore we have a small and improperly blinded and randomized study showing a modest clinical effect. This does not significantly alter the low prior probability of a treatment effect from needle placement.
This study should also be considered in the context of other trials looking at acupuncture and depression. This very recent Cochrane review concluded:
We found insufficient evidence to recommend the use of acupuncture for people with depression. The results are limited by the high risk of bias in the majority of trials meeting inclusion criteria.
Specifically – there was no difference between verum acupuncture and sham acupuncture in the clinical trials reviewed.
Given the low plausibility and overall negative character of the clinical evidence, it is reasonable to conclude that no further research into acupuncture for any indication is warranted. However, acupuncture is a modality with dedicated practitioners (acupuncturists) and proponents (by contrast, for example, there is no medical specialty dedicated to a particular drug – there are no penicillinists). And therefore it is likely that further research will be conducted.
In that event, given existing research, it would be useful to conduct only highly rigorous trials, using sham and/or placebo acupuncture (where the needle or fake needle does not penetrate the skin) with adequate blinding. Such trials would need to be large with consistent replicated positive results in order to have sufficient weight to overturn the current mass of basic and clinical evidence.
144 Responses to “Acupuncture for Depression”
Re plausibility of acupuncture meridians and points:
there are some interesting studies by Langevin suggesting acupuncture meridians and points have unique physiological properties including location at intramuscular connective tissue planes.
And the actually effect of needle rotation in an acupuncture point elicits very specific surprising effects on connective tissue remodelling that may initiate broader signalling cascades.
The significance of these findings is still unclear but the authors are also looking at the broader question of signalling in the connective tissue fascial system in a manner that might be analogous to glia in the brain, since some connective tissue cells play a similar structural role to glia in providing scaffolding for nerve cells in the periphery (glia have recently been associated with surprisingly robust calcium signalling functions in the brain).
(Re: the conclusion) Isn’t one of the tenets of SBM that it doesn’t make sense to do a study to test a treatment which has no plausible method to work.
I didn’t read the whole study but I felt the massage group was unnecessary at best and deceptive at worst. It seems that they frequently focused on the comparison of the treatment group to the “combined control” group rather than to the control acupuncture group, which makes me think they are trying to enhance their results by dragging the control numbers down by including the totally unblinded massage group.
It seems obvious that there is very great potential for the unblinded massage group to influence the control group results up or down.
At the very least, including an unblinded “control” like massage introduces an unknown confounder. You can’t expect the placebo response for massage to be similar to control acupuncture, and you can’t expect the massage group to not have an actual therapeutic response either.
I’ve seen this before where an acupuncture study included an extra, unblinded and seemingly unneeded “control” group to their study. The last study I saw like that used the extra group to conclude that their “control” was also effective rather than their treatment was no more effective than placebo.
ceekay – these kinds of studies amount to little more than anomaly hunting – yeah, stuff changes when you stick a needle in it. But these do not provide plausible mechanisms for the claimed clinical effects. Also, there is no plausible connection between TCM acupuncture points and physiology.
From anatomy classes in medical school, I know that the exact location of things like the end branches of nerves and blood vessels is highly variable from one individual to the next. The same spot on two people’s legs can be innervated by L4 in one person and by L5 in the other. I can’t believe that practitioners could be capable of finding exact acupuncture points with any degree of accuracy. If the “de qi” sensation is important in verifying the proper location, I would expect many failures to find it, requiring many re-insertions.
I love the analogy with “penicillinists”!
Massage sounds like a horrible control group. As someone with rather crippling depression, I have to say that getting a massage on a regular basis sounds like a heavenly way of combating my anxiety and low mood. Anecdotal evidence and all that, but it certainly sounds like a better time than getting poked with tiny needles.
Exactly my response. “CAM” begins with interventions and looks for indications; real medicine begins with diagnoses and chooses the most appropriate interventions, and biomedical research searches for better interventions. That’s why all but one of the NIH sub-institutions and centers are named for diseases or organ systems (cancer, diabetes, infectious disease, heart/lung/blood, etc.). The exception is the NCCAM. Imagine the hue and cry from anti-modern medicine paranoiacs if an NIH affiliate were named “the National Institute of Coronary Artery Bypass Surgery” or the “National Center for Electroconvulsive Therapy.”
What I find particularly impressive about this article is a gem of a phrase right out of the Weasel Words of Woo: “acupuncture specific for depression.” Hmmm: I can’t find “depression” in the Yellow Emperor’s Classic of Internal Medicine.
Steve: “Also, there is no plausible connection between TCM acupuncture points and physiology.”
Steve, I’ve just offered what may be a plausible account: mechanical changes in connective tissue may initiate specific changes in neural and immune measures (and these, btw, may be related to inflammatory cytokines that are implicated in depression). Obviously, this is only a hypothesis that requires empirical testing. Any test of the hypothesis requires a complex progression of studies involving in vitro, animal and human studies.
But, given that we don’t know what sorts of answers these studies might find, are you asking us to prejudge them in advance?
Harriet: “The exact location of things like the end branches of nerves and blood vessels is highly variable from one individual to the next… I can’t believe that practitioners could be capable of finding exact acupuncture points with any degree of accuracy.”
Harriet, I agree. Many studies have shown that acupuncturists only achieve rough agreement on point location. I guess the question is whether acupoints are broad target zones (in which case, exact topographical agreement might not matter) or are very exact point locations. My guess is that acupuncturists exaggerate somewhat the specificity of their needling techniques in order to burnish their apparent skills.
My own hunch is that the effect of acupuncture may be derived from an enhanced placebo effect (that includes pulse-diagnosis as healing touch along with empathic interaction) along with some non-exact real acupuncture needling effect that comes from a connective tissue signalling mechanism.
You can dismiss the components of acupuncture+placebo package as containing too much placebo to be treated seriously. When you add the entire treatment is does seem to produce positive outcomes in some people (and that is all the patient cares about).
ceekay on what matters in acupuncture:
“I guess the question is whether acupoints are broad target zones (in which case, exact topographical agreement might not matter) or are very exact point locations.”
The fact that after 2200 years this question has still not been answered strongly suggests to me that none of it matters.
While I completely agree with Steve’s assessment of the article, his comparison between acupuncturists and “penicillinists” isn’t completely valid. For example, an oral surgeon defines him/herself by a treatment modality as opposed to a specific disease. The key is for said practitioner to ascertain which diseases/conditions are best treated or managed by the modality in which they are trained. Taking out a wisdom tooth won’t do much for appendicitis, but it’s great for getting rid of a wisdom tooth infection!
“The fact that after 2200 years this question has still not been answered strongly suggests to me that none of it matters.”
This seems like a superstitious attitude…. Imagine if we approached cancer or alzheimers this way, “no answer yet… must not matter”…
What if Prusiner had approached Kuru, the prion disease afflicting Papua New Guinea tribesmen, this way?
Traditional accounts of acupuncture matter. But why should our scientific understanding of mechanism be bound to these earlier ideas?
ceekay,
I don’t know how long we’ve been clubbing seal pups in Canada but I do know that crushing their skulls is universally acknowledged to kill them. There is no debate as to whether crushing the tail might work as well. It’s the head. I suspect it didn’t take seal-pup clubbers very long to figure out the best spot because the outcomes were so obvious. Say, less than an hour.
If acupuncturists have been trying to figure out the best spot to aim their needles at for 2200 years and still haven’t managed to, that suggests that the outcome they are looking at is so subtle as to be nonexistent.
There is no evidence that the placement of acupuncture needles matters in the least. There is no evidence that puncturing the skin matters in the least. Tapping people randomly with toothpicks seems to work just fine to help them feel better. Ditto waving your hands around in the air and calling it Reiki. Ditto supplying them with complicated homeopathic regimes to keep themselves busy.
Looking for a mechanism seems premature when there is no compelling evidence acupuncture works beyond placebo.
An alleged connective tissue mechanism would not explain why there are supposed to be different acupuncture points relating to different symptoms – that is my point.
Jayhox – I agree that some specialists have areas of treatment expertise. For example – surgeons use surgery – although no particular surgical procedure, and they can also prescribe medicine or any other intervention. Broad areas of treatment expertise are fine.
The only specialty I know of that is tied to a specific intervention is that of radiation oncology.
But further keep in mind – treatment modality specialists are not primary care practitioners. They are not the first people making treatment decisions. Rather they have patients referred to them when their treatment may be indicated.
This is all distinctly different from acupuncturists, homeopaths, and chiropractors.
I agree Steve. Thanks for clarifying and amplifying.
off topic, but whats the difference between chiro and acupuncture anyway…?
http://www.guardian.co.uk/science/2010/mar/01/simon-singh-libel-case-chiropractors
Anyone know any more about this? Looks like the evidence/science based community may enjoy some vindication after all
@ceekay
If indeed there is some sort of inflammatory response to acupuncture, why is it such a panacea? The cytokine release is supposed to fix back pain, relieve depression, lower blood pressure, and everything else all at once? Certainly the medications we give often have effects on multiple systems, but very predictable, identifiable, and consistent effects. Random induction of inflammation doesn’t seem to fit there.
I saw this paper this past weekend and found several problems with it (I apologize if these have already been mentioned; I haven’t read through all the comments upthread yet). In addition to the problems Steven mentioned, I had a problem with the differentiation of acupuncture into specific and non-specific for depression. If I assume that sticking needles into the body actually does something (i.e. if I consciously set aside Steven’s prior plausibility criterion), it is not clear to me how the study ensured that needles stuck in “non-specifically” did not evoke physiological responses that “specific” needling produced. This seems to be corroborated by the rather modest outcome difference in the Hamilton scale, ~(-)11.5 in the specific, and ~(-)9.0 in the non-specific, or for that matter,
~(-)9.5 in the massage group, as well as by a Cohen’s d of 0.39 (which is in the range of a ‘small’ change) between specific acupuncture and combined controls. Yes, the authors have shown a statistically significant difference between specific and combined controls, but statistics is a function of numbers. The question is: is that significance biologically
relevant?
Secondly, their practice of combining the control groups (non-specific acupuncture with massage) is dubious. The modality of the massage has nothing in common with that of the acupuncture; why club those as a group and subject them to statistical tests that depend upon the sample size, unless both of the controls are expected to be completely ineffective and thereby provide a sharp contrast to the treatment group? This seems to be corroborated by the lack of any difference in outcome between the controls at week 4
and very slight difference at week 8.
Thirdly, the results section of the article was very poorly reviewed and edited, leaving very ambiguous statements that seem to mean quite different from what the authors intended. Two examples are:
This seems to indicate that the specific group had no difference with the massage group (Freudian slip?)
…and
Look at the underlined group
descriptions and tell me if it makes sense!!
The authors indicate that the remission rates were not significantly different between the treatment and control groups. Besides, if one goes by the numbers in Table 3, the ‘specific’ acupuncture group reported a lot more of the side effects compared to the other groups. I didn’t see any effect size statistics on that!
I was surprised (and oddly pleased) to see the use of effect size as a statistic in this study. Effect size is a descriptive statistic that measures the magnitude of relationship between two variables in a sample-based estimate of that parameter, without making a statement about the representation of that relationship in the population. While it effectively complements inferential statistics, such as p-values, and is useful in exploratory studies (which is what this study was billed
as) and in meta-analyses, it does not prima facie indicate whether the observations are generalizable to the population or not. Standardized effect size measures, such as Cohen’s d (which is difference of two group means divided by pooled standard deviation; used in this study), may not have any biological significance when used in individual studies. Besides, the authors provided no justification for setting their study standard to a moderate/medium effect (defined as Cohen’s d of 0.5). For effect size measures, I would have liked to see Odd’s ratio and/or Relative Risk measures, which are standard for case-control studies and RCTs.
In summary, despite a lot of fancy statistics (what David aptly
described as statistical legerdemain), the study suffers from
inadequacies (for instance, the insufficient blinding), and more
devastatingly, absence of a strong and reliable outcome. Sadly,
though, this study would be touted as proof positive of efficacy of acupuncture as therapy by hordes of pseudoscience-worshippers.
Thank you Dr Novella for writing about this – and thanks also to commenters for very useful comments. – Not that it’s surprising at all; I wouldn’t have expected acupuncture to be a helpful treatment, for all the reasons Dr Novella mentions.
No doubt part of the impetus for this study is anxiety about pharmacological treatments during pregnancy. The thing is, there is much more anxiety about that than there is evidence for harm. A recent paper from American Psychiatric Association and the American College of Obstetricians and Gynecologists (my summary here: http://www.tsuken.co.nz/midweek-medicine-antidepressants-in-pregnancy/ ) goes through the available evidence – and highlights the gaps). Overall, we can do a lot that is safe and effective (recent flawed and over-generalising meta-analyses notwithstanding) to treat depression in pregnancy, without resorting to something like acupuncture.
ceeekay: “Steve, I’ve just offered what may be a plausible account: mechanical changes in connective tissue may initiate specific changes in neural and immune measures (and these, btw, may be related to inflammatory cytokines that are implicated in depression). Obviously, this is only a hypothesis that requires empirical testing. Any test of the hypothesis requires a complex progression of studies involving in vitro, animal and human studies.”
———————————————
As indicated by Steve, a scientific hypothesis has worth only so far as it provides the best explanation for generally replicable phenomena. A fail on that, I think.
But I mainly wanted to remind you of strong contrary evidence for such a hypothesis, from a well-explored model of connective tissue “connections” i.e. surgical patients.
We surgeons have been disrupting acupuncture points and meridia, in connective tissues or wherever else they may hide unfelt and unseen, for centuries. We have cut into them, excised them, widely disconnected them and even amputated them in large numbers, without producing the health effects that we might reasonably expect such actions to have under TCM theory.
There are indeed physiological responses to surgical trauma, but they are very stereotyped. They lack the anatomical specificity TCM requires with both site of the stimulus and the target organ. They are invoked mainly by known humoral mechanisms, and they are specific for need to survive and to recover from tissue trauma.
Some, such as endorphin release, may have broader roles in other contexts, even possibly explaining some of the responses to acupuncture and to placebos generally.
“The study compared acupuncture designed specifically to treat depression, and in fact tailored to the individual patient, according to principles of Traditional Chinese Medicine (TCM)…
Geting down to basics…Just what is the evidence for the existence of “acupuncture designed specifically to treat depression”?
As hinted by Kim Atwood, one need not have gone through the entire writings of the Inner Canan of the Yellow Emperor, or through all the writings of those who preceded and followed, for that matter, for reference to specifically directed acupuncture.
There isn’t any. Nor has there been a TCM claim for any.
It should no longer be necessary to point out here that neither acupuncture, Chinese herbs, or any other TCM method was designed to treat any specific condition. TCM did not categorize diseases, let alone attempt to determine specific causes and specific treatments. [TCM methods are directed toward restoring a balance between the cosmos, the Earth, and the person - "nothing more, nothing less."]
Specific assumptions have been made up by mostly European and No. American proponents, followed by immigrant Chinese to those areas. (As has been pointed out frequently by Unschuld, David Ramey, Bob Imrie, and lately here by Ben Kavoussis. And grudgingly, I’ve taught about this at Stanford for some 20 years, and have the honor of never having been called by the NCCAM and NCI awardees at Stanford, some of whom conceived and produced this worthless paper.
Worthless? Well, maybe worth something, because…given 1) the high implausibility of acupuncture and 2) the lack of proof of prior existence of verum acupuncture, any difference between verum and controls should be assumed to be due to systematic or random error in the experiment.
Thus the authors should search for the source of experimental error, not look for other ways to prove acupuncture efficiacy.
WS
“I’ve seen this before where an acupuncture study included an extra, unblinded and seemingly unneeded “control” group to their study. The last study I saw like that used the extra group to conclude that their “control” was also effective rather than their treatment was no more effective than placebo.”
Yes, I remember the headline “True Acupuncture as Effective as Sham Acupuncture in the Prophylaxis of Migraine” which, of course, should have read: “Acupuncture No More Effective Than Placebo in the Prophylaxis of Migraine”.
Yet again an SBM article reviews a paper but utterly fails to summarize the weight of the evidence of the study.
