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Placebo Effects Revisited

In the Wall Street Journal last week was a particularly bad article by Melinda Beck about acupuncture. While there was token skepticism (by Edzard Ernst, of course, who is the media’s go-to expert for CAM), the article credulously reported the marketing hype of acupuncture proponents.

Toward the end of the article Beck admits that “some critics” claim that acupuncture provides nothing more than a placebo effect, but this was followed by the usual canard:

“I don’t see any disconnect between how acupuncture works and how a placebo works,” says radiologist Vitaly Napadow at the Martinos center. “The body knows how to heal itself. That’s what a placebo does, too.”

That is a bold claim, and very common among CAM proponents, especially acupuncturists. As the data increasingly shows that acupuncture (and other implausible treatments) provides no benefit beyond placebo, we hear the special pleading that placebos work also.

But is that true? It turns out there is a literature on the placebo effect itself, and the evidence suggests that placebos generally do not work.

That may seem counter-intuitive, since the gold standard of clinical trials is placebo-controlled, because placebo effects can be quite large. However, most such trials do not contain a no-treatment arm (comparing a placebo intervention to nothing at all). What this means, as I have written about before, is that placebo effects, as measured in clinical trials, includes a host of factors – everything other than a physiological response to an active treatment.

These placebo effects include the bias of the researchers, the desire of the subjects to please the researchers and to get well, non-specific effects of receiving medical intervention and attention, and other artifacts of the research process. When we remove all of these biases and artifacts, is there a real effect left behind – what most people think of when they think of “the” placebo effect: a mind-over-matter but real improvement?

Proponents of so-called CAM would like you to believe that “the” placebo effect is all a real biological effect resulting from the body’s self-healing ability. But it turns out, this is simply not true.

Hróbjartsson  and Gøtzsche have been studying the placebo effect for years, reviewing the literature, especially for trials that contain a no-treatment arm. Their most recent review is very illuminating. They conclude:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Let’s break this down a bit. First, they found that when you look at any objective or clinically important outcome – the kinds of things that would indicate a real biological effect – there is no discernible placebo effect. There is no mind-over-matter self healing that can be attributed to the placebo effect.

What the authors found is also most compatible with the hypothesis that placebo effects, as measured in clinical trials, are mostly due to bias. Specifically, significant placebo effects were found only for subjectively reported symptoms. Further, the size of this effect varied widely among trials.

This latter feature is very important. If there were a significant physiological placebo effect we would expect to see a consistent or baseline effect among trials. The tremendous variability suggests that it was the rigor of trial design that allowed for lesser or greater bias resulting in a measured placebo effect.

Further:

Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo.

So the more patients were involved in the reporting of outcomes (as opposed to measuring outcomes) the greater the placebo effect. This is most consistent with bias as a cause. Also, as has been reported before, physical interventions result in a large placebo effect.

Some have hypothesized that time and attention provided by some “alternative” practitioners result in a greater placebo effect, justifying the intervention. However, that was not a factor apparent in this study. Another study, comparing placebo effect sizes for homeopathic treatments and mainstream treatments (which are comparable in terms of the physical intervention) found no difference in placebo effect sizes.

Conclusion

Existing evidence strongly suggests that placebo effects are mostly comprised of bias in reporting and observation and non-specific effects. There is no measurable physiological benefit from placebo interventions for any objective outcome. There is a measured benefit for some subjective outcomes (mostly pain, nausea, asthma, and phobias), but the wide variation in effect size suggests this is due to trial design (and therefore bias) rather than a real effect.

In any case, any perceived benefit in subjective symptoms seems to be greater for physical interventions (perhaps a hands-on benefit) but is the same for mainstream vs novel treatments.

Therefore, there is no justification to be found in the placebo effect for using unscientific or dubious interventions. Placebo medicine is a sham. And any potential placebo benefit worth having can be fully realized with science-based interventions.

Which means that Dr. Napadow may have been unwittingly correct when he said that acupuncture is no different from placebo.

Posted in: Acupuncture, Homeopathy, Science and Medicine

Leave a Comment (32) ↓

32 thoughts on “Placebo Effects Revisited

  1. Gabor Hrasko says:

    “As the data increasingly shows that acupuncture (and other implausible treatments) provides no benefit beyond acupuncture, we hear the special pleading that placebos work also.”