You gave us the means of the treatment effects but no idea of the variability. It gives the impression of utter cluelessness/incompetence about how to judge evidence. I have to read the paper or rely on commenters like Datta to be told what the data actually looked like.
Your statistics – it sucks. Get it together.
The claim that acupuncture is “all placebo” depends on the assumption that if it did have any purely mechanistic, not culturally mediated biological activity, that activity would not be present in sham acupuncture, which often (though not always) provides similar results in clinical trials. However, I’ve seen on TV a generally anti-CAM program depicting the practice of sham acupuncture on a sample patient, who thought based on the sensation that she was being stuck with a penetrating needle. Clearly, there was some kind of stimulation of nerve endings going on, and I don’t think we know enough to rule that out as a biological source of pain relief. The fact that animal studies often show benefit for acupuncture hints that it might be.
The other quibble I have is that doctrinaire SBM supporters speak of “placebo” as if all placebos were alike in their (limited) activity. We know that a sugar pill will produce less relief of arthritis pain than an analgesic, which provides both the placebo relief of the sugar pill plus a mechanistic pharmacological effect. However, it has been found repeatedly that acupuncture provides more relief of certain painful conditions than analgesic treatment. If the former is indeed “all placebo,” it must therefore have a super-duper-placebo effect, strong enough to exceed both the sugar pill’s placebo effect and the drug effect put together. If the only biological change you’re after is pain relief, and a super-placebo treatment may provide the greatest available relief (without any risk of wrecking your stomach or kidneys), why is that not the best option? Seems to me that your reasons for refusing to consider it are philosophical rather than practical/scientific, and my philosophy – I care about how well my pain is relieved, not about how that happens – is just as valid for me as yours is for you.
The claim that acupuncture is “all placebo” depends on the assumption that if it did have any purely mechanistic, not culturally mediated biological activity, that activity would not be present in sham acupuncture, which often (though not always) provides similar results in clinical trials. However, I’ve seen on TV a generally anti-CAM program depicting the practice of sham acupuncture on a sample patient, who thought based on the sensation that she was being stuck with a penetrating needle. Clearly, there was some kind of stimulation of nerve endings going on, and I don’t think we know enough to rule that out as a biological source of pain relief. The fact that animal studies often show benefit for acupuncture hints that it might be.
Not really relevant. When the same effects may be obtained by random tapping with toothpicks, it’s completely unacceptable and unethical to penetrate the skin for the same end, as that’s a riskier operation.
So the argument you’re making cannot justify the use of acupuncture.
Certainly it can. Let us suppose for the sake of argument that the benefits of acupuncture are entirely psychological/cultural (i.e., “placebo”). Placebos are of course far safer than drugs. The rationale for automatically rejecting the use of placebos is that they are presumed to be less effective than standard treatments, which have the same placebo activity as well as (we hope) a mechanistic benefit. But in some cases, that’s not true: if your goal is relief of joint pain, acupuncture may be more potent than analgesics.
And it is certainly less “risky”; tens of thousands of Americans die annually from using analgesic drugs as instructed, whereas I know of one death from acupuncture (some bizarre offshoot method that apparently used small skewers). It is simply ludicrous to suggest that acupuncture could be more dangerous than long-term analgesic use.
If the CAM treatment is more effective AND safer than the standard treatment, a consumer’s choice to use it is adequately “justified.” Could acupuncture be made even safer still by switching to non-penetrating needles, acupressure, etc., without losing any of the benefit? Maybe, but to determine that it would be necessary to conduct studies that focused more on patient-centered efficacy than on blinding.
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Apteryx, yes, I agree! What you are suggesting is within the bounds of present scientific knowledge. In fact, studies are emerging as we speak suggesting that procedural placebos (with associated care) may perform as well as or better than drugs in real-world cost/risk/benefit terms. It will be at least a close-run thing in some settings, I think.
The same methods don’t perform better than sham in other studies but that is asking a different question.
The only reservation I have is that we don’t yet know whether “placebo responders” (a horrible term for an integral, unavoidable, nurturing aspect of medical care), including those who describe dramatic responses to dubious alternative methods are “really, really” better or whether they are exaggerating or lying or misinterpreting, for a number of plausible reasons.
That aside, I think the evidence is suggestive enough to make us cautious, especially if we value patient autonomy to the degree we profess when condemning placebo use by doctors.
To a large extent I would argue that depends on what you mean by “placebo use by doctors”. I make a conscious effort whenever proposing a treatment plan, to try to maximise the non-specific effects of treatment. I try to instill hope, raise expectations, increase support, project confidence, and so on. Givewn that I do that while embarking on treatments that have evidence for specific efficacy, I don’t see there’s anything wrong with that. I’m not sure however that I would be so happy about doing all that while prescribing a pill or procedure (or whatever) that demonstrably lacked specific effect.
… despite acknowledging that a good chunk of people who get better with the pills and potions are actually doing so through those non-specific effects, rather than the pills (or whatever) themselves. The thing is, we don’t know which of our patients will respond to the non-spcific (ok, placebo) effects, and which will need the physiological treatment. I submit in that instance it’s better to use an active treatment – while maximising all the rest of it as well.
How is it any longer acupuncture when you can stick the needles in wherever you like and not even stick them in. Surely we need a different name here.
But the problem is that it is unethical for a doctor (well anyone) to use a placebo and not inform the patient of this fact. This may not eliminate the placebo effect but it can compromise it.
The other issue is the inadvertent (or deliberate) promotion of pseudoscience and the resultant conditioning of the population to accept pseudoscience of any type including those that are useless or even harmful.
apteryx:
“Placebos are of course far safer than drugs.”
I see. So a chiropractic neck-cracking makes you feel better though non-specific effects, and even with the risk of stroke is far safer than which drug for which problem?
Placebo surgery is of course far safer than… ?
Alison, you are correct, but I was explicitly talking “in cost/risk/benefit terms”. That would preclude neck manipulation for headache, but not necessarily as a late resort for disabling neck pain not responding to other treatments with no otherwise clearly correctable pathology abd with fully informed consent. I am sure apteryx means somethign similar.
Tsuken, it is taken for granted that there should be no superior evidence-based treatment on the same cost/risk/benefit standard.
Billyjoe, there are benefits to patients having access to simple safe placebos, which you need to allow for when you start to weigh up the risks.
There are also already certain safeguards, in that the public are demonstrably not as indiscriminate in the use of placebo CAM medicines as skeptics tend to think. In fact they do mainly use them where the mainstream lacks simple, safe, cheap and wholly reliable treatments.
But this is strange territory for SBM, I know.
Does this “shopping for placebos” attitude say we should take efforts to study which placebos or near-placebos are most effective? In this study you folks were complaining about comparing to massage, but that’s seems where you are going now (I had no trouble with making that comparison, it’s the conclusion where you need to watch your socks).
How do we stop folks who want to offer very expensive placebos, which they never compare to cheaper ones?
What claims do you make for the placebos? “Here’s a list of things you might want to consider, and I’ll just say nothing about the effectiveness, since your beliefs will lead you to the placebo best suited to you. I personally like shaman who calls herself Sofonda. She’s $300/hr.”
I’m not being completely sarcastic, I want education. Is there a famous position paper?
Boy, it would be nice if there were two separate words for placebo.
One to describe the social/psychological effect of instilling hope, raising expectations, increasing support, projecting confidence, etc.
One to describe a procedure or “sugar pill” that a doctor would recommend knowing it was a sham in order to illicit a placebo effect.
It would make conversations much clearer or at least more brief.
Regarding the social/psychological effect of a placebo, It is not inconcievable to me that different procedural placebos would have different pain response effects.
For instance, a caring gentle massage could trigger hormones that signal relaxation, lower stress hormones. It’s possible being poked with needles may trigger more of a slight “thrill” or cortisol response (mild roller coaster exhilaration). Could one be more useful than the other in pain control?
Might I suggest “placebo effect” vs. “placebo treatement”, respectively?
Oh, I didn’t see rork’s comment before I posted mine. Mine is not a response to his/her’s. Although reading it, it may seem so.
# rorkon 05 Mar 2010 at 9:30 am
“Does this “shopping for placebos” attitude say we should take efforts to study which placebos or near-placebos are most effective? In this study you folks were complaining about comparing to massage, but that’s seems where you are going now (I had no trouble with making that comparison, it’s the conclusion where you need to watch your socks).”
I guess I don’t understand why you would approach it differently than other SBM medicine. You see an effect, you try to understand it. Perhaps with understanding you can increase positive results, lower risk. You look at risk, benefit, cost. You try to set up criteria for who will benefit and hierarchy of methods most likely to least likely to help.
Just because it is a psychological response does not make it unscientific or completely unpredictable.
scott said “Might I suggest “placebo effect” vs. “placebo treatement”, respectively?”
Sounds good to me.
Alison, I dislike the common habit of yelling “straw man” to dispose of disliked counterarguments, but there’s no other term for your argument above. Neck-cracking certainly has biological effects (including, sometimes, tearing arteries). I was speaking not of “things that have a placebo effect” – which include ALL medical treatments, even mechanistically effective drugs and surgeries – but of “placebos” specifically, i.e., a sugar pill as compared head-to-head against a pharmaceutical drug. Since the sugar pill has no significant bioactivity, it can have no significant side effects, and therefore it’s got to be safer than the drug (as virtually all drugs have side effects for some users).
michele – “Regarding the social/psychological effect of a placebo, It is not inconcievable to me that different procedural placebos would have different pain response effects.
For instance, a caring gentle massage could trigger hormones that signal relaxation, lower stress hormones. It’s possible being poked with needles may trigger more of a slight “thrill” or cortisol response (mild roller coaster exhilaration). Could one be more useful than the other in pain control?”
You’re right in some ways, though what you’re actually proposing in the second instance isn’t really a placebo effect or a psychological effect. What you’re describing is a physiological effect, where the experience/psychological effect follows a physiological effect (rather than the other way around).
I’d have to do some digging to find studies but I remember reading (and have seen) that eople who are very effected by the placebo effect tend to have a bigger response to a more dramatic treatment (this doesn’t mean more or less gentle or painful, it just means more ritual and bigger symbolic ojects/tools). We can’t entirely disentangle the placebo effect/response from ritual because it’s the ritual that creates the placebo response a lot of the time. Relaxation can be useful in pain management but for reasons that aren’t directly related to placebo effects and it’s much more useful for a patient to know why relaxation helps with pain management (and not everyone relaxes when being massaged, for some people it’s invasive and tension inducing to have people touching them).
Since the sugar pill has no significant bioactivity, it can have no significant side effects, and therefore it’s got to be safer than the drug
There’s still some non-zero risk, though – contamination, for instance. And that’s entirely disregarding the point regarding the ethics – are you suggesting that doctors should tell patients it’s a placebo (in which case it will be less effective), or are you suggesting that doctors should lie to patients (please explain how that would be ethical, and simply not mentioning it is lying by omission)?
Plus, the discussion was originally about acupuncture, which certainly has significant risks – puncturing the skin always has the potential for infection, and acupuncture generally does not include proper measures to guard against that.
Whoops, I referred to pain management because of another set of comments in “Press Release” This post is regarding pregnant women and depression.
So, some anti-depressants have a good history of showing no negative effects on fetuses. But some women either do not feel comfortable taking anti-depressant, may not want to tolerate the side-effects on top of pregnancy or are not lucky enough to respond to the saver medications.
To re-orient my comments in that context any placebo effect treatment option would have to have some benefit over CBT or show some evidence to have benefit in addition to CBT.
scott – “…are you suggesting that doctors should tell patients it’s a placebo (in which case it will be less effective)…”
Actually, you can tell people that a treatment has no proven effect and is not better than a placebo but if they still believe it “works” then it will. Cognitive dissonance doesn’t effect everyone, some people don’t experience any dissonance when holding two contradictory ideas (or, they make up narratives to bridge the gaps or smooth over the contradictions).
As we’ve seen here, people who desperately want to believe that their faith-based ideas or subjective beliefs are actually scientifically viable and objectively true will go to great lengths to create narratives that support their subjective beliefs (and this is very much the source of psuedoscience, people who are simply honest about their faith don’t need to construct pseudoscientific narratives to justifying their faith or calm the cognitive dissonance caused by the conflict between their faith, science and their own desire to consider themselves entirely rational). For instance, quantum woo is clutching at straws (and erecting strawmen) to try to build a viable scientific concept to support faith-based beliefs. It’s used by gurus and conmen to manipulate people who want the reassurance of faith and neat answers for life, the universe and everything but that don’t actually have the capacity to have faith (hence the pseudorational aspects so that people can pretend they’re not just indulging in magical thinking and a slightly more sophisticated sounding version of The Secret).
“You’re right in some ways, though what you’re actually proposing in the second instance isn’t really a placebo effect or a psychological effect. What you’re describing is a physiological effect, where the experience/psychological effect follows a physiological effect (rather than the other way around).”
Yes, you are right, or to add another layer here is how I imagined the process I’m describing: Fear of a potential danger (psych) Cortisol response (physio) Thrill sensation (psych).
For example: I used to do martial arts. Sparring is somewhat frightening/thrilling even with a partner you know that is not trying to hurt you and wearing gloves. You know you might catch an elbow, knee or knuckle in the nose, etc. The low fear has a thrill effect that is invigorating and can lift a dark mood. But of course in Martial Arts it is impossible to separate the thrill effect from the exercise effect from the mental focus effect. And if my doctor told me to do it, the placebo effect.
FiFi “(and not everyone relaxes when being massaged, for some people it’s invasive and tension inducing to have people touching them).”
Yes, I can relate, not a big massage fan myself. Although I will tolerate it in the case of deep tissue massage for muscle spasms. But that is a purely physiological response.
michele – “To re-orient my comments in that context any placebo effect treatment option would have to have some benefit over CBT or show some evidence to have benefit in addition to CBT.”
Michele, you keep associating CBT with placebo effects and I think there’s a very important distinction to be made (plus I suspect it may be helpful for you to better understand what each is and how they function). I mean no offense but I suspect you don’t quite understand what CBT or a placebo effect is because CBT is almost the opposite of a placebo effect! This may get in your way of better understanding both and some of the features of placebo effects and CBT.
In very simple terms, CBT involves becoming conscious of how our thoughts, feelings and actions are interconnected and cause each other. It’s a mindfulness technique that’s about becoming more aware so that one can change unconstructive habits/rituals. A placebo response is somatized, meaning it’s unconscious (even if someone is aware they’re getting a placebo, they remain unconscious of the interconnection between their thoughts, feelings and the actions involved). It’s all about ritual/habit.
Now, interpersonal therapies (which are about the relationship between the therapist and the patient) can certainly have a somatic element and work on an unconscious level and this is where you see a psychosocial aspect to placebo effects (how relationship and/or interaction between the therapist/doctor and patient influences the perception of a treatment). This doesn’t mean that interpersonal psychotherapies are just a placebo effect, it just means that part of the process can be unconscious on the patient’s part (the therapist would be conscious of the transference and counter-transference – and this ability is essential to being a good psychotherapist or psychiatrist).
I hope pointing out this distinction is useful for you
michele – “to add another layer here is how I imagined the process I’m describing: Fear of a potential danger (psych) Cortisol response (physio) Thrill sensation (psych).”
I don’t think most people are afraid of their acupuncturists though or think acupuncture is dangerous! I think I get what you’re saying vis a vis being in certain states – relaxed or excited – but I’m not sure they apply to the placebo effect in quite the way you think they may. However, that said, when some people have chronic pain they do tend to start to live in a heightened state of alertness/tension and to protect the injury (whether it need to be protected or not). And, obviously, chronic pain can also interfere with sleep and relaxation. That’s why both relaxation exercises and also zen and mindfulness practices can be useful for pain management. (Though zen meditation has a physiological effect on on neuroanatomy, there’s a different thing going on than simply learning how to relax.) Like depression, there are many interrelated psychosocial aspects to chronic pain (though that doesn’t mean we may not one day come up with a procedure or medication that can bypass these aspects and deliver relief…apart from massive doses of narcotics, which are very effective at providing pain relief but they can reduce functionality and we have some very weird social beliefs – that are entirely moral in nature – about both pain and addiction that have made effective pain treatment increasingly difficult in some places).