    I guess there is an error in this sentence.

  2. Galadriel says:

    Thought you might be interested in this story too:
    http://www.forbes.com/forbes/2010/0329/opinions-placebo-harvard-health-medicine-ideas-opinions.html

    “The Nothing Cure” (linked on BoingBoing with the title “Placebo isn’t a dirty word”)

  3. devadatta says:

    How do you relate this to the two physiological placebo mechanisms presented here:
    http://www.scientificamerican.com/article.cfm?id=placebo-effect-a-cure-in-the-mind

  4. cervantes says:

    It’s worth noting that there is also a (quite large) placebo response in depression and some other psychiatric entities. That’s consistent with the overall theme here — the measures are self-reports of subjective experiences. However, it’s ontologically puzzling whether these self-reports can really be viewed as somehow invalid — they are the only measure we have of the subjective experience and maybe it really has improved.

    Let’s not forget the passage of time as well — lots of problems just get better on their own, including pain and depression.

    In other words placebo effects probably include real subjective improvement in response to the expectation of feeling better; and of course it is true that the body heals itself so even if the placebo isn’t speeding that up, it’s still happening.

  5. jonny_eh says:

    I recall when reading R. Barker Bausell’s excellent book “Snake Oil Science” that there was one study where researchers were able to block the placebo effect in patients.

    Harriet Hall talked briefly about it in her review of the book. They were able to block the placebo effect using opiod blockers.

    Could it be that the placebo effect only appears with self reported symptoms because those are the only symptoms that it effects? In other words, they both have the same cause, not that one is causing the other.

  6. wales says:

    Dr. Benedetti has been studying the placebo effect for years. Among other things, he was a consultant to the NIH on their Placebo Project. I recommend his book “Placebo Effects: Understanding the mechanisms in health and disease” (Oxford Univ Press, 2008)

    http://www.amazon.com/Placebo-Effects-Understanding-mechanisms-disease/dp/0199559120/ref=sr_1_1?ie=UTF8&s=books&qid=1269450386&sr=8-1

  7. SkepticalLawyer says:

    Along the lines of the mind’s effect on the body, I recall reading/hearing about studies that showed that people are more likely to die of natural and non-self-inflicted causes right after a major holiday or family event. I have two questions for Dr. Novella or anybody else who may be able to answer them:

    1. Is my memory correct? Are there any studies that show this?

    2. If the studies exist, is that a placebo-like effect? In other words, would the studies be evidence of the brain’s ability to control the body’s health or condition to some extent?

  8. Bagfields says:

    Here is big medicines take on placebo:

    http://www.wired.com/print/medtech/drugs/magazine/17-09/ff_placebo_effect

    As a colon cancer patient myself, I don’t care what does the job, I only want the EFFECT !!

    I would say that it’s better if the substance and placebo cooperate to get the job done.
    Placebos doesn’t have any side effects either, but chemotherapy has a whole bunch, trust me.

    After reading the article in Wired, I realised that it’s much better if big medicine and healthcare personnel, starts to use the placebo effect consciously, so that 2+2 always >= 4

  9. twaza says:

    Your excellent article makes a strong case to talk about “true placebo effects” and “perceived placebo effects”, as Edzard Ernst’s suggested in 1995 http://www.bmj.com/cgi/content/short/311/7004/551

    If we don’t do this and continue to talk about placebo effects being the same as non-specific effects, we encourage muddled thinking that leads to the value of the evidence on CAM therapies being seriously overestimated, because the risks of bias in the results are overlooked.

    Your post comes to this conclusion, but I would like to explain in a little more detail just why talking about placebo effects leads to confused thinking.

    True placebo effects are to be welcomed (when they are positive), and special studies are needed to measure them.

    Perceived placebo effects” are all the non-specific effects, including true placebo effects and cognitive measurement biases. They are the effects perceived / observed / measured in the placebo arm of a controlled trial, which is why it is so natural to call them placebo effects.

    When people talk about placebo effects as being the same as non-specific effects it encourages confused thinking along the lines of: non-specific effects are placebo effects (but without the pejorative associations of “its only a placebo); placebo effects are good, therefore non-specific effects are good.

    The thinking stops there without considering the possibility of
    negative true placebo effects and negative cognitive measurement biases in the control group, and positive cognitive bias effects in the experimental group.

    This is very convenient for advocates of CAM because all these biases are likely to be present; they are likely to be greater than the specific effect of the CAM therapy; they look like real benefits of the CAM therapy; and the sleight of hand is unlikely to be noticed by many people other than Steven Novella and Edzard Ernst.

    Perhaps I should explain why negative placebo effects are likely in the comparison group. This really only applies to open (unblinded) controlled trials, so called “pragmatic trials”. Pragmatic trials are being promoted as the way forward for CAM/IM research, see for example this editorial in the BMJ:
    http://www.bmj.com/cgi/content/extract/339/sep01_2/b3335

    With therapies such as acupuncture and chiropractic, people in the comparison arm of an open pragmatic trial will usually be given “best care”, which will already have failed to treat their back pain or headache or other chronic condition. They will therefore be disappointed not to be receiving the special treatment given to the experimental group, and the disappointment will show in patient-reported measures of pain and disability: they will have a negative true placebo effect, and negative cognitive measurement bias effects.

  10. weing says:

    “Placebos doesn’t have any side effects either, but chemotherapy has a whole bunch, trust me.”

    That is not really true. Placebos do have side effects. I’ve seen cases where patients would have a reaction to a medication and when we checked afterwards, it turned out the patient had a placebo. The part about chemotherapy is true.

  11. pmoran says:

    “Further, the size of this effect varied widely among trials.

    This latter feature is very important. If there were a significant physiological placebo effect we would expect to see a consistent or baseline effect among trials.”

    Why? Placebo influences are likely to be generally dampened in this kind of study through subjects not knowing whether they are “supposed” to feel better or not. This is another reason (to those of Twaza and others) why the Hrobjartsson study may be telling us very little about the potential of “true” placebo reactions, especially under specific conditions that can apply within some testimonials.

    Nevertheless, patient expectations are likely to aroused to very different degrees in different studies and different medical conditions differ greatly in placebo responsiveness. The variability you describe could thus be interpreted as being in line with expectations of placebo reactions. I agree that it is very difficult to distinguish them from patient reporting biases.

    It was predictable many years ago that we would reach this point, where the main remaining issue regarding most “alternative” methods is whether they can be of value to those using them as part of a package of care, even when able to perform no better than sham treatment in controlled studies.

    It is time SBM tried hard to fill in this blind spot in its understanding of medicine, i.e. we need to know what, if anything, is left after patient reporting biases and spontaneous events are subtracted from what are commonly referred to as “placebo effects”. We do not KNOW this with anywhere near the degree of confidence that we have regarding most of the other matters that SBM considers and we are not entitled to assume that we do from studies that are not designed to shed light upon this specific question (and which in fact do show some of the effect they are supposed to be dismissive of).

    It is also not certain that lying people down for twenty minutes or so two or three times a week while prodding them with needles or toothpicks has the exact same physiological or psychological effects as the ho hum provision of a pill, even before you add on a bit of oriental mystique.

  12. JMB says:

    Just a small correction to the WSJ article, Dr Napadow has a PhD in biomechanics. He studies acupuncture using fMRI. He is not a radiologist.

    I concede to Dr Novella about the points on placebo effect. It was specifically that Cochrane collaboration article I had criticized in previous posts as underestimating the placebo effect. Dr Novella is in a better position to assess that than I (I rely on past experience).

    There are still ethical arguments against CAM. A physician still has an ethical obligation to provide an education for the patient that is based on scientific consensus. I would argue that using CAM concepts (such as vertebral subluxation, flow of vitality, quantum entanglement, dilutions, etc.) in describing the treatments to a patient is unethical. Charging $100 for a CAM treatment because you spent $1500 for a course in CAM is also unethical. Any preparation that does not show a greater benefit than a sugar pill, or needle application that does not show greater effect than a saline injection, should not be sold for more than the cost of a sugar pill, or the cost of a saline injection (and only the cost of one injection). I think that the best counter to IM is to acknowledge the importance of placebo effect, but emphasize the ethical use.

    So I am in total agreement with the idea that SBM should counter the acceptance of CAM in mainstream medicine, but I would rely more on ethical arguments about acceptable use.