I saw a list of CAM alternatives occupying a whole page in handouts to folks considering joint replacement (U of Michigan), and I was appalled. It came after weak weasel-words expressing doubt of the evidence of effectiveness, but then explained each ah, er, modality, in not unflattering terms.
Doesn’t an authority condoning shamanism have the de facto effect of advocating it? Doesn’t it permit ever further multiplication of the absurd, and increased money inducing folks to invent further absurdities? The slope seems icy to me. Show me how to draw a line.
I thought a common point was that it deflects folks from methods with evidence too (if any).
I’m not comfortable yet, but am off conjuring some new form of Bose-Einstein visualization therapy (BEVT) to sell the weak-minded cancer patients, since y’all seem ready to help me line my pockets (as long as I do little harm). Good for autism too.
Scott – saying that acupuncture has “significant risks” implies not just that it’s conceivably possible to get an infection from it, but that a meaningful proportion of users actually suffer real harm. If the chances that a treatment will cause me serious illness or injury are less than the chances that I will be killed by lightning, I don’t consider the risk “significant.” Do flu shots have “significant risks” if one in twenty million people die of them?
I will “explain” that science does not and cannot support your personal ethics as being superior to anyone else’s. Again imagining for the moment that the benefits of acupuncture had been proven to be all psychological, a doctor could still honestly say: “Studies have found that acupuncture may relieve your elbow pain as well as or better than an analgesic, with less risk of side effects.” What the patient cares about is the degree of relief, not the mechanism of relief, and so recommending the treatments with the best combination of safety and efficacy in practice would be entirely ethical. I have never seen a doctor who showed any interest in explaining the mechanisms of action of every treatment prescribed. However, if you were a doctor and felt that to be a moral necessity across the board – good luck with that – you would need to add: “Studies show that acupuncture relieves pain through psychological mechanisms alone, rather than through direct biological effects on the skin or nerves.”
Michele, you keep associating CBT with placebo effects and I think there’s a very important distinction to be made (plus I suspect it may be helpful for you to better understand what each is and how they function).”
Sorry FiFi, I was trying to be brief, but maybe I was not clear. The only association I have between CBT and placebo is that I was talking about things that MAY have some positive benefit on depression (regardless of the mechanism.)
So if you can’t take anti-depressants, (or if you can) CBT is shown to have a clinically significant benefit. So, in the end, one would have to compare the results and reliability of ANY potential treatment against the results of CBT (and/or exercise for that matter, which I think has some clinical evidence of benefit.)
I do not believe I confuse the two separate mechanisms, But, I can see how in my first comment it would look that way, since I was rather sloppily grouping placebo effect in with a hypothetical psycho/physio effect.
“(plus I suspect it may be helpful for you to better understand what each is and how they function). I mean no offense but I suspect you don’t quite understand what CBT or a placebo effect is because CBT is almost the opposite of a placebo effect! This may get in your way of better understanding both and some of the features of placebo effects and CBT.”
I’m sure you don’t mean to sound patronizing in this paragraph. I suspect it is just your habitual style of writing. But, other posters do seem to be able to make a point or correct a fact without a paragraph on why the previous commenter needs to hear or listen to that point.
Just let me assure you, I am perfectly happy to read any comment or information in response to mine (time allowing) without first seeing the argument that it will correct a deficit in my knowledge.
Yes, I would consider that to be significant.
Based on previous discussions, my understanding of the current consensus of medical ethicists is that no, a doctor CANNOT honestly say that.
Scott – I don’t know if that’s true – even if it is, though, a group of medical professionals disproportionately from one culture are not the only people whose ethical perspectives matter. Again assuming that acupuncture beats drugs solely due to its superior psychological effects, if it does beat the drug, from my perspective (and that of probably a large majority of the world’s population) it is perfectly ethical for anyone to admit to that fact. Conversely, I would regard it as unethical for a doctor to tell a patient that acupuncture could not possibly help him, if studies show that in practice it may be the best available source of the effect desired by the patient!
Your view of “significant risks” illustrates that individuals’ value judgements vary, and that science cannot tell us whose are “right” or “wrong.” If five people per year die of getting a flu shot, if I otherwise desire to get a flu shot I will not consider that a reason to change my mind or make out my will ahead of time. I consider such risks too small to worry about. If you consider it worth worrying about, you have a right to that perspective. But your use of the quasi-scientific word “significant” to describe the risk implies that there’s an objective reason why the people who aren’t worried about it really ought to be, which is just not true.
I’m not comfortable yet, but am off conjuring some new form of Bose-Einstein visualization therapy (BEVT) to sell the weak-minded cancer patients, since y’all seem ready to help me line my pockets (as long as I do little harm). Good for autism too.
I’m sorry, perhaps if you did a pull quote, I’d understand. I do not see who here is encouraging a sham cure for cancer or autism.
sorry, pull quote error myself
rork said “I’m not comfortable yet, but am off conjuring some new form of Bose-Einstein visualization therapy (BEVT) to sell the weak-minded cancer patients, since y’all seem ready to help me line my pockets (as long as I do little harm). Good for autism too.”
I’m saying – I’m sorry, perhaps if you did a pull quote, I’d understand. I do not see who here is encouraging a sham cure for cancer or autism.
apteryx,
” Since the sugar pill has no significant bioactivity, it can have no significant side effects”
Please allow me to expand the definition of “side effect” to include the following:
- the “nocebo effect”.
- the dumbing down of the science literacy of the population.
- the harm to the doctor patient relationship when the patient finds out he’s been lied to or taken for a fool.
- the increased tendency of the patient to accept other atlmed modalities that may be harmful in themselves or prevent him form getting a proper diagnosis hence delaying proper treatment.
“a doctor could still honestly say: “Studies have found that acupuncture may relieve your elbow pain as well as or better than an analgesic, with less risk of side effects.””
No, that is dishonest. Period. It’s not the acupuncture. It is the placebo effect. And most patients now understand what is meant by the placebo effect – if not, please do them and society a favour and explain it to them.
“Conversely, I would regard it as unethical for a doctor to tell a patient that acupuncture could not possibly help him”
No, because the plain fact of the matter is that acupuncture cannot possibly help you. But you will probably get a placebo effect especially if it’s just pain relief and not cure that you are after.
It is unethical, and there is no excuse, to lie to patients.
(There are exceptions but this has no relevance to the present discussion)
Ok, micheleinmichigan, I’ll leave off my last sentence quipping from now on, since it detracts from my (ignored) main questions. Sorry.
Billyjoe: “No, because the plain fact of the matter is that acupuncture cannot possibly help you.”
You do NOT know that. You only know that it doesn’t work obviously better than sham versions. In the above study of major depression all groups were quite dramatically better (8 points on a 23 point scale within four weeks) with the various “treatments” used. We expect many of those would have improved naturally, but how many would have with no treatment at all, or with drug use? Do you know?
Such findings don’t even place an upper limit on what non-specific medical nurture including a placebo can achieve, because we expect that to be dependent upon the world view of individual patients and characteristics of a particular practitioner and of any “treatment” used.
This discussion ALWAYS stalls at the “it is unethical for doctors to consciously use placebos” stage when there are, to me, a number of equally important questions that need answering.
With my seriously limited word-power, compared to some writers here, I am trying to convey a dilemma that I see in relation to science’s right to have a final say about alternative methods. That right is limited wherever we are unable to reliably predict how any individual will react. It is also never absolute.
“Doesn’t an authority condoning shamanism have the de facto effect of advocating it?”
From a patient’s prospective:
I would look to my doctor to inform me on the evidence to any common procedure (SBM, CAM or another specialty) that is related to my condition. I do want them to “advocate” for a particular treatment, but I do respect their need to re-explain any consequences of a treatment or non treatment if they believe I don’t understand. I also respect that they can’t know it all outside their specialty. They can say they do not know and offer a referral, reference or caution as they see fit.
If the doctor thinks a prominent CAM method is dangerous or is safe, but works only as a placebo. They should say so and explain. I think that will increase the trust between doctor and patients.
I deal with health professional a reasonable amount. I recently had a provider who seemed to feel that they had to “advocate” for one SBM choice over another SBM choice. I have no doubt that their intentions were good, but their preference was so obvious, I could not trust that they were giving me ALL the facts. So I had to switch providers.
But, it is not unusual for me to ask a provider who I trust what they would do when the decision is difficult, with conflicting evidence or procedures that have equal pro/cons. I have to be pretty impressed with a provider to do this.
I believe that the provider should give the patients all the honest information they can and accept that the patient will make the final decision AND deal with the consequences. But, I do not expect a doctor to perform procedures they can not condone and I feel it is their right to discontinue service to a patient if they are too frustrated with the patients choices.
Regarding placebo treatment. I think if my doctor prescribed a placebo pill or treatment without informing me it was a placebo, they would lose credibility with me. I probably would switch doctors. If knowing undermines the placebo effect, so be it.
A tip regarding using good bedside manner to bring about the placebo effect. I would remind doctor’s to be as genuine as possible. The first time a doctor told me “You’re doing everything right. You are asking all the right questions.” at the end of a consultation regarding a surgery for my son, I felt competent and happy. The fourth time I heard the same line (from three different providers), I began to suspect the line was in the hospital manual under “dealing with parents who ask too many questions.”
Regarding research funds – whether we like it or not, I think research has to be done on popular CAM methods. If they are common we need to know more about them. If this is hard to swallow, think of them as a potentially invasive species like emerald ash borer.
rork, This is my attempt to address your question. But I suspect I have probably missed some viable concerns that a doctor may have.
Billyjoe: “No, because the plain fact of the matter is that acupuncture cannot possibly help you.”
pmoran”You do NOT know that. You only know that it doesn’t work obviously better than sham versions.”
Okay let me substitute then:
Acupuncture doesn’t work better than placebo.
micheleinmichigan,
“If the doctor thinks a prominent CAM method is dangerous or is safe, but works only as a placebo. They should say so and explain. I think that will increase the trust between doctor and patients.”
“I think if my doctor prescribed a placebo pill or treatment without informing me it was a placebo, they would lose credibility with me. I probably would switch doctors. If knowing undermines the placebo effect, so be it.”
I can only agree.
michele – “The only association I have between CBT and placebo is that I was talking about things that MAY have some positive benefit on depression (regardless of the mechanism.)”
The way you’d associated CBT and placebo on more than one occasion makes it appear you believe they’re the same thing. Sorry if I offended you by responding but this is a topic that brings out my inner nerd and you seem quite interested in the subject. I find a lot of people are very, very confused about what a placebo is and how CBT, meditation and different therapies that exploit neuroplasticity work, so even if you’re not confused yourself you’re unintentionally perpetuating a general confusion. Certainly there are still a lot of unknowns, both about depression and how the mind/brain function, but it’s worth being clear on what we do know – if only because there are so many gray areas and some of the reality of cognition is quite counterintuitive.
apteryx – “a group of medical professionals disproportionately from one culture are not the only people whose ethical perspectives matter.”
That’s just ignorant and downright racist. People from all different “cultures” (nations, ethnicities, etc) go to medical school, practice SBM and engage in medical research. (And have throughout history.)
Whether CBT is a placebo or not depends on what the definition of “placebo” is.
The definition of “placebo” that I like to use is an effective treatment that is not pharmacologically or physically active, i.e. is not a physiologically active chemical or surgery. Under that definition, CBT is a placebo because it does not involve the use of drugs or surgery and it has positive therapeutic effects.
You have to come up with the definition of “placebo” first, and then see if a treatment modality is a placebo or not. You can’t decide which treatments are not placebos first and then look at the common characteristics of those treatments to figure out your placebo definition.
The reason you can’t decide which treatments are placebos first is because all effective treatments have a placebo component. Even opiates for pain relief have a placebo component that is different depending on how they are administered. Injected morphine provides more pain relief than does oral morphine. In my blog on the placebo effect I quote a resident saying that there is something about putting cold steel into someone while saying “this is going to make you feel better” that really works.
Dr Novella is exactly right, first you have to determine if there is an effective therapeutic effect, and then determine what the physiology is. If you get a therapeutic effect that is no different from a known placebo, then your treatment is indistinguishable from placebo. If a treatment is indistinguishable from placebo, it is a placebo.
All placebos are not equivalent. Hitting someone on the head with a hammer, might relieve a headache (in a very small class of people with headaches). If it does work, it is through a placebo effect. Acupuncture might work better for headache for most people than hitting them on the head with a hammer. That does not make acupuncture a non-placebo.
Sorry if I offended you by responding but this is a topic that brings out my inner nerd and you seem quite interested in the subject.
That’s okay FiFi. I understand. We all forget our manner sometimes when we are excited about a topic.
Billyjoe: “Okay let me substitute then:
Acupuncture doesn’t work better than placebo.”
Actually acupuncture works better than sugar-pill type placebos, at least to the satisfaction of many patients.
This is why we have to go to desperate lengths when blinding patients as to what “treatment” they are receiving in controlled clinical trials.
Might it also work better than some weakly active drugs?
We should be thinking this through, folks. There is nothing very reassuring in the current research.
I emphasise again that this is about certain niches within medicine. For many or most medical purposes placebos are useless, although they may be capable to bring additional comfort to many.
Dr. Atwood said, “CAM” begins with interventions and looks for indications..”
This is the Texas Sharpshooter Fallacy. We need to teach critical thinking in the elementary schools. Maybe someday we won’t have to waste time with arguments like these.
BillyJoe said: “Okay let me substitute then:
Acupuncture doesn’t work better than placebo.”
pmoran replied: “Actually acupuncture works better than sugar-pill type placebos”
A sugar pill is not the appropriate placebo for acupuncture.
So, my statement stands:
Acupuncture doesn’t work better than placebo.
“BillyJoe said: “Okay let me substitute then:
Acupuncture doesn’t work better than placebo.”
pmoran replied: “Actually acupuncture works better than sugar-pill type placebos”
A sugar pill is not the appropriate placebo for acupuncture.
So, my statement stands:
Acupuncture doesn’t work better than placebo.”
=====================
Like most skeptics, and myself at one time, your mind is fully focused upon what you think is THE question i.e. “does this method have the intrinsic medical efficacy that is being claimed?”.
It does not undermine the prime importance of that question in many medical settings to say that the studies intended to study it, using comparisons with sophisticated sham treatments, tell us very little about what placebos/sham treatments can do on their own. Nothing at all, in fact, if the study doesn’t include an “untreated” or waiting list group and probably only a lowish approximation when it does.
So it remains quite feasible that acupuncture and other procedural placebos could perform better than some accepted drugs for some conditions. There are already studies that suggest that the former performs as well as and safer than usual medical treatment in migraine prophylaxis, in studies where the fairly objective outcomes recorded in migraine diaries are being measured.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub2
An extract: — “In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of ‘true’ acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.”
Even this does not establish potent effects for placebo per se. Perhaps the drugs used in these comparisons are further examples of the second-rate crap occasionally foisted on us by drug companies. Perhaps the enforced relaxation/meditation of 20 min acupuncture sessions two or three times a week is the active agency, perhaps sometimes along with counterirritant effects or endorphin release. If so, it is not a placebo in the usual sense of being a completely inert medical activity.
Note that those ways of evading the question of “placebo power” also fail to confer on us the right to condemn acupuncture’s use under all circumstances and they can hardly justify too aggressive a pot-kettle-black stance when we state that “it cannot work”.
I am not asking you to go all the way with this (yet). There is merely sufficient uncertainty about some matters as to make some of our rhetoric over-the-top for a supposedly science-based group.
pmoran – I found and interesting article on the AMA ethics report for placebos.
http://www.medpagetoday.com/MeetingCoverage/AMA/3555
You might be interested. One part I found intriguing.
“Dr. Sade said that a permissible single-patient clinical trial approach may be useful in making a diagnosis when the physician is faced with significant clinical uncertainty. Patients should be told that they will be alternately given a substance that is “not pharmacologically specific for the condition being treated” but may be helpful and in any case will not worsen the condition.”
The original report is here. http://www.ncbi.nlm.nih.gov/pubmed/18552054
But I could not access even a summary.
“pmoran – I found and interesting article on the AMA ethics report for placebos.”