  13. Tsuken says:

    pmoran, I take your point, but prescribing of medication should never be “ho-hum”. I think it was Glen Gabbard who wrote about the psychodynamic aspects of prescribing, and it really is – or can be – and important interaction, beyond the pill itself. Perhaps that’s moreso in psychiatry, but not necessarily irrelevant or unimportant for other specialties.

  14. pmoran says:

    “pmoran, I take your point, but prescribing of medication should never be “ho-hum”. I think it was Glen Gabbard who wrote about the psychodynamic aspects of prescribing, and it really is – or can be – and important interaction, beyond the pill itself. Perhaps that’s moreso in psychiatry, but not necessarily irrelevant or unimportant for other specialties.”

    That is true, but I remain less sure than Steve or some other writers here are that the average doctor will be as good at exploiting the psychodynamic aspects of prescribing as the average charlatan, especially if the doctor is to eschew all traces of artifice in the pursuit of his superior ethical and informed consent objectives.

    For example I assume the strict SBM/EBM doctor will be obliged to inform patients when there is only a thirty to one chance that taking a particular pill will do them any good and some chance that it will do them harm. Lots of luck, chaps!

  15. pmoran says:

    Sorry, that should, of course, be a “one in thirty chance”.

  16. pmoran on the psychodynamic effects of prescribing:

    “I remain less sure than Steve or some other writers here are that the average doctor will be as good at exploiting the psychodynamic aspects of prescribing as the average charlatan, especially if the doctor is to eschew all traces of artifice in the pursuit of his superior ethical and informed consent objectives.”

    Back when I was really, really depressed – bipolar II having interfered with developing a normal life, I hadn’t finished my degree, I’d never had a full-time job, I was in a dysfunctional relationship that I didn’t have the psychic or financial resources to leave, and I wasn’t sure how much longer I could keep myself alive – I met my psychiatrist.

    She was worried about me. I was really, really depressed. She prescribed me some Zoloft, which she doesn’t normally do on a first appointment. She told me that it wouldn’t take effect for six to eight weeks, and that she was giving me a very small amount. If I were to experience side effects at a low dose, then there would be no point in increasing to a high dose, and it would be easier to switch to another medication if I were only taking a low dose of this one.

    You might think that she wasn’t offering me much: a less than effective dose of a medication that wouldn’t work for two months even at full dose, and a significant risk of side effects.

    You would be wrong. She was offering me hope. She recognized that I needed help* and was offering it. She was promising to stick with me. That was huge.

    There are doctors who totally suck at the psychodynamic effects of prescribing. I have met some of them. Most doctors, however, exploit the psychodynamic effects of prescribing quite well; some superbly, while maintaining complete honesty.

    * Not always obvious with bipolar II. With atypical depression many of us have the curse of being able to present well even when quite ill. When we are no longer able to present well we are very, very ill indeed. In my case I spent years of being told that I should kick myself in the butt and get over myself. And that I should stop trying to get sympathy by inventing stories about being depressed, because I clearly wasn’t. A meeting with a professional who wanted to do something for me was novel for me.

  17. Thank you, Dr. Novella, for revisiting the placebo effect. Unfortunately, the placebo effect is greatly misunderstood by people in the medical field, even so-called “experts.” Take for example an excerpt from the new text book from Cambridge publishing, Acute Pain Management by RS Sinatra et al. (penned mostly by your colleagues at Yale) that makes the following claim in the section on acupuncture (the logical fallacies run deep in this section, but that is for another discussion entirely):

    “…today acupuncture is regarded as having a greater analgesic effect than can be accounted for by placebo (reference A). Some authors even account for the benefits of placebo effect, while clearly showing an improvement on placebo analgesic effect with the inclusion of acupuncture (reference B).”

    The current understanding of “today” comes from an oft-quoted by CAM proponents 1977 study by DJ Mayer et al (ref A). And ref. B is a 1976 study by B Pomeranz et al, in which the placebo group had IV saline injections that they were told was a “really strong medicine.” I am disappointed that most CAM folks still use this today as “evidence” for the effects of acupuncture, but I am encouraged by the fact that there are some who are at least agreeing that that acupuncture is equivalent to placebo. This is a step forward in my opinion. It would be great if we could get all of the proponents of acupuncture, homeopathy, chiropractic, and other such woo to take the official stance that “X is equivalent to placebo, and placebo works, therefore X works,” then we could simply pull a bait-and-switch by showing placebo to be a sham. Unfortunately, logic doesn’t work on the illogical mind.

    It seems to me that we are still at the point where the official stance of acupuncturists is that it works better than placebo, as indicated by the above excerpt. The evidence to the contrary has been discussed previously at SBM by Drs. Novella and Hall. The scary part is that the quoted text is from a mainstream medical text book authored by many leaders in the field of anesthesiology and considered the closest thing to an authoritative book on the management of acute pain.

    I have seen first-hand that the medical education system in this country does not spend much time teaching about the placebo effect. Unfortunately, the placebo effect appears to be such a simple concept that most of my colleges mistakenly believe that they know all there is to know about it. Ignorance is bliss; ignorance about ignorance can be dangerous.

  18. ceekay says:

    Placebo acupuncture is more powerful than a pill placebo, according to a large clinical trial published in BMJ.

    Placebo acupuncture is a really effective treatment for chronic pain:

    two recent german studies showed placebo acupuncture relieved chronic back pain and in migraine at a much higher rate than usual care. Much higher… (by memory, about 50% achieved relief in placebo, 17% in the usual care group).

    We don’t know how the effect is achieved–it may even have something to do with how acupuncturists are trained to interact with patients.

    If you are a chronic pain patient, this is a no brainer: get the acupuncture…..

    For researchers, we have to do a much better job understanding why the placebo acupuncture ritual is so effective and so much better than other placebos…..Any ideas?

  19. pmoran says:

    “For researchers, we have to do a much better job understanding why the placebo acupuncture ritual is so effective and so much better than other placebos…..Any ideas?”

    First we need to resolve a recurring differences of opinion as to whether the reported results are actually clinically meaningful or whether they are mainly due to misleading artifact in certain trial designs. The studies you describe show (yet again) that acupuncture “works” much the same as sham but they do not elucidate what that means for medical practice.

    Take the one* showing that both acupuncture and sham acupuncture are substantially better than usual care for patients with very chronic low back pain. Most or all of this reported “effect” could be due to patient reporting biases (answers of politeness or experimental subordination), with no worthwhile change in the underlying condition of the patient.

    What is also needed are as objective, bias-free, and independently observable endpoints as possible: measured analgesic consumption, number of days off work, activity sensors, or whatever else smart people can dream up to reveal the true level of patient disability.

    * http://www.ncbi.nlm.nih.gov/pubmed/17893311?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed

  20. @ ceekay-

    I agree with you about fake acupuncture (I eluded to placebo acupuncture > placebo pill/injection which is one of the reasons why the conclusion from the Acute Pain Management text book that acupuncture is better than placebo is flawed), but I wholeheartedly disagree with your recommendation that chronic pain patients get acupuncture just for the placebo effect. It’s funny how anti-big pharm nuts are so quick to point out all of the side effects of mainstream medications, while seemingly ignoring possible harms of their “alternative” treatments.

    Acupuncture is most likely generally safe if performed in a controlled and sterile manner, but it is certainly not without its complications. For instance, have you ever heard of cases of pneumothorax, MRSA infections, hematomas, or even death from pericardial puncture associated with acupuncture? Well, these complications do occur. The CAM folks even admit it in their own literature:

    “White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004; 22: 122-133.”

    While shadowing an acupuncturist at my own facility I witnessed him using “sterile” needles, but he never wore gloves and only rarely washed his hands. And this is the head acupuncture professor for one of the biggest naturopathic schools in the world (Bastyr University in Seattle, WA). He is mentoring hundreds of new acupuncturists, and I can only assume that they are picking up his sloppy and dangerous techniques, putting thousands of “clients” in danger, while selling the practice as completely safe. In my opinion, these practitioners should be obligated by law to get informed consent from their patients with something along the following lines: “Acupuncture is generally safe, but there is a possibility of infection, bleeding, or very rarely even a worse outcome.” And ideally would also include something like: “Also, the benefits of acupuncture are the same if we pretend to stick in the needles, but don’t actually pierce the skin, avoiding all possibly dangerous side-effects. We do not claim to cure any conditions, even if our deceptive advertising brought you to that conclusion. This is primarily for entertainment purposes.”