There is no unanimity of opinion.
There cannot be when there are occasions when doing what is almost certainly best for the individual patient, and must be admitted to be so when properly argued out, conflicts with concerns about interfering with patient autonomy.
The concerns about patient autonomy do not prevent some from wanting to extend a sometimes shaky but always patronising scientific hegemony over which treatment methods patients should have access to at their own volition, even developing a derogatory name for any who feel some unease concerning that — the despised “shruggie”.
pmoran,
” There are already studies that suggest that the former performs as well as and safer than usual medical treatment in migraine prophylaxis, in studies where the fairly objective outcomes recorded in migraine diaries are being measured.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub2″
No, you have misread the review.
When you study the write up of a clinical trial – or a systematic review as in the above – the first thing to do is to ignore the authors’ conclusions. Especially when the authors have a conflict of interest as do these authors. Because the authors’ conclusions are often not supported by the results, as in this case, or a spin on the results. Instead you need to read the actual results (well, the methodology as well but in this case there does not seem to be a problem with methodology).
What I am saying here is: don’t take the authors’ word for it. This systematic review does not say what they say it says and I see no reason to change my conclusion about acupuncture which is:
Acupuncture is no better than placebo.
pmoran,
“It does not undermine the prime importance of that question in many medical settings to say that the studies intended to study it, using comparisons with sophisticated sham treatments, tell us very little about what placebos/sham treatments can do on their own. Nothing at all, in fact, if the study doesn’t include an “untreated” or waiting list group and probably only a lowish approximation when it does.”
If you want to study the effect of placebos then use a non-treatment or waiting-list control.
If you want to study the effect of acupuncture use a sham control.
Acupunturists love the non-treatment control so if all else fails – as it usually does – they can at least say that acupuncture works better than doing nothing.
pmoran,
“perhaps sometimes along with counterirritant effects or endorphin release. If so, it is not a placebo in the usual sense of being a completely inert medical activity.”
Any supposed mechanism for acupuncture is trumped by the consistently negative trials (counting only the methodloogically sound trials of course)
pmoran,
“The concerns about patient autonomy do not prevent some from wanting to extend a sometimes shaky but always patronising scientific hegemony over which treatment methods patients should have access to at their own volition even developing a derogatory name for any who feel some unease concerning that — the despised “shruggie”
You don’t have to be patronising and you don’t have to be derogatory. Patients can choose acupuncture if they want to, just don’t pretend that it works any better than placebo.
Fifi wrote:
“apteryx – “a group of medical professionals disproportionately from one culture are not the only people whose ethical perspectives matter.”
That’s just ignorant and downright racist. People from all different “cultures” (nations, ethnicities, etc) go to medical school, practice SBM and engage in medical research. (And have throughout history.)”
Fifi – Watch with the reading comprehension, please. I was responding to Scott’s claim regarding “the views of medical ethicists,” in response to which your comment is senseless. There most certainly have not been professional medical ethicists “throughout history” – or medical schools, for that matter; the former in particular is a recent occupational niche. And you are not free to conflate culture with race. I’m sure there are African-American and Asian-American professional medical ethicists, but how many medical ethicists are there from Zaire or Cambodia? Are there any Jivaro or Kikuyu professional ethicists? If there should be any, they were trained in Western or Westernized university systems, and their current opinions would be likely to conform to those considered acceptable by the faculty at those institutions, making their values no longer representative of the values of others from their native culture – just as Dr. Arthur Caplan and his less famous colleagues are not necessarily representative of ordinary Americans’ values.
If you don’t mind my saying so, I would have thought SBM’s recent Dr. Amy fiasco would have taught you a lesson about spewing unwarranted personal insults towards those whom you view as inferior because they disagree with you on some point. You consider yourself to be one of the skeptical elite, but the minute you questioned Dr. Amy, you wound up on the receiving end of that treatment, didn’t you? Didn’t like it, did you? Then you might refrain from dishing it out.
Billyjoe: “You don’t have to be patronising and you don’t have to be derogatory. Patients can choose acupuncture if they want to, just don’t pretend that it works any better than placebo.”
Do you not see a bit of a tension between those two sentences? ‘OK, go ahead, but know that if it should help with your problem it is “just placebo”‘, with the unjustified implication that that would be somehow not real, not of any true value.
I am a little offended that you should htink that I should not udnerstand the significance of the clinica
Sorry for the incomplete post.
——————————————-
I was saying that I was offended by your assumption that I did not understand the clinical study data I quoted.
I am trying to get across some subtle but important matters. Let’s try another tack.
Patients mostly don’t care “how it works” and will approach the question of efficacy of dubious methods with far less certainty than we will, even when knowing that doctors and scientists don’t believe in them. That is their right. It is even sensible, by their lights, when they have an unresolved medical problem.
For them acupuncture and the like is simply something else to try when when the doctors are not helping enough or they don’t like what is on offer from them, often on reasonable grounds if you stand back and look at pharmaceuticals and their potential for ill effects dispassionately. With most everyday complaints they are going to be better within a few weeks whatever treatments they may choose to use, and most have a sense of when it is best that they consult a doctor.
So I think that in some contexts we as doctors should be wishing them well from any benefits they may derive from placebo and other non-specific effects of CAM. It is deeply counterproductive to react with what can so easily look like spite, even somewhat dog in the mangerish.
The information we should be getting across to the public is that acupuncture is useless as a treatment for most defined diseases but it can ease symptoms for some. That is firm ground, and all that the available evidence allows us to say.
A useful concept is “comfort measures.” I think this is what pmoran is gettiing at. Comfort measures don’t do anything objective to shorten the illness, but they are a humane addition that make the patient’s experience of illness less unpleasant, and they can include measures as simple as holding a hand or covering with a warm blanket. I have no objection to acupuncture or any other “ineffective” treatment being used as a comfort measure – as long as it doesn’t carry enough risk to outweigh the benefits and the patient isn’t lied to.
pmoran – “There is no unanimity of opinion. ” regarding placebo ethics AMA article
Yes, the article I linked says that. That is why I linked to it. I thought some might find the different opinions interesting, but I did not want to cut and paste the whole article in the comment box.
Yes, Harriet, comfort medicine is part of it, but there are many elements. Even just satisfying that deeply implanted urge to “do something” when sick can have merit. Not all patients will follow or respond positively to careful explanations as to why treatment is being withheld fro some complaints.
Sometimes a placebo/symptomatic treatment can buy time, while an unclear diagnostic situation clarifies itself, or the patient gets better by themsleves, leaving the practitioner still in play and not risking the loss of the patient to someone with less knowledge of them and less medical savvy.
Why are we so shy about allowing that just sometimes, possibly, highly trained and experienced professionals who know the patient very well do know what’s best, in the many fringe situations that arise within medicine?
And there may be more serious medical applications. Who knows for sure whether or not the addition of acupuncture to other management might enable susceptible patients to need less narcotics for their cancer pain? No one. There are no suitable studies that I can find, but one is I think planned by the NCCAM.
The “working better than placebo” model of medical practice precludes us even trying to find that out. As usually applied, it would also reject any positive studies as just showing placebo effects. Hmmmh!
I say again, this all refers to situations where there is no entirely satisfactory medical treatment.
pmoran,
“Do you not see a bit of a tension between those two sentences? ‘OK, go ahead, but know that if it should help with your problem it is “just placebo”‘, with the unjustified implication that that would be somehow not real, not of any true value.”
I said “don’t pretend that acupuncture is any better than placebo”.
If a patient asks you about acupuncture are you going to lie and say: “acupuncture works” [and under your breath "but no better than placebo"] or are you going to be upfront and honest and say “there is no evidence that acupuncture works better than placebo”.
In my experience, once you lie to people you are always on the back foot, you have to keep lying to cover up your initial lie. Also you’re promoting ineffective altmed treatment and perhaps unwittingly pushing your patient to try other – and maybe this time dangerous – altmed treartments.
pmoran,
“I was offended by your assumption that I did not understand the clinical study data I quoted. ”
Okay, I misread your post.
On second read, it is clear that you understand that systematic review pretty well.
Apologies to you, and embarrassment for me
But I wasn’t suggesting that patients choosing acupuncture be condemned – just not lied to. Especially if they come to you for information. Maybe the placebo effect of acupuncture works better than some medical treatments (because they aren’t accompanied by the ritual that produces the placebo effect of acupuncture).
But it’s the ritual that works, not the acupuncture. The acupuncture itself does not work (you can stick the needles in anywhere you like, and you don’t even have to stick them in), and there’s no getting away from that. I could even say that, because sham acupuncture works just as well as true acupuncture and is safer, you should be recommending sham acupuncture.
I suppose, though, that sham acupuncturists might be in fairly short supply.
BillyJoe – Outside of the context of a clinical trial, there’s absolutely no need to lie to people about things that work no better than a placebo – be they acupuncture or certain kinds of knee surgery that are no better than placebo surgery. It’s quite possible to tell the truth and say to a patient, “clinical trials have shown that this procedure is no better than a placebo – some people find it makes them feel a bit better and others don’t.” In areas like chronic pain or depression, the placebo effect can sometimes be quite powerful. My only caveat is that it’s always best to be teaching a patient how their own mind works and how to create these experiences for themselves (rather than becoming dependent upon a practitioner, though sometimes a period of dependency before transitioning to being more self managing is part of the treatment process so it’s really about having self management as the ultimate goal).
Fifi,
I largely agree with what you say.
However I’m finding it hard to imagine someone performing acupuncture on themselves knowing that it is a placebo treatment getting the same effect as someone who believes in acupuncture attending a skilled acupunturist who also believes in acupuncture.
Also there is the down side that I have mentioned several times.
Trouble is, we really don’t know how acupuncture works, whether it has a mechanistic nervous-system effect or a super-placebo effect or both, and if the latter, what accounts for its extraordinary activity. If it has been adequately demonstrated that acupuncture relieves a particular condition better than drugs, the fact that some people believe acupuncture is functionally equivalent to “poking yourself with toothpicks” does not mean that poking yourself with toothpicks will likewise be more effective than drug treatment. Someone who tried that and found that it was ineffective might wrongly conclude that acupuncture would likewise not benefit them.
Billyjoe: ” But it’s the ritual that works, not the acupuncture. The acupuncture itself does not work (you can stick the needles in anywhere you like, and you don’t even have to stick them in), and there’s no getting away from that. I could even say that, because sham acupuncture works just as well as true acupuncture and is safer, you should be recommending sham acupuncture.”
That is roughly my view, too. Acupuncture, being a somewhat invasive procedure involving periods of enforced ‘time out” while being cared for in a sympathetic environment has some additional plausible reasons for having medical activity over some other healing rituals. And, of course, the whole therapeutic envirnement is critical. Perfunctory treatment by a surly practitioner may not “work”.
apteryx,
Sorry to nitpick your post, but I think the nitpick is necessary.
“Trouble is, we really don’t know how acupuncture works”
Acupunture doesn’t work.
“…whether it has a mechanistic nervous-system effect or a super-placebo effect or both…”
There is a super placebo effect associated with acupuncture.
“and if the latter, what accounts for its extraordinary activity.”
The ritual.
” If it has been adequately demonstrated that acupuncture relieves a particular condition better than drugs…”
It hasn’t and it doesn’t.
” the fact that some people believe acupuncture is functionally equivalent to “poking yourself with toothpicks””
Yes, they are both useless.
“does not mean that poking yourself with toothpicks will likewise be more effective than drug treatment.”
It isn’t (see above)
“Someone who tried that and found that it was ineffective might wrongly conclude that acupuncture would likewise not benefit them.”
It wouldn’t.
Poking yourself with toothpicks doesn’t work at all.
The ritual associated with “poking yourself with toothpicks” probably doesn’t work very well.
Acupuncture doesn’t work either.
But the ritual associated with acupuncture works pretty well in certain conditions.
Sorry BillyJoe, but like many issues, the definition of words like “works” and “useless” seems to be a philosophical question and not a scientific one. If studies show, let’s say, that patients with elbow pain randomized to acupuncture have less pain and regain more range of motion than those randomized to drug treatment, I would conclude that acupuncture works for that specific use and hence is not useless. You conclude the opposite. To me, if I were to declare that acupuncture was useless, I would also have to declare that the drugs, which provided less relief and have many more side effects (including, according to a new study, increased risk of hearing loss), were useless. Science offers no reason to believe that your personal definitions are superior to mine.
As a scientific issue, it has not been proven that the effects of acupuncture are entirely due to “ritual,” as the only studies that show equivalence to “sham” acupuncture involve dermal stimulation probably comparable to that of real acupuncture. There are modern alternative practices, such as reiki and “therapeutic touch”, that likewise involve plenty of ritual, caring treatment of the patient, the opportunity for the patient to rest and relax for periods of time, etc., but that (based on both clinical trials and human experience) seem clearly to be less effective than either acupuncture or drugs at relieving pain. If the pain relief of acupuncture is all due to ritual, why are those other practices not just as good? (There is also the issue that, though highest-quality studies are few in number, there is some evidence that acupuncture and similar methods affect animals. Animals, of course, are not susceptible to culturally mediated placebo effects.)
“If studies show, let’s say, that patients with elbow pain randomized to acupuncture have less pain and regain more range of motion than those randomized to drug treatment, I would conclude that acupuncture works for that specific use and hence is not useless.”
If that study included a sham acupuncture control group and the effect in the true acupuncture group was no better than that in the sham acupunture group, then the conclusion is that acupuncture is no better than placebo. If something is no better than palcebo, that means it does not work.
“As a scientific issue, it has not been proven that the effects of acupuncture are entirely due to “ritual,” as the only studies that show equivalence to “sham” acupuncture involve dermal stimulation probably comparable to that of real acupuncture.”
Acupuncture is the placement of needles at specified acupuncture points to a depth of about 1cm (there are variations of course but they all have there own problems). This has been shown to work no better than putting the needles in wherever you like and, in fact, not putting them in at all – as in sham acupuncture. Sham acupuncture is the ritual of acupuncture without the acupuncture. It is the ritual of acupuncture, not the acupuncture itself (which is the placement of needles at specidfied point to a depth of 1cm) that has the effect. This ritual of acupuncture is the placebo effect of acupuncture.
“If the pain relief of acupuncture is all due to ritual, why are those other practices not just as good?”
Because all rituals (ie placebo effects) are not equivalent. It seems that actually touching the skin has a greater placebo effect that nearly touching the skin (as with TT and Reiki). Just as an injection of normal saline works better than a sugar pill as a placebo.
“there is some evidence that acupuncture and similar methods affect animals. Animals, of course, are not susceptible to culturally mediated placebo effects.”
They don’t need to respond to the placebo effect. In fact, there is little evidence that they do. Their owners, on the other hand, are ready to swear that their animals have been helped when clearly they haven’t.
…sorry, that was in reply to apteryx.
BillyJoe – “However I’m finding it hard to imagine someone performing acupuncture on themselves knowing that it is a placebo treatment getting the same effect as someone who believes in acupuncture attending a skilled acupuncturist who also believes in acupuncture.”
Can someone even perform acupuncture on themselves? It seems quite unlikely and I’ve never even seen it suggested or advocated (acupressure, yes, but not acupuncture). The problem is that you’re proposing two entirely different things and contexts here – doing something to oneself that one doesn’t believe in and someone else doing something to you that you both believe in. Surely you can see how these aren’t equivalent at all in any sense in regards to acupuncture and particularly in terms of the placebo effect?
Speaking to apertyx’s point that he believes acupuncture to be superior to reiki and TT and the effects not due to ritual… It’s been shown that the placebo effect is amplified by having a more dramatic ritual or procedure…bigger needles equals bigger placebo effect, for instance, when a placebo injection is being given. So, with this understanding, it makes perfect sense that the more dramatic and “medical” intervention of being stuck with needles (or believing that one is being stuck with needles in the case of sham acupuncture) will have a more pronounced placebo effect for those prone to the placebo effect and who like dramatic interventions. (It’s a bit like how some people tend to believe that only medicine that tastes bad works. You see this bad tasting version of the placebo effect all the time regarding medicines – both herbal and pharmaceutical.)
Apteryx, what basis do you have for saying that placebos do not work on animals? Animals can be conditioned to do all sorts of things, everything that humans can be conditioned to do. Why can’t animals be conditioned to respond to acupuncture too?
BillyJoe – you are simply repeating your definition of “does not work”, with no apparent willingness to understand that other people have a different definition that they can equally well justify by rational argument based on observed facts.
There are various modern “energy healing” or chiropractic-offshoot practices that involve gently physically touching people. (I recently had the joyous experience of listening to a small swarm of chiropractors yack about this at some length.) Have any of these been observed to improve pain and range of motion better than pharmaceuticals? I don’t think so, therefore, I remain unconvinced that acupuncture’s benefit is all due to “ritual.” Even if it were, I, like many people, care only about getting maximum relief with minimum risk. If I could really do that through ritual, that’s fine with me; according to my values, the mechanism of relief is a matter for intellectual curiosity but not a basis for decision-making.
daedalus2u – I don’t think there is incontrovertible evidence that acupuncture benefits animals, but if it does, I would not believe that that was a placebo effect. Placebo effects are culturally mediated: you have to have positive expectations of a treatment in order to benefit. How do the animals learn that acupuncture is supposed to relieve their pain? It just happens to be annual vaccination time for my cat, and though she does demonstrate understanding of a very limited English vocabulary, I have never been able to get across the concept that she’s being hauled to the vet and stuck with a needle for her own good. She’ll sit still for it, but she clearly thinks that she’s being ill used. I suspect she would react the same way to acupuncture.
When we talk about treatments like acupuncture and other methods that show variable or limited utility, much of the disagreement seems to come down to confusion about what exactly is the “placebo effect” and whether any benefits observed from the placebo treatment or the test treatment (if its results aren’t significantly superior to placebo) are “real”.
For understanding this problem, I found Dr Novella’s article from last October to be illuminating even though it only got 12 comments. I think I have looked it up 2 or 3 times in preparing comments for other blog posts such as this one.
Here is the link:
http://www.theness.com/neurologicablog/?p=1130#more-1130
I especially like his definition/description:
“What most people mean when they say “the” placebo effect is a real physiological effect that derives from belief in the effects of a treatment – a mind-over-matter effect. However, the placebo effect, as it is measured in clinical trials, has a very specific operational definition. It is any and all measured effects other than a physiological response to the treatment itself.
This includes any physiological responses to belief in the treatment, but also a host of psychological factors such as reporting bias, confirmation bias, risk justification, and assessment bias. It also includes non-specific effects of being in a clinical trial – people treat themselves better when they are being observed, when they are being reminded of their illness because of frequent attention, and when they are encouraged by the hope of benefit. Such things actually affect compliance with other treatments and healthy lifestyles – in other words, people will be more compliant with other medications they may be on, and may eat better and exercise more, etc.
These variables and others are the reason for double-blinding experiments. Without doubling blinding, these placebo effects will be mixed in with the physiological effects of the treatment, if any.”
For diseases like HIV/AIDS or the severe forms of cancer with a relatively straight-forward and prompt progression to death, it is fairly easy to see (at least for most people) that standard therapies like HAART or surgery/chemotherapy/radiation therapy are significantly superior in most cases to complete placebos like a sugar pill (not that that would be an ethically valid study) or even some pharmacologically active substances such as aspirin.
However, for diseases without a good medical “cure” or even a satisfactory treatment that can reduce the condition to the nuisance level, we are stuck with looking for slight or marginal improvements over existing therapies. Because these are slight, they are hard to distinguish from the random variation in results that is simply part of the normal process of trying to conduct a study (i.e., the placebo effect). Chronic pain and depression are two major targets for this category of studies.
Because a lot of people suffer from these conditions, even slight positive results can be interesting and worthy of follow-up. But, unless those results can be repeatably and reliably replicated, there just isn’t sufficient basis to call for an immediate change in the standard of care. This is where the popular media and most CAM advocates jump the gun.
Some people think of the placebo effect as a real, beneficial therapeutic effect that we just don’t understand yet. I think this is misleading and it makes more sense to me to think of the placebo effect as the random variation in the standard response that we are trying to use as a basis for comparison to look for a real or significant improvement.
Thus, for acupuncture, even if it has a slight but real beneficial effect (which is dubious), the best studies show that it does not work the way its proponents say it does. It does not matter where you stick the needles (proponents say it does) and it does not matter if the needles even penetrate the skin (proponents say it does). So, in the absence of a definable or measurable mechanism, we are left with only the simple participation in the treatment process (the “ritual”) as the source of any improvement (in other words, the placebo effect).
If the person being treated for depression wants to get their back poked and prodded and hopes that it will help, I think that I can ethically recommend (even as a non-medical practictioner) that they keep their money, avoid the risk of infection from getting needles stuck through their skin, and get their spouse or partner to give them a good back scratching (and vice versa) and see what happens.
If nothing else, the results may help to mitigate a side effect of a common medical treatment for depression.
http://www.johnshopkinshealthalerts.com/reports/depression_anxiety/130-1.html
BillyJoe said: “However I’m finding it hard to imagine someone performing acupuncture on themselves knowing that it is a placebo treatment getting the same effect as someone who believes in acupuncture attending a skilled acupuncturist who also believes in acupuncture.”
Fifi replied: ” Surely you can see how these aren’t equivalent at all in any sense in regards to acupuncture and particularly in terms of the placebo effect?”
That was exactly my point.
It was apteryx who bought this up when he said something about comparing acupuncture with sticking toothpicks into yourself as somhow demonstrating that acupuncture is effective. My point was that they are both placebo efffects and it’s just that the second placebo effect is much stronger than the first.
Fifi, my response is in moderation so you’ll have to wait.
I wish they would fix the damn thing.
apteryx,
“BillyJoe – you are simply repeating your definition of “does not work”, with no apparent willingness to understand that other people have a different definition that they can equally well justify by rational argument based on observed facts.”
If your definition leads to you saying – incorrectly – that acupuncture works when it clearly does not and all you mean is that it has a placebo effect – albeit a powerful one – then your definition is misleading and you should discard it. That’s all I’m trying to say.
(If you followed the discussion about the use of the word “observer” in quantum physics, you’d understand what I mean)
“I remain unconvinced that acupuncture’s benefit is all due to “ritual.””
Then I think you just don’t want to be concinced, because I’ve already explained that “sham acupuncture” encompases the ritual (which is the placebo effect of acupuncture) and “true acupuncture” is the placebo effect + the effect of acupuncture itself (which is the placement of needles at specific acupuncture points to a depth of 1cm). All clinical trials comparing “sham acupuncture” and “true acupuncture” show that there is no difference. The logical and inescapable conclusion is that acupuncture does not work.
“Even if it were, I, like many people, care only about getting maximum relief with minimum risk. If I could really do that through ritual, that’s fine with me; according to my values, the mechanism of relief is a matter for intellectual curiosity but not a basis for decision-making.”
I prefer to know the truth of the matter, the benefits come second.
If the truth means I don’t get the benefit so be it, I’m not going to sacrifice the truth.
I read a nice little takedown of the concept of the placebo effect as a “thing” a while ago. I don’t know whether it was after Wired’s article in September or whether I had read it earlier, so of course I can’t locate it. Perhaps someone here has an online reference to something similar.
Anyway. The article pointed out that a placebo effect isn’t necessarily — or even usually — a benefit someone is actually getting from a placebo treatment. It’s a benefit that they are recorded to have reported getting. It includes many sources of bias, including the subject’s wanting to please someone who has invested a certain amount of effort in them, and saying they feel better than they actually do.
Unless you have a way of taking apart all the different contributors to the placebo effect, you don’t know how much is real but nonspecific effects (from social contact, from being touched) and how much is just saying Yes I feel better, now leave me alone — and without that you can’t justify saying that placebo “works.”
Oh goody — what squirrelelite already said at 1:15 pm.
Thanks, squirrelelite!
There’s a whole book on the placebo effect that was published several years ago; you might look it up. A number of elegant studies have made it clear that there is a “placebo effect” for pain relief, which can be influenced by both patient and caregiver expectations, and which operates in part through the activity of endogenous opioids in the brain. If people think they are getting a drug for pain, though they are really getting IV sugar water, they report less pain than if they don’t think they are. However, if they are also secretly given naltrexone, an opioid antagonist, they report much less pain reduction. If a sizeable component of the “placebo effect” is due to the poor silly sheeple putting on a brave face to please the investigator, this implies that suppressing the activity of endogenous opioids makes people enormously less eager to please. I’d have to see some substantive evidence before I accepted that presumption.
This please-the-doctor hypothesis also raises the question of how then anyone could conduct any kind of study of pain, or any other symptom that exists solely in a patient’s perceptions. You can’t consider reports of change on standardized pain scales to be reliable and meaningful only when you approve of the treatment being tested.
Regarding this “mysterious” placebo effect: Irvin Yalom studied the factors that providers and patients believed had led to improvements from group psychotherapy. He arrived at a list of 11: instillation of hope, universality, imparting of information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, cohesiveness, catharsis, existential factors. These are reported in the ubiquitous, readable text, “Theory and practice of group psychotherapy.” A few of these would obviously be operating for someone recruited into any psychiatric drug study. Study staff would typically be friendly and encouraging, and likely portray cautious optimism toward any treatment arm. Also, the clincal / research setting itself probably contributes toward some of these effects.
In a drug study, you would get: instillation of hope, universality, imparting of information, and interpersonal learning.
Carl Rogers, another research-evidence-driven psychologist, noted the “necessary and sufficient conditions” for a person to benefit from psychotherapy. To some degree, these conditions can be invoked in a drug trial, regardless of drug efficacy per se. These include: an obvious, perceived therapeutic relationship, in which the provider has unconditional positive regard for the patient; this regard includes genuineness / honesty / transparency. This could be communicated by the drug trial personnel through the entire process of participation. Rogers believed that these therapeutic effects normally happen when human beings have these sorts of relationships, anyway, with others – it is not limited to mental health professionals. An example of benefit from such a realtionship is the classic positive influence that a school teacher can have on a student.
In the field of psychotherapy research, we have known this for decades, and it is part and parcel of our research. A term for these factors is “nonspecific therapeutic factors,” as opposed to specific factors such as cognitive therapy striving to challenge and replace maladaptive thoughts, behavioral therapy striving to provide classical exposure-and-extinguishing experiences, and psychodynamic therapy striving to re-create a significant powerful interpersonal experience with one in which there is a corrective emotional experience.
You can act like these therapeutic influences are some sort of black box mystery if you want. If you are in the field of mental health / psychiatry research, that is being woefully ignorant of decades’ worth of major bodies of knowledge. This is bread-and-butter in psychology research and practice. We all have Yalom’s book on our shelves. Sadly, when I read these medication studies, this ignorance of nonspecific therapeutic factors is the status quo.
Nice summation Medsvstherapy.
You’re welcome, Alison.
Steven’s post from today is also of interest on this subject:
http://www.theness.com/neurologicablog/?p=1714#more-1714
apteryx,
“If a sizeable component of the “placebo effect” is due to the poor silly sheeple putting on a brave face to please the investigator, this implies that suppressing the activity of endogenous opioids makes people enormously less eager to please. I’d have to see some substantive evidence before I accepted that presumption.”
There is nothing right about what you’ve said above from “poor silly sheeple” to your mathematics, but I’m having no luck explaining things to you so I’ll leave it to some other more competent person to have a go.
Evidence concerning the potential for and the nature of placebo responses is vast, and derived from many sources.
We can be sure that a lot of the benefits often attributed to placebo benefits are illusion and actually due to spontaneous happenings or patient reporting biases.
OTOH, laboratory studies show very strong apparent placebo “activity”, and suggest the activation of endorphin activity and symptom-relieving cerebral pathways on MRI. If such data is being interpreted correctly, it offers very solid evidence that placebo reactions are genuine responses to treatment in every sense other than in being mediated by psychological rather than pharmacological or physiological influence.
It would have been helpful if RCTs comparing patients receiving placebos with those on no treatment, or on waiting lists for treatment, gave conclusive results, but they are also difficult to interpret*. They actually provide “effect sizes” for placebo upon subjective symptoms such as pain that are not huge but too large to ignore. The usual clinical trial is not conducive to strong placebo influences so, again, the power of placebo remains elusive.
Anecdotal evidence has certainly always suggested strong effects under the right conditions.
So how powerful is the placebo? I don’t know for sure. I also suspect bias when anyone is dogmatic on the subject.
* Hrobjartsson, A., Gotzsche, P. C. (2001). Is the Placebo Powerless?. N Engl J Med 345: 1276-1279
Nicely said Dr Moran. Placebo effects don’t equal no effect. Another thing that’s worth considering – that I suspect a lot of the general public doesn’t really think about – is that most medications act as a push for a release (or dampening) of chemicals that already naturally exist in our system.
One example of this is how drug addicts can get a phantom high from watching or going through the ritual of taking their particular drug of choice. Not just a craving but an actual sensation (not long lasting or likely to satisfy someone in withdrawal but it still happens). It’s a matter of having a Pavlovian or conditioned placebo response, a physiological response. This may or may not be different than one or some of the placebo effects people experience during clinical trials but it certainly points to our body’s capacity to be pushed into a physiological response via environmental stimulus.
An interesting article that looks at the neurobiology of placebo response (for anyone interested in delving further into this topic).
http://www.medscape.com/viewarticle/571129
apteryx – The existence of placebo effects doesn’t actually make a good argument for the efficacy of acupuncture, nor does it prove that it “works” as anything other than an elaborate/dramatic (and often expensive) ritual that could be replaced by any other elaborate/dramatic (and inexpensive) ritual. And the fact that people have placebo responses doesn’t make them “sheeple”, it’s just an interesting facet of human nature and worth exploring for what it is (rather than dressing it up in false explanations/lies about how it “works” via meridians and chi and so on, or charging poor suckers lots of money and eating up years of their life to study lies about meridians and chi).
BillyJoe: “There is nothing right about what you’ve said above from “poor silly sheeple” to your mathematics, but I’m having no luck explaining things to you so I’ll leave it to some other more competent person to have a go.
”
Thanks, Fifi, for having a go
Very interesting article. I was only able to skim the 107 comments, so I apologize if what I’m about to say has already been covered.
Sample size is often based on an estimate of the expected size of the test and control treatment effects. If the sham intervention is assumed to be inert, calculations are based on general ideas about the size of the placebo effect. This is often pegged at 30% based on Beecher’s original work. However, his calculations have been found to be erroneous and most placebo researchers today believe the effect is higher. (http://bit.ly/bbFKFa) To demonstrate a difference between sham at 30% and active treatment at 70% requires a relatively small sample size. But if the sham intervention is closer to 50% effective, a larger sample size will be needed to demonstrate effectiveness. The majority of acupuncture trials have suffered from inadequate sample sizes. (http://bit.ly/9HJgOT)
Trials that assume sham is inert are at greater risk of showing false-negatives. De Craen et al showed that if the effect of the noninert placebo is small, the will be biased if the treatment effects are also small. This bias increases if the effects of noninert placebo are larger. (http://bit.ly/cuhrTp) So, inadequate sample size is one factor that has compounded acupuncture research.
It has long been known that surgery is associated with strong placebo effects. Various reasons have been offered ranging from the degree of physical discomfort during the procedure to the meaning attributed to shedding of blood. But the human body has protective and restorative mechanisms that are triggered by injury. These are not placebo effects – they are direct and predictable responses of the body to the trauma of surgical incision.
Puncture of the skin by acupuncture needles, like surgical incisions, provoke a cascade of physiologic responses which not only repair the wound but also trigger a range of biologic effects that have systemic effects in the body. These responses are well-documented and include activation of the blood coagulation and immune complement systems. Recent work by Maier et al and Tracey et al have shed light on how the brain controls certain types of inflammation and therefore pain. Their work has given us clues on how acupuncture reduces inflammation and relieves pain. For example, they explain that inflammatory formation is transmitted through sensory nerves to the hypothalamus, where input signals are processed, resulting in anti-inflammatory output via the humoral system and the ANS via the HPA axis. (http://bit.ly/afuPqV)
I’ve often heard the claim that “little is known about the analgesic effects of acupuncture.” On the contrary, according to Professor Bruce Pomeranz of the University of Toronoto, “We know more about acupuncture analgesia than about many chemical drugs in routine use. For example, we know very little about the mechanisms of most anesthetic gases, but still use them regularly.” (http://bit.ly/9L0NYV) I’d add aspirin to that list.