    **sigh** What a wonderful world that would be…

    So, in conclusion ceekay, a chronic pain patient would be better off trying to find a SHAM acupuncturist (maybe I can do this on the side for some extra cash), or better yet getting a referal to a clinician that can offer an actual treatment.

    DoR

  21. And for anybody interested in the references for death after acupuncture:

    After pericardial needle insertion:

    Vincent C. The safety of acupuncture. BMJ 2001;323:467–8.

    After bilateral pneumothoraces:

    Kasuda S. A CASE OF SUDDEN DEATH DUE TO BILATERAL TENSION PNEUMOTHORAX AFTER ACUPUNCTURE. J Nara Med Assoc 2004:VOL.55;NO.6; Pp 331-335.

    You will also find within these references cases of the more common causes of death resulting from acupuncture (infection, including septicemia, endocarditis, etc).

    As a side note, of the 3 additional cases of death from acupuncture-associated pneumothorax that I could find, at least one was from needling the “kidney meridian” which for some mystical and ancient Chinese reason runs along side the sternum.

  22. “Take the one* showing that both acupuncture and sham acupuncture are substantially better than usual care for patients with very chronic low back pain. Most or all of this reported “effect” could be due to patient reporting biases (answers of politeness or experimental subordination), with no worthwhile change in the underlying condition of the patient.”

    I was thinking about this the other day. I have been treated with physical therapy and/or cortisol shots for various back/shoulder/foot pain and also had to go to ER for severe stomache pain twice. In these occassions it is common for practitioners to use a 1-10 pain scale. (1 lowest 10 the most pain possible).

    I’m not sure if this is commonly used in the studies, but for me it was very difficult to settle on a number. I mean, is it a 5 or a 6? or maybe if you reframe it as a comparison to a really intense short term pain, it’s only a 3 or if you think about it in terms of how it negatively effects your daily life over a long time – perhaps it’s an 8….etc. Within this system it’s actually quite difficult to know if you are lowering your number just to give the practitioner points for effort or raising it because you are concerned they won’t address your issue if they think it’s not severe enough.

    So within this system, I could see how patient accuracy in reporting of pain would be a very real concern. The goal for treatment is that patients should actually experience less pain, not just report less pain.

  23. pmoran says:

    Yes, that is the point, Michelle. There are bound to be a number of people who are not sure whether they are better or not, but don’t want to upset the findings of the study by giving a “wrong” answer. “Perhaps I’m a bit better, and I’ll say so”.

    Deaths from acupuncture are serious, in view of its obviously limited medical activity, but much of the force of the argument from risk rests upon the skeptic’s assumption that it does no good at all. Remember that we justify serious risk from quite routine conventional medical activities by pointing to the benefits.

    This is, again, why we need more clear-cut evidence as to the value/non-value of placebo CAM medicine as it is presently provided.

    Otherwise we are setting mere opinion up against the strong inclination of many to give these methods the benefit of the doubt while others are claiming benefit from them. No one has to take our word for anything.

  24. ceekay says:

    pmoran — I take your point about chronic pain patients’ possible biased reporting in acupuncture trials. Although, it is important to note that this is also a problem in trials of physical therapy for chronic pain and other behavioral procedures that is not exclusively an “acupuncture” problem.

    While I’m sure acupuncturists are embarrassed by the huge effect sizes achieved by fake acupuncture, physicians should also be embarrassed.

    Chronic pain is a huge cause of suffering. Current approaches offered by science-based medicine utterly fail to address this suffering in many cases.

    The subjectivity of suffering is at the heart of the problem–and it is embarrassing that the warm sincerely delivered procedures, even in sham conditions, offered by acupuncturists do so well in randomized trials. I don’t think this can be dismissed as mere bias (since people also “vote with their feet” and pay for these procedures with their own money).

    Until we understand chronic pain patients’ multidimensional suffering as a cognitive emotional and sensory phenomenon …

    Until figure out what it is that acupuncturists are delivering that may address this suffering

    (ignoring what they say they are delivering — since “real” acupuncture appears to do no better than sham), we aren’t going to get anywhere.

    Chronic pain and suffering are the real mystery here…. Any discussion decrying the poor science of acupuncture that does not directly face the mystery of human suffering amounts to spinning our wheels. — My 2 cents.