The recently developed noninvasive sham needle of Streitberger and Kleinhenz is considered to be an inert placebo needle by its inventors. However, reports of its use suggest otherwise. One researcher in Germany cause bleeding in a patient using the Streitberger needle.
Also, since the effects of acupuncture are largely nonspecific, involving the stimulation of innate healing mechanisms, the results of treatment will depend upon 1) the status of the patient’s immune system and overall potential for self-healing, and 2) the potential of the body to “self-heal” the condition in question. #1 depends on a multitude of factors difficult (nutritional status, medications, etc.) difficult to control for in a clinical trial.
When placebo effects interact with or are inseparable from other effects, placebo-controlled trials become difficult if not impossible. This has prompted authors like Gotzsche to suggest that the concept of placebo should be discarded. He points out that the nonspecific effects of so-called “placebo” can’t be assumed to be the same in two arms of the same trial, or from one trial to another. Some effects, such as the increased skill of an investigator and “white coat syndrome” could be different in different groups. And unless the outcome was survival it would be hard to measure the effect in the untreated group without interference. (http://bit.ly/cph1cV)
Finally, Moffet’s recent review in the Journal of Clinical Epidemiology demonstrates that acupuncture is distinguishable from placebo and affects outcomes. (http://bit.ly/9LoBJc)
While I agree that 1) the effects of acupuncture are nonspecific, 2) there is no demonstrable difference between sham and active acupuncture, provided the sham stimulates the same nonspecific mechanisms as the active treatment, and 3) there is no support for traditional methods of point selection nor any indication that point selection makes a difference, I think it’s inaccurate to claim that acupuncture is indistinguishable from placebo.
Chris Kessler
“While I agree that 1) the effects of acupuncture are nonspecific, 2) there is no demonstrable difference between sham and active acupuncture, provided the sham stimulates the same nonspecific mechanisms as the active treatment, and 3) there is no support for traditional methods of point selection nor any indication that point selection makes a difference…”
1) The effects of acupuncture has not been reliably demonstrated to be greater than zero.
Note: acupuncture is defined as sticking needles through the skin to a depth of 1cm at specific acupuncture points.
(If you are using a drastically different defintion, you are no longer describing acupuncture.)
2) There is no demonstrable difference between sham and active acupuncture.
Note1: It is now possible to do effectively double blind acupuncture trials using sham acupuncture needles.
3) There is no support for traditional methods of point selection nor any indication that point selection makes a difference, or that you even need to stick the needles through the skin.
“I think it’s inaccurate to claim that acupuncture is indistinguishable from placebo.”
I’m going to assume this is a typo, because the part of your post that precedes it (ie the rest of your post) suggests the exact opposite: that the effect of acupuncture above placebo is zero – meaning that acupuncture does not work.
What of Moffet’s 2008 review of 78 trials indicating that acupuncture is distinguishable from placebo? (Link in previous post) To claim that the effect hasn’t reliably been demonstrated as greater than zero ignores the reviews that claim the opposite. Nor is it accurate to claim that studies reliably demonstrate the effect IS NOT greater than zero. There are numerous issues with the way acupuncture trials are performed that are still confounding results, as I described in my comment.
It’s not correct that acupuncture is defined as needles piercing the skin at a 1 cm. depth. There are over 80 styles of acupuncture in China alone, not to mention styles in Japan, Korea and other countries. In Japan there is a style called “contact needling” that involves stimulation of the points with needles without breaking the skin. It cannot be ruled out that the so-called sham treatment in many studies is causing the same nonspecific effect that penetrative acupuncture is stimulating.
According to Moffet:
“The practice of making a priori assumptions about what are acceptable placebo effects in a trial needs to be re-examined, because this has been responsible for introducing faulty assumptions about the nature of placebo, and bias against the therapy being investigated. Often these a priori assumptions are based on ignoring published literature about treatment effects and biologic mechanisms that are known to arise in response to the proposed treatment methods.”
If a non-invasive sham procedure is used in a trial, it has to be investigated for physiologic effects to establish that it is actually inert, and more complete procedures must be used to separately control for other nonspecific physiologic effects.
Since the therapeutic effect of acupuncture is achieved by activating the body’s self-healing mechanisms, it’s essential to determine that these natural healing processes (that are in fact the goal of treatment) aren’t confused with placebo and are controlled for in sham trials. There are very few trials that have done this, and it remains to be seen whether it can even be done reliably.
Chris Kessler,
“What of Moffet’s 2008 review of 78 trials indicating that acupuncture is distinguishable from placebo? ”
Of the 78 trials:
22 trials compared acupuncture to usual care alone or other non-acupuncture controls – in other words they failed to control for placebo effects.
That leaves us with 56 trials.
40 trials compared acupuncture interventions mainly differentiated according to traditional acupuncture theories – still no placebo control.
That leaves 16 trials.
16 trials did use placebo controls; and 11 had statistically significant differences in outcomes.
But, without being able to access the details – unless you are willing to pay for them – how do we know that the placebos where adequate to account for the total placebo effect associated with acupunture?
I’m willing to bet – because I’ve seen this sort of thing many times before – that the 5 that showed no effect were the ONLY ones with an adequate placebo control.
Chris Kresser
“It’s not correct that acupuncture is defined as needles piercing the skin at a 1 cm. depth. There are over 80 styles of acupuncture in China alone, not to mention styles in Japan, Korea and other countries.”
And what does this tell you about acupuncture?
(hint: does it support your view of acupuncture or does it support my view that you can stick the needles in wherever you like and you don’t even have to stick them in.)
“In Japan there is a style called “contact needling” that involves stimulation of the points with needles without breaking the skin.”
And what do the clinical trials testing for the effectiveness of Indian Style Acupuncture show?
Chris kessler,
“If a non-invasive sham procedure is used in a trial, it has to be investigated for physiologic effects to establish that it is actually inert”
Placebos are not inert.
“Since the therapeutic effect of acupuncture is achieved by activating the body’s self-healing mechanisms:
There is no point speculating about mechanism whereby acupunture achieves its effects if clinical trials have shpown no effect.
“..it’s essential to determine that these natural healing processes aren’t confused with placebo”
Whereas acupuncture has been shown to be ineffective, this is not true for placebos. Two placebo tablets are more effective than one placebo tablet, placebo capsules are more than placebo tablets, placebo injections are more effective than placebo capsules, etc etc.
There’s lots of clinical trial support for placebo effects, and no support for an effect of acupuncture.
How can you be willing to speak of placebos in conventional pharmaceutical dose forms being variably “effective” – as in, acknowledging that patients will gain more relief from a placebo capsule than a placebo tablet – but not grant the same status to acupuncture-as-placebo, even when the acupuncture gives yet more relief? If the sugar pill provides less relief than ibuprofen and the acupuncture provides more, how many people would say that the sugar pill is effective and the acupuncture ineffective? Your definitions of these words are starting to look not just different from those of many average people, but quite idiosyncratic.
“16 trials did use placebo controls; and 11 had statistically significant differences in outcomes.
But, without being able to access the details – unless you are willing to pay for them – how do we know that the placebos where adequate to account for the total placebo effect associated with acupuncture?”
And how do you know they WEREN’T adequately controlled?
I hate to tell you, but “because Billy Joe has seen this kind of thing before” isn’t exactly a valid scientific reason for the rest of us to dismiss the the 11 out of 16 trials that showed a statistically significant difference in outcomes.
And here’s the thing: as I’ve pointed out, there are few trials with a sham control that doesn’t activate the same physiologic mechanisms that are the goal of acupuncture treatment.
Gotzsche’s definition of placebo is as follows: “The placebo effect is the difference in outcome between a placebo treated group and an untreated control group in an unbiased experiment.” It reflects the impossibility of defining the placebo effect in a single case, where biases of various types can’t be excluded (including regression to mean, investigator effects and changes in patient’s behavior).
In studies with a parallel untreated group (i.e. no placebo or other intervention, as with waiting list controls) these additional nonspecific effects would produce the same response as in a “placebo group” – except for the true placebo effect. Then the effects observed in the untreated control group can be subtracted from those in the placebo group to get the true placebo effect. A three-arm study like this is the most unbiased way to evaluate placebo effects in the context of a clinical trial, but to my knowledge very few have done this with acupuncture.
So-called sham acupuncture can’t be assumed to be adequate placebo control until 1) it is proven that sham doesn’t stimulate the same biological effects as “active” acupuncture, and 2) it is proven that sham acupuncture doesn’t improve outcomes more than an untreated control group.
I’m not arguing that acupuncture is more effective than sham acupuncture. I’m arguing that there aren’t enough properly designed trials to support your claim that acupuncture isn’t more effective than placebo.
apteryx,
“How can you be willing to speak of placebos in conventional pharmaceutical dose forms being variably “effective” – as in, acknowledging that patients will gain more relief from a placebo capsule than a placebo tablet – but not grant the same status to acupuncture-as-placebo…”
I don’t deny it.
In fact I have acknowledged that the placebo effect associated with acupuncture is a very effective one. What you don’t seem to want to accept is that the acupuncture itself has no effect.
Clinical Effect = Placebo Effect + Acupuncture Effect
Acupuncture Effect = 0
“…even when the acupuncture gives yet more relief?”
The effect of the acupuncture itself is zero.
It is the placebo effect associated with acupuncture that is more effective than many other forms of placebo.
“Your definitions of these words are starting to look not just different from those of many average people, but quite idiosyncratic.”
I’m trying my level best to be accurate.
If your take home message from clinical trials of acupuncture is that acupuncture works, you are either wrong, or misleading, or lying. Acupuncture itself does not work. But the placebo efffect associated with acupuncture is pretty good as far as placebo effects go.
But, in that case, and if you want to follow the evidence where it leads, why not use sham acupuncture and avoid the risk of inserting needles into the skin.
Chris Kessler,
“And how do you know they WEREN’T adequately controlled?”
That’s a bit unfair.
You direct me to some evidence, but I have to pay to find out what that evidence is. Well, it doesn’t work that way. If you have evidence that acupuncture is effective please provide it.
“I hate to tell you, but “because Billy Joe has seen this kind of thing before” isn’t exactly a valid scientific reason for the rest of us to dismiss the the 11 out of 16 trials that showed a statistically significant difference in outcomes.”
I don’t expect you to.
It just my own reason to suspect what I will find if I looked at those trials ansd my reason for not paying to look at them.
“And here’s the thing: as I’ve pointed out, there are few trials with a sham control that doesn’t activate the same physiologic mechanisms that are the goal of acupuncture treatment. ”
What I am pointing out is that the physiological mechanisms activated by acupuncture are no different from the physiological mechanisms activated by the placebo effect.
You mentioned 80 different types of acupuncture, but if we stick with what we might call Traditional Acupuncture”, these are the facts:
1) You can stick the needles in anywhere you like.
2) You don’t need to stickthe needles in.
Where does that leave Traditional Acupuncture?
And, if you want to consider the 80 other types of acupuncture, you will need to show that they are more effective than Traditional Acupuncture.
I suspect that Moffet’s “40 trials comparing acupuncture interventions mainly differentiated according to traditional acupuncture theories” addresses this point and I suspect that it shows that [the placebo effect associated with] Traditional Acupuncture works better than the other types is was tested against, but I’m not going to pay to fine out
“In studies with a parallel untreated group … A three-arm study like this is the most unbiased way to evaluate placebo effects in the context of a clinical trial, but to my knowledge very few have done this with acupuncture.”
You haven’t looked very far. One example is a systematic review of acupuncture for the prophylaxis of migraine. You can google it if you like. And you won’t have to pay.
“So-called sham acupuncture can’t be assumed to be adequate placebo control until 1) it is proven that sham doesn’t stimulate the same biological effects as “active” acupuncture, and 2) it is proven that sham acupuncture doesn’t improve outcomes more than an untreated control group.”
The onus of proof is on acupuncture. You must show that acupuncture does not just “stimulate the same biological effects” as placebo.
And, if you haven’t seen evidence of the effect of sham acupuncture above that of untreated controls you haven’t looked. I refer you again to that systematic review.
Billy Joe,
What is your definition of placebo?
Chris,
There is a whole literature on placebos which anyone can access. A brief reply here is bound to be incomplete and would be a set up for a demolition job or endless rounds of discussion.
Remember that it is up to proponents of acupuncture to prove an effect. They need to define what acupuncture is. You say there are 80 different types. Then pick one type and define what you think it is, what is does, and how it does it.
Traditional Acupuncture proposes the existence of a number of entities that have never been shown to exist:
- chi
- meridians
- acupuncture points
You might say that that doesn’t matter if it can be shown to work. So how is it done? Well, there are specific points [which have nothing to distinguish them anatomically from any other points] on the skin [aligned along non-existent meridians] and if you select a specific group of these points [groupings which seem to have no logic behind them at all] and stick needles through the skin at these points to a depth of 1cm, you can help relieve all sorts of ailments [though AT BEST relief of some limited list symptoms such as pain, nausea, and depression only has been demonstrated].
But the truth is that the use of placebos has demonstrated that:
- it doesn’t matter where you stick the needles in.
- it doesn’t matter if you don’t stick them in.
So, I ask you again: where does that leave Traditional Acupuncture? And where are the studies that show any of the 80 other types of acupuncture are any better than Traditional Acupuncture.
I think it’s informative that you have not been able to respond in any meaningful way to my criticisms, including my criticisms of the study you linked to in your support of acupuncture [at the very least I have reduced your list of 78 trials to 16 of which 11 apparently showed "some effect" - and you do know what they say about extraordinary claims, don't you?].
BillyJoe
BillyJoe,
I think a few people have been asking, what if “stimulating the skin somewhat noxiously” has an effect on perception of pain? Could that be considered a treatment for pain in itself or must it always be considered a placebo?
Clearly, the ancient Chinese were wrong about HOW acupuncture worked; there’s no such thing as meridians that carry qi. However, that does not mean that acupuncture, and/or every single other thing done by Chinese healers who believed in qi, does not work at all. It only means that when people do not have the necessary scientific infrastructure and equipment to explore the real microscopic causes of observed phenomena, they almost always invent explanations as a way of making sense of their world.
“what if “stimulating the skin somewhat noxiously” has an effect on perception of pain? Could that be considered a treatment for pain in itself or must it always be considered a placebo?”
If that’s true, it’s an argument for stimulating the skin, not for all the rigamarole of acupuncture.
Some people think one of the mechanisms for the placebo response is production of endorphins in the brain, but that happens after placebo pills without any noxious stimulation.
Harriet Hall on acupuncture:
“If that’s true, it’s an argument for stimulating the skin, not for all the rigamarole of acupuncture.”
True. But there are some people on this thread trying to talk about whether stimulating the skin has an effect.
When they posit that stimulating the skin could be effective in pain relief and therefore that someone who visited an acupuncturist could get pain relief from skin stimulation in addition to the ritual, they run into other people who say that “acupuncture doesn’t work.”
I don’t think anyone on commenting on this thread has proposed the existence of chi that needs realigning.
There are not-weird people who have proposed that skin stimulation might be beneficial for pain, and who have wondered whether acupuncture studies might support that hypothesis, but they often have trouble engaging knowledgeable people on this blog.
I find this a little odd. How much does it matter if skin stimulation is called “skin stimulation” or “acupuncture”? Does changing the name of the intervention change the result of the study? Or do studies not support the idea that skin stimulation has any effect at all, no matter what it’s called? Or does it not matter, because skin stimulation is nonspecific and therefore can never be anything other than placebo?
I don’t think these questions are that off the wall. I’m never going to see an acupuncturist so I personally don’t care, but I do think it’s odd when someone asks “Is there any evidence that skin stimulation relieves pain?” and are consistently responded to with “There’s no such thing as chi.”
… A long time ago, I thought that acupuncture for pain relief was fairly well-supported, possibly through triggering of endorphins.
Then I read that it wasn’t. Which is fine. I dropped my belief in acupuncture for pain relief.
But when on this blog we look at the studies of acupuncture, while meridians are clearly not supported, and penetration of the skin is clearly not supported, it does appear that skin stimulation might be supported. Maybe it’s not, but it’s not clear to me that it’s not. And if it’s not, I wouldn’t mind a discussion of how we know that.
Most of us have had the experience of rubbing a painful area and thinking that it seems to help. There is some evidence that acupuncture relieves pain by causing endorphin release in the brain, but we don’t know what that means because it has not been adequately compared to other kinds of skin stimulation or counter-irritation. And we have some evidence that taking placebo pills can have a similar effect. What if we could definitely show that placebos actually produce endorphins. Would we have to stop calling them placebos? Would it be acceptable to prescribe them for patients?
We know that only a minority of patients respond to placebos whereas a majority respond to morphine. I suspect we will find that rubbing the sore spot really doesn’t help much, just as acupuncture doesn’t really help much; so even if skin stimulation produces endorphins, the magnitude of clinical usefulness is likely to be low.
My crystal ball says that studies will show that skin stimulation relieves pain, but not enough to matter.
Alison Cummins,
“BillyJoe, I think a few people have been asking, what if “stimulating the skin somewhat noxiously” has an effect on perception of pain? Could that be considered a treatment for pain in itself or must it always be considered a placebo?”
Well, it sure as hell aint acupuncture!
A mother wincing in pain at her stubbed toe suddenly forgets all about her pain as she leaps to her feet to save her infant from falling off the change table.
Is that a placebo effect?
I dunno, but it sure as hell aint acupuncture.
)
(Okay, that was little abstruse
apteryx,
“Clearly, the ancient Chinese were wrong about HOW acupuncture worked; there’s no such thing as meridians that carry qi. However, that does not mean that acupuncture, and/or every single other thing done by Chinese healers who believed in qi, does not work at all.”
Seems I’m not the only one being abstruse!
” It only means that when people do not have the necessary scientific infrastructure and equipment to explore the real microscopic causes of observed phenomena, they almost always invent explanations as a way of making sense of their world.”
In other words, they were flat out wrong.
Alison Cummins,
“…there are some people on this thread trying to talk about whether stimulating the skin has an effect.”
Not really. They are trying to make a case for acupuncture out of it.
“When they posit that stimulating the skin could be effective in pain relief and therefore that someone who visited an acupuncturist could get pain relief from skin stimulation in addition to the ritual, they run into other people who say that “acupuncture doesn’t work.””
The two are not mutually exclusive.
The ritual and the skin stimulation provides the total effect. The sticking in of needles at specified acupuncture points (ie acupuncture) adds nothing.
“I do think it’s odd when someone asks “Is there any evidence that skin stimulation relieves pain?” and are consistently responded to with “There’s no such thing as chi.””
I don’t think that is in any way an accurate characterisation of the discussion we’re having here.
Dr. Hall: “We know that only a minority of patients respond to placebos whereas a majority respond to morphine. I suspect we will find that rubbing the sore spot really doesn’t help much, just as acupuncture doesn’t really help much; so even if skin stimulation produces endorphins, the magnitude of clinical usefulness is likely to be low.”
I recognize you have a philosophical opinion about acupuncture that is just not going to change, but your argument is countered by studies that show acupuncture to be better than active medication for certain types of pain. If we really want to know what “the magnitude of clinical usefulness” for a given condition is, we have to depend on data rather than belief (i.e., what you “suspect”).
BillyJoe: “In other words, they were flat out wrong.”
Yes, indeed, about their explanation for WHY observed phenomena occurred. It is a natural human trait to try to find means of explaining what happens to you; you don’t want to think you live in a dangerous and chaotic universe without cause and effect. Ancient Greek and Asian physicians therefore came up with explanations for diseases, like imbalanced humors or qi, that later science has demonstrated to be false. That does not mean that those physicians weren’t able to recognize specific diseases, like diabetes, or that the patients they reported to have those diseases weren’t really ill at all. Likewise, they were able to observe that opium relieved pain; if they wrongly believed that it did so by rebalancing your humors or restoring your qi, that doesn’t change the fact that it did work.
Here’s the thing Billy Joe: we’re not actually that far off.
I’m an acupuncturist (at least I will be in four months – I’m finishing school). But I don’t believe that qi = energy, or that energy is flowing around the body in imaginary lines called meridians.
As a matter of fact, I just finished writing a series of posts on my blog explaining that the “energy meridian” model is a western creation. It’s not a historically accurate description of Chinese medicine. It’s instead the result of mistranslations of key Chinese characters by a French bank clerk named Soulie de Morant who lived in China in the early 1900s and was responsible for introducing Chinese medicine to the west. Read more at my blog: http://thehealthyskeptic.org/acupuncture.
Further, I’m not making an argument for what is called TCA in the scientific literature. (Again, it’s a western idea that there is such a unified theory called TCA. Chinese medicine is in reality a collection of many different theories. “TCA” was created by Mao & co. during the communist revolution in an effort to standardize the medicine and make it easier to teach to the “barefoot doctors”.)
I agree that the literature doesn’t support the idea that point selection matters, or that needling technique makes a difference, or that even breaking the skin makes a difference. However, I’ll also say that just because the literature doesn’t yet support a difference that doesn’t mean there isn’t one. As I pointed out earlier most studies on acupuncture are underpowered because sample sizes are based on the assumption of a 30% placebo effect, which is unsound.
You say that stimulating the skin without breaking it is not acupuncture. Perhaps not as it’s defined on the west. But here we have another mistranslation. Jesuit monks living in China translated the character “zhenzi” as “acupuncture”. Acus (needle) punctura (puncture). A more correct translation of the term is needle therapy. Sometimes the Chinese punctured the skin and left the needles there. Sometimes they used them for bloodletting. (Before you dismiss bloodletting as hopelessly archaic, keep in mind that it’s still used in modern medicine today. In fact, a fairly recent study showed that leech therapy [bloodletting] was more effective than surgery for osteoarthritis of the knee.) In Japan, some styles don’t puncture the skin at all.
My disagreement with you is on the nature, meaning and clinical significance of placebo.
Last week a patient came in to the clinic with a history of severe acid reflux / GERD. He had an h. pylori infection with ulcer about twelve years ago, and since then he’s had intractable reflux. He’s been treated with all of the PPIs and H2 blockers, has seen numerous doctors and has tried several different special diets. Nothing helped. As a last resort he came to try acupuncture. This was a difficult decision for him because he works as a research scientist. He came in saying “I don’t believe in this stuff, but I don’t want to have surgery so I’m willing to try it.” Fair enough, I said. Let’s give it a shot.
After four acupuncture treatments his symptoms have improved by 80%. For the first time in twelve years he is able to eat without having heartburn afterwards. And he’s been able to completely get off his medication.
You may argue that this is “placebo”. You may be right. But I say, “so what”?
What my patient is concerned with is getting rid of his problem. The western drugs, which arguably have a stronger placebo effect than acupuncture because of the widespread cultural belief in their effectiveness, weren’t able to help. Acupuncture has almost completely cured his problem in just two weeks. Do you think he cares whether it’s “placebo” or “active treatment”?
Experiences like this are common in the clinic. That’s why more and more people are getting acupuncture, in spite of what the clinical research shows or doesn’t show. People want to feel better and address their health problems, and acupuncture helps them do that.
I’m sorry this is so long but I still have a few points to make. My argument, as I already stated above, is that the concept of placebo has probably outlived its usefulness. Why? Because defining it in a consistent way that distinguishes it from specific treatment effects seems impossible. We should instead be focusing on the choice of outcome measure and the magnitude of the effect, rather than on interventions that are difficult to define.
As an example, when compared with usual obstetric care, the presence of a support person during labor has dramatic effects on the use of analgesics, anesthesia, episiotomy, and cesarian section and the incidence of severe postpartum depression. (http://www.ncbi.nlm.nih.gov/pubmed/10796179)
What do we call the additional effect of a support person, which are clearly measurable and are clearly producing real physiological changes? Do we call it placebo? Why? How is that distinguishable from the effects of the other methods of obstetric care?
The answer is that it’s only distinguishable by the name and meaning we’ve applied to those effects. We’ve decided that they are secondary (and by implication less important) than the effects of the treatment being primarily studies. But I assure you that from the patient’s perspective (and one would hope the doctor treating her) those so-called “placebo” effects are no less significant in the outcome.
Let me pose a hypothetical question for you. Say you could choose between two treatments for a particular condition. Both of these treatments have roughly the same outcome in clinical studies. However, one treatment carries significant side effects and risks, including irreversible physiological damage that in fact perpetuates and worsens the problem you sought help for. The other treatment is relatively free of side effects and risks, is well tolerated, and does nothing but improve your problem.
Which would you choose?
The scenario above is not hypothetical. It describes the choice a patient with depression has when deciding between an SSRI or a sugar pill. Sapirstein and Kirsch conducted a meta-analysis of 3,000 patients who received either antidepressants, psychotherapy, placebo or no treatment at all. They found that 27% of therapeutic responses were attributable to drug activities, 50% to psychological factors, and 23% to “non-specific” factors. In other words, 73% of the response to the drug was unrelated to its pharmacological activities – and antidepressants may be no better or more specific than placebos. (Read this article for more info: http://thehealthyskeptic.org/antidepressants-not-as-effective-as-research-suggests)
If you’re going to be consistent with your terminology, you’ll have to refer to antidepressants (and some other commonly used drugs) as placebos. They are no less of a placebo than acupuncture is according to the research.
Some doctors are in fact aware of this, and yet they go on prescribing them. They argue that the benefit of recovering from depression outweighs the ethical considerations of prescribing a placebo without the patient’s knowledge. Doctors are willing to do this in spite of the fact that these “placebos” (active drugs, in this case) have serious side effects and risks.
If it were me, I’d take the placebo, thanks. I’ll get the same improvement without any of the risks.
This is why I asked you what your definition of placebo is. The terminology is important here, because what you refer to as placebo is in fact a measurable treatment effect with a significant clinical outcome.
Moreman and Jonas suggest what I believe is a more useful term, which is “meaning response”. They define the meaning response as “the physiologic or psychological effects of meaning in the origins or treatment of illness.” (http://www.annals.org/content/136/6/471.full) They provide many examples where the meaning ascribed to a treatment produces different outcomes.
One of my favorites is a study in which 835 women who regularly used analgesics for headache were randomly assigned to one of four groups. One group received aspirin labeled with a widely advertised brand name. The other groups received the same aspirin in a plain package, placebo marked with the same widely advertised brand name, or unmarked placebo.
In this study branded aspirin worked better than unbranded aspirin, which worked better than branded placebo, which worked better than unbranded placebo. Aspirin relieved headaches, but so does the knowledge that the pills you are taking are “good” ones. (http://bit.ly/9JxGe0)
It is also known that placebo and acupuncture analgesia elicit the production of endogenous opiates. In both cases the analgesic effect can be blocked with injection of nalexone.
So, to say that a treatment such as acupuncture “isn’t better than placebo” does not mean that it does nothing. Nor does it mean that acupuncture doesn’t improve clinical outcomes. Nor does it mean that acupuncture is not a better choice than another treatment with similar outcomes, when all factors are considered (side effects, risks, complications, etc.)
In any event, while the research community goes on insisting that acupuncture is “just placebo” (an inane statement that reflects a lack of understanding of the nature and value of placebo), I will go on giving my so-called “placebo” treatment to patients and improving their health and quality of life.
I leave you with a quote:
“Most of us have been taught that western medicine is based on science, and science represents the unbiased, objective way to search for truth. However, subjective judgments lie behind all the facets of “scientific” research. (Not to mention that nowadays, most clinical research are funded by pharmaceutical companies)
All data are theory-, method-, and measurement-dependent. That is, “facts” are determined by the theories and methods that generate their collection; indeed, theories and methods create the facts.
This means that how the problem will be defined, which model(s) of inquiry will be considered to be relevant to the problem as defined, which model(s) of inquiry will be considered to be relevant to the problem as defined, where one shall look (and, by implication where on shall not look) for evidence–and even what one shall consider to be constitutive of evidence–are all determined by the paradigmatic “map” or world view to which the scientist is committed.”
–John Ratcliffe, Notions of validity in qualitative research methodology
“I agree that the literature doesn’t support the idea that point selection matters, or that needling technique makes a difference, or that even breaking the skin makes a difference.”
So why did you become a acupuncturist?
“However, I’ll also say that just because the literature doesn’t yet support a difference that doesn’t mean there isn’t one.”
I don’t consider that a good reason to become an acupuncturist. Even it what you said is true, don’t you feel you need positive evidence of an effect rather than just no evidence of no effect before you decide to practise acupuncture?
“In fact, a fairly recent study showed that leech therapy [bloodlettting] was more effective than surgery for osteoarthritis of the knee.”
I’m guessing they compared leech therapy to arthroscopic lavage. Am I right? If so, it might interest you to know that Arthroscopic lavage has been shown to be no more effective than sham arthroscopic lavage. It may also interest you to know that the procedure has been largely abandoned for being ineffective (ie no better than placebo). Similarly for ligation of the internal mammary artery in the treatment of angina. It was found to be no better than sham surgery and has long since been abandoned.
I think there’s a lesson there somewhere.
“Last week a patient came in to the clinic with a history of severe acid reflux / GERD….After four acupuncture treatments his symptoms have improved by 80%. ”
That is an anecdote.
Here’s why anecdotes are underwhelming as evidence: I have to rely on your honesty in reporting the anecdote as described by the patient. You have to rely on the patients honesty in describing his history to you. Apart from honesty, there is the question of whether either or both of you have exaggerated the case or simply fooled yourselves in the retelling. I have to take it on trust that the patients GORD has been accurately diagnosed and that his present symptoms are indeed due to relux and do not represent psychosomatic symptoms for example. Maybe he has pancreatic cancer and your acupuncture has given him some temporary relief.
“He came in saying “I don’t believe in this stuff…”
Look that just makes me laugh, sorry. He doesn’t believe in this stuff, yet here he is fronting up for something he doesn’t believe in. I mean really. I don’t believe in the power of prayer, so I suppose I will just shuffle along to the parish priest when I need surgery instead! Goddamn how people can fool themseves – and others along with them!
“Acupuncture has almost completely cured his problem in just two weeks. ”
That would be a little difficult wouldn’t it, seeing as he walked into your clinic only a week ago? I only mention this little gaff to demonstrate the unreliability of testimony even when earnestly given. The more important point here is that you could have no idea – in only one or two weeks – that you have cured him.
“Experiences like this are common in the clinic. That’s why more and more people are getting acupuncture, in spite of what the clinical research shows or doesn’t show.”
People swear by homoeopathy as well, and for exactly the same reasons. Sorry, patient satisfaction surveys are no substitute for proper clinical trials.
“My argument, as I already stated above, is that the concept of placebo has probably outlived its usefulness. Why? Because defining it in a consistent way that distinguishes it from specific treatment effects seems impossible. ”
You know what the real problem is? Defining what acupuncture is. We started with the definition of traditional acupuncture and ended up with something that looks like sham acupuncture. No wonder you have trouble defining the placebo. You have taken it to define acupuncture!
“http://thehealthyskeptic.org/antidepressants-not-as-effective-as-research-suggests”
The phase 111 trials demonstrated an effect of antidepressants in patients with major depressive disorder. The follow up study demonstrated that these results are not applicable to patients with milder forms of depression. So, what is your point? It would seem to me that your headline should have read: antidpressants should be approved and precribed only for patients with major depressive disorder. If that had been you headline you would have had my admiration. But, it seems you’re too busy “challenging mainstream myths”.
“If you’re going to be consistent with your terminology, you’ll have to refer to antidepressants (and some other commonly used drugs) as placebos. They are no less of a placebo than acupuncture is according to the research. ”
Well, I just hope you can see your error now.
If you ever decide to use acupuncture on a severely depressed patient, I hope you don’t end up with a dead patient on your hands.