  25. squirrelelite says:

    ceekay,

    I agree that

    “Chronic pain is a huge cause of suffering.”

    However, I think it is a little confusing when you say that:
    “Current approaches offered by science-based medicine utterly fail to address this suffering in many cases.”

    “Utterly fail” is very absolute, but “in many cases” implies that in all the rest of the cases (whatever fraction that turns out to be), science-based medicine does not “utterly fail”. So, science-based medicine does have some proven and demonstrable value even it is not as good as we would like.

    As I recall from looking at the results from several months ago when the acupuncture versus sham acupuncture versus standard therapy study came out, the initial results showed an advantage for either “real” or sham acupuncture. But, when I looked at the later numbers (near the end of the six month study period), that advantage was much less.

    Thus, I think it not unlikely that if the same study were continued for another six months or six years or the rest of the patients’ lives (as is generally necessary for long term chronic pain), after a few cycles of severe pain followed by regression to the mean, a lot of patients would start to realize that the acupuncture was having no real long term benefit. (just a guess)

    And, the reported reduction in the “patients’ multidimensional suffering as a cognitive emotional and sensory phenomenon” might not be such a big benefit after all.

    And so, until science-based medicine advances to the point where we can really fix the underlying physical cause of the pain (such as by targeted genetic therapy to allow regrowing damaged nerve and muscle and bone tissue), we need to continue to look for better ways to mitigate the suffering of each and every patient.

    But, I am less sanguine that devoting major effort to “figure out what it is that acupuncturists are delivering that may address this suffering” is likely to be a productive strategy.

  26. Alison, regarding pain chart * – http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

    Hilarious! and yes, because my view is, if I’m going to be in pain I should at least be able to get a good laugh out of it (which confuses some people). Also, anybody who presented me with the second chart would instantly win my “oh, they get it!” award.

    Of course one improvement would be to add – It hurt when I made the appoint 2 weeks ago and it most certainly will hurt worse tomorrow, but today it feels just dandy, thank you. (I have no idea what number that would be.)

  27. michele,

    Yeah, sorry — don’t know what happened there. Glad you were able to make the connection — and glad you appreciate the pain chart!

    Hm. Yes, the “not right now but every other time” chart could be interesting. I think in an immediate sense in the ER it doesn’t matter because their question is do they need to offer you pain meds right now.

  28. Yes, the ER chart needed is definitely different than the PT, Ortho, GP chart. It’s hard to work bear mauling into a PT chart.

    Although when I was in college, I did take a friend to the ER after he experienced intense chest pain with breathing. Once we got there, he said he felt totally better and wanted to leave (Monty Pythonesque). Luckily it was a slow day, so the doc said, “let’s just listen to your chest before you take off.”

    Turns out he had had a ruptured cyst that resulted in a collapsed lung. I think, that is a sad face on the first chart.

  29. cloudskimmer says:

    ceekay and squirrelite: Having a close family member suffering long-term from severe chronic pain has given me some second-hand experience with the condition. As bad as our experience has been with conventional medicine, dealing with sCAM (so-Called Alternative Medicine) was even worse. At least Doctors can offer prescription medication which does give some help; unfortunately there are side effects. With acupuncture, all you get are side effects, since the “treatment” is a sham. And the acupuncturist we visited (only once) was a complete quack, not paying attention to sterility, and also saying that “everyone needs to take enzymes” which they conveniently sold, plus applying a homeopathic ointment. What a load of rubbish! No help, more pain, dizziness, nausea and vomiting followed. The acupuncturist denied being the cause of these problems, but you can bet she would’ve taken credit if a reduction of pain had been the result. So, if needles can balance the chi, couldn’t they also cause an unbalance to the chi and make the symptoms worse?
    Probably most acupuncturists believe in what they do, but they are self-deluded, practicing something that is most likely ineffective. So, there’s no possibility of it improving you situation, and a small chance that it could cause harm. I would strongly urge chronic pain patients avoid acupuncture. After all, it anecdotes are evidence, it causes increased pain, nausea, vomiting and dizziness.

  30. JMB says:

    Dr Novella,

    Just a teaser topic when you are all having drinks together:

    Do you think you could observe placebo effects in a patient with “la belle indifference”?

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