“Some doctors are in fact aware of this, and yet they go on prescribing them….If it were me, I’d take the placebo, thanks. I’ll get the same improvement without any of the risks.”
Me? I’d just stop lying to people. And stop using useless treatments (whether its acupuncture or antidepressants in mild to moderate depression). Maybe, just maybe, patients might respond just as well to some empathy, care, and understanding. Is that such a novel idea?
“what you refer to as placebo is in fact a measurable treatment effect with a significant clinical outcome”
What you are saying here is that placebo works better than doing nothing. In other words, the patient who enters a clincal trial and gets paid attention to but gets the sugar pill does better than a patient sitting on the waiting list. Are you expecting me to disagree with that?
“It is also known that placebo and acupuncture analgesia elicit the production of endogenous opiates. In both cases the analgesic effect can be blocked with injection of nalexone. ”
Meaning what? That acupuncture works like placebo?
Hmmm…I thought that was my argument!
“So, to say that a treatment such as acupuncture “isn’t better than placebo” does not mean that it does nothing.”
No. It means that acupuncture does not work better than placebo. It is really that simple.
“Nor does it mean that acupuncture doesn’t improve clinical outcomes.”
It doesn’t. The effect is due to placebo.
“Nor does it mean that acupuncture is not a better choice than another treatment with similar outcomes, when all factors are considered”
Agreed.
Some placebos work better than others.
Chris – as an educated member of the patient class, I hold pretty much the same opinions that you have expressed. Unlike BillyJoe (according to his previous remarks), I care far more for whether I am better off than why I am better off.
We are just different then.
I care for the truth first and foremost.
Everything else comes second.
And, in my opinion, any benefits based on the placebo effect of acupuncture can be achieved by methods that do not involve lying to patients.
Also the areas in which the placebo effect of acupuncture can help are extremely limited. There is pain and not much else.
As a scientist, I too am interested in truth. However, when people seem to be coming to different conclusions than I do because they have different philosophies about which truths matter or count and which don’t, I try not to reflexively respond by accusing them of “lying”, as if I were channeling Sen. James Inhofe.
You are still missing the point, Billy Joe. What you dismissively refer to as placebo can be the difference between pain and absence of pain, sickness and health, dysfunction and function.
You say you care for the truth. But you make the mistake of assuming “truth” is found exclusively in randomized, “placebo”-controlled studies. Perhaps you should read this paper: “Why most published research findings are false” (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124)
Perhaps I should also remind you of the many times the so-called “truth”, as presented in the scientific literature, later turned out to be false. What are we to make of that, Billy Joe? For decades researchers told us that heart disease was caused by consumption of saturated fat and high LDL cholesterol. Today, the literature conclusively demonstrates that is not true. So what is “the truth”?
While you cling to your myopic point of view, Americans are spending $34 billion on alternative healthcare. Why? Because 1) they’re dissatisfied with the level of care they receive from the medical establishment, and 2) they are getting better results from so-called “alternative” practitioners.
You will likely argue that these millions of people are simply throwing their money away on placebos. But they don’t care what you think, because they’re feeling better and getting healthier.
The arrogance and almost religious fervor of the “evidence-based” medicine movement never ceases to amaze me. Especially because there’s not much to arrogant about. The U.S. ranks just 34th in the world in life expectancy and 29th for infant mortality. Of 13 countries in a recent comparison, the United States ranks an average of 12th (second from bottom) for 16 available health indicators. (http://bit.ly/avlcYh)
Even worse, a recent study by Dr. Barbara Starfield published in 2000 in the prestigious Journal of the American Medical Association demonstrated that iatrogenic incidents (events caused by medical intervention) are the 3rd leading cause of death in this country, causing more than 250,000 deaths per year. Only heart disease and cancer kill more people. (http://bit.ly/d0RZBW)
Michael Jordan has a reason to be arrogant. Tiger Woods has a reason to be arrogant. The medical establishment does not.
This will be my last post here because it’s abundantly clear that this is not a dialogue where information is being shared in an open-minded and exploratory spirit. I’m not even sure why I’ve gone this far. I’ve learned long ago that this type of debate is largely a waste of time.
But I’ll leave you with a few quotes from a paper called “The placebo disavowed: or unveiling the bio-medical imagination” (http://bit.ly/dd3yHO) It’s a fascinating read for anyone interested in broadening their understanding of the significance of placebo in the context of healing.
“What bioscience (especially in its contemporary corporate forms) wants and needs is to establish unilateral relations between material treatments and documented cures which it can then use both to demonstrate its practices and market its products…
“The possibility that the imagination of a person who suffers might play a curative role within the event of illness is a priori excluded from scientific medicine because it introduces a non-reducible variable which de-centers bioscience’s self representation as the only legitimate agent of healing. Thus, within scientific medicine, the ‘placebo effect’ is bracketed not because it doesn’t produce healing effects, but *precisely* because it does.”
“To designate an experience of healing as a ‘placebo effect’ is not only to set it apart from the ‘real’ domain of biochemical causality (while retaining the hope that some day a biochemical explanation may appear to account for this seeming deviation) but also to restrict the extent to which its existence can appear as a credible alternative to the deterministic claims of biomedicine. Moreover, the implicit causality retained within the placebo designation maintains the giver rather than the receiver of the placebo as the active agent in the healing process, despite some limited recognition that ‘placebo effects’ are a subclass of self-healing. Taken together, these interpretations defend advocates of bio-medicine against the recognition that they are *not the only agents of healing*, and moreover against the recognition that healing, whenever it occurs, occurs through the life process of the person who is ill…”
And here are a few gems from Miller and Kaptchuk’s paper (http://bit.ly/9O0Hpw):
“Healing resulting from the clinical encounter consists of a causal connection between clinician-patient interaction (or a particular component of the interaction) and improvement in the condition of the patient. That aspect of healing that is produced, activated or enhanced by the context of the clinical encounter, as distinct from the specific efficacy of treatment interventions, is contextual healing.”
“The common description of the placebo effect as ‘non-specific’ is unsatisfactory. There is a valid contrast between interventions that have specific efficacy… and placebo interventions that do not. However, rigorous laboratory experiments have detected a variety of specific mechanisms underlying the reported effects connected with placebo interventions presented (deceptively) to research subjects as real treatments…. By virtue of causing a real change in a specified outcome, treatments that work only by means of the placebo effect *must work by some specific mechanism*. Just as placebo treatments with real effects are not absolutely inert, so they are not absolutely non-specific.”
“Fixation on the efficacy of treatment intervention obscures the fact that the technological tools of medicine are always applied in some context, which itself may contribute significantly to therapeutic benefit.”
“Instead of focusing exclusively on the therapeutic power of medical technology and thereby ignoring or dismissing context, we should see the context of the clinical encounter as a potential enhancer, and in some cases the primary vehicle, of therapeutic benefit.”
“Attention to contextual healing signifies that there is more to medicine than diagnosing disease and administering proven effective treatments. This has long been recognized under the rubric of ‘the art of medicine’. However, biomedical science, animated by the search for specific therapeutic efficacy, has left the art of medicine shrouded in mystery.”
Another perspective on “the truth”.
apteryx,
“I try not to reflexively respond by accusing them of “lying””
Sorry, that was not meant as an accusation.
I should have said “unintentionally lying”, or “unknowingly not telling the truth”, or “being a little inexact with the truth”.
“people … coming to different conclusions … because they have different philosophies about which truths matter or count and which don’t”
I think there are rare occasions where lying is acceptable. And I guess there IS a philosophy behind that. That philosophy being that you aim not to harm anyone. Sometimes lying to them is the only way to avoid that harm. A dying man doesn’t need to know that his favourite nephew just died in a car acident on his way to visit him.
regards,
BillyJoe
Chris, “Perhaps you should read this paper: ‘Why most published research findings are false’ ”
Assuming that is true, what is your point? That if objective studies usually give false conclusions, guesses and beliefs are more reliable than objective studies? If so, I think history proves you wrong.
Chris, “You will likely argue that these millions of people are simply throwing their money away on placebos. But they don’t care what you think, because they’re feeling better and getting healthier.”
I assume that you conclude that based on your personal experience. My personal experience leads me to a different conclusion. There are many people, I don’t have numbers, throwing their money away on snake oil. Many of them feel better after that for awhile for a variety of reasons only to eventually feel sick and unhealthy again. So they throw away more money on the same or a different kind of snake oil often continuing the procedure until the snake turns around and bites them. Most of the time they never tell their saviors, the healers or snake oil salesmen, that their “cures” were temporary and that they had to buy additional “cures”, and snake oil salesmen aren’t known for record keeping or follow up studies or even hearing unpleasant things so they usually never know.
Chris, “The arrogance and almost religious fervor of the ‘evidence-based’ medicine movement never ceases to amaze me. Especially because there’s not much to arrogant about. The U.S. ranks just 34th in the world in life expectancy and 29th for infant mortality.”
You have arrogantly and conveniently left out statistics comparing the health and longevity of those who live in areas where scientific medicine is available with those living in areas where it is not. Maybe you should visit Cambodia with Andrew or read some history.
Chris, “This will be my last post here because it’s abundantly clear that this is not a dialogue where information is being shared in an open-minded and exploratory spirit.”
Promises. Promises. You sound like one of the alts who writes to me out of the blue making all kinds of outrageous claims he can’t substantiate who is amazed when I respond, cannot provide me with the evidence I request, answers by calling me names and stating that scientific medicine, the kind based on independently verifiable evidence, is bad and therefore the alternative, the unscientific kind based on belief, has to be good. Then he adds that he is ending the conversation by which I understand that he has delivered his sermon and is leaving the room because he knows he hasn’t convinced anyone that he is correct and he knows that further discussion may just convince listeners how wrong his unverifiable beliefs are.
Chris’ last post must have been in moderation when I looked last.
He says he won’t be back so I guess there is no use responding. Just to say, that I thought all along that he must have an agenda below his calm exterior. His website says it all. Against all mainstream medicine and for all alternative medicine. Black and white with no shades in between.
At least he showed his true colours in the end.
And I expect we won’t see him back now that he has exposed himself so embarrassingly
BJ
…oh, and the extensive quotes – is that supposed to prove something like you can quote someone who agrees with you so you must be right?
Anyway it’s a classic sign of someone who cannot actually think for themselves.
There is real physiology behind the placebo effect.
http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html
I would call the reduced need for pain treatment during birth with an attendant being due to the placebo effect. My definition of the placebo effect is any treatment that produces positive effects not mediated through either pharmacology or surgery (or some other physical intervention). Acupuncture is indistinguishable from a placebo.
Having an attendant present does produce positive effects through a placebo effect because the individual feels safer because the individual actually is safer because there is someone there to help, or to summon more help if something goes wrong.
Ignoring the pain of a stubbed toe when trying to catch your falling baby is placebo effect too. Pain is a signal. It is a signal that your body is exceeding physiological limits and damage is likely. Your body still lets you use body parts that are in pain, the pain is to let you know that damage is likely. When your baby is falling, the pain of a stubbed toe is inconsequential compared to the risk of injury to your baby, and so your body removes that distracting signal. The toe is not miraculously healed during that time, the pain signal is blocked to maximize function within the degraded physiological capacities of the already damaged toe, so as to better accomplish the needed task of catching the falling baby.
I think it is ironic that acupuncturists lament millions wasting money on placebos, rather than spending money on acupuncture, a field they profit from and are actively promoting.
It is also ironic to blame Harriet’s unwillingness to accept acupuncture as different than placebo because of her philosophy, without mentioning what her philosophy is, the philosophy of requiring data to support beliefs. Blaming her lack of belief in acupuncture as being due to her philosophy rather than to the lack of data supporting acupuncture is disingenuous. If acupuncture actually did work better than placebo, it would be possible to get good, substantial and reliable data that it is better. There is no such data. If there was data, Harriet’s philosophy would require her to believe it was effective.
“There is real physiology behind the placebo effect.”
That is news to Chris who seems to think that, because there is a physiological change when acupuncture is administered, it must be working. He wants to compare acupuncture to a placebo that has no physiological effect so that he can actually claim the placebo effect for acupuncture.
And, yes, he has provided no evidence that acupuncture can heal, though he has made that claim.
Anyway, there is little headway to be made with someone who rejects science when it disturbs his cosy little view of the world.
Its pretty clear there is no strong evidence of acupuncture itself (specifically placed needles) being good for anything, and only glimmers of any possible mechanism by which it might work.
But as often happens, in enthusiasm to dismiss it, people step over the mark. Eg:
“Looking for a mechanism seems premature when there is no compelling evidence acupuncture works beyond placebo.”
– I would have thought that positing a mechanism prior to finding or looking for evidence is part of establishing plausibility. We can’t have it both ways: if SBM requires plausibility, we have to accept people looking for possible mechanisms. Some medical research starts from a plausible mechanism and looks for effects; others start from an observed effect and looks for a mechanism. The problem lies with practices which are already established in supposedly therapeutic practice, which are being tested scientifically after the fact. Acupuncture is one such.
I think Dr Novella’s previous article about placebos is instructive. “It is any and all measured effects other than a physiological response to the treatment itself.”
For psychological ailments, this would have to be modified to “any and all curative effects other than a response to the treatment itself.” However, this is a problematic definition with depression, because:
a) It is not always possible to separate responses to the treatment itself from other effects, even with a well-designed and controlled study;
b) CAM proponents repeatedly redefine what _they_ mean by “the treatment”.
However, that shouldn’t stop us trying. It is worth funding studies to provide evidence to help eliminate bad medicine of all kinds, particularly where there is already an entrenched non-scientific practice.
But they must (among other things):
* be well-designed
* test for medical effectiveness, not just statistical significance
* be thoroughly desk-tested at the experiment design stage, to ensure that the definitions of controls and placebo are pre-determined and agreed by factional interests.
And then when they are reported, just don’t use the word ‘placebo’. It has too many meanings, and doesn’t help. “Acupuncture works better than doing nothing” or “Acupuncture works better than random poking” are worth testing and reporting. I’ve got a pretty good idea what the answers would be, but a lot of ‘health consumers’ (ie sick people) out there are much less clear, and more hopeful. We need quality information to talk to them with. I think outcome testing is the best information to use.
AoA.
“I would have thought that positing a mechanism prior to finding or looking for evidence is part of establishing plausibility.”
Yes, but what about treatments that are already popular despite there being no plausible mechanism. It seems to me you have to procede to clinical trials despite a lack of plausible mechanism in these cases.
“We can’t have it both ways: if SBM requires plausibility, we have to accept people looking for possible mechanisms.”
Not if a wealth of clinical evidence already tells us that there is no benefit. Why search for a mechanism in that situation?
“Some medical research starts from a plausible mechanism and looks for effects; others start from an observed effect and looks for a mechanism.”
Nothing wrong with that in my book.
“The problem lies with practices which are already established in supposedly therapeutic practice, which are being tested scientifically after the fact. Acupuncture is one such.”
If a treatment is popular but unproven (because of a lack of clinical trials showing whether or not it works) then, despite lack of a plausible mechanism, we have no choice but to conduct those clinical trials.
BJ
BJ
Thanks to Steve for the review of the RCT.
As a group pregnant women do not have medication options so it is rational that they will seek alternatives and have a right to have these treatments evaluated for their effectiveness.
While I take the point about the lack of blinding in the massage group, blinding of patients is actually hard if not impossible to achieve in physical therapies. We have this problem in physical therapy clinical trials all time; unlike dishing out a tablet which is easy to conceal whether or not it has an active ingredient, there is usually considerable skill, and interpersonal contact involved in delivering the therapy. I understood the logic behind the massage was that you WOULD have a treatment that would produce some non specific effects just as would be the case in the two acupuncture groups and it was to see if there was any added benefit of depression-specific acupuncture
The results were completely disappointing and the analysis and discussion were misleading in suggesting the improvement was useful. As is often the case with hypothesis testing. statistical significance was really quite clinically meaningless in this case. The effect size was unimpressive and with very little certainty that the effect size was clinically meaningful. And as Steve said a mean difference between the controls and the acupuncture for depression of 2.5 points on the Hamilton Rating Scale is virtually useless especially given the amount of treatment required. One would expect to get twice that amount of improvement just by going for a 10 minute walk